From what we hear from readers of our syndicated newspaper column and visitors to this website, most patients are not warned about how to stop duloxetine (Cymbalta). Perhaps the prescriber assumes that they will need to take this antidepressant for the rest of their lives. Or perhaps there is a reluctance to mention anything negative about a new prescription. Whatever the motivation, a lot of people are not adequately warned that they must never stop duloxetine suddenly.
Cymbalta for Pain Led to Distressing Withdrawal:
Q. I was on Cymbalta for about a year to treat pain in my shoulder and neck. When it was diagnosed as a torn rotator cuff, the doctor said I could get off the drug. He gave me 30 mg for a week and said I would be fine. I had been on 60 mg.
I did as I was told. Once I finished that week of 30 mg doses, I was pretty sick. I had horrible stomach pain, diarrhea and headaches. I felt so nauseated and dizzy I was miserable.
I also fly off the handle easily and feel like I never get enough rest. I’m wondering how long this withdrawal will take. They should really tell people to wean off slowly and not so suddenly.
A. Duloxetine (Cymbalta) is prescribed for pain as well as depression. Doctors have a name for the symptoms you describe: “discontinuation syndrome.” As you have noted, it can be extremely challenging.
To avoid such distress, medications like duloxetine should be tapered very gradually. This may take months instead of weeks. We discuss this process in our eGuide to Dealing with Depression. You can find this electronic resource in the Health eGuides section of this website.
Stopping Any Antidepressant Can Be Challenging:
Americans have had a love affair with antidepressants ever since Prozac (fluoxetine) made the cover of Newsweek over 30 years ago. There are now so many similar drugs that we have lost count. The most popular in descending order are: sertraline (Zoloft), escitalopram (Lexapro), bupropion (Wellbutrin), trazodone (Desyrel), citalopram (Celexa), fluoxetine (Prozac) and duloxetine (Cymbalta).
Many people find such drugs helpful. We only wish that health care professionals would be more forthcoming when they prescribe these medications. That is especially true if it becomes necessary to stop such antidepressants. There is now an official name for the withdrawal symptoms: Antidepressant Discontinuation Syndrome (ADDS).
An article in the journal Therapeutic Advances in Psychopharmacology (July, 2020) is surprisingly candid:
“Coming off psychotropic drugs can cause physical as well as mental withdrawal, resulting in failed withdrawal attempts and unnecessary long-term drug use. The first reports about withdrawal appeared in the 1950s, but although patients have been complaining about psychotropic withdrawal problems for decades, the first tentative acknowledgement by psychiatry only came in 1997 with the introduction of the ‘antidepressant-discontinuation syndrome’. It was not until 2019 that the UK Royal College of Psychiatrists, for the first time, acknowledged that withdrawal can be severe and persistent.”
The Many “Indications” for Duloxetine:
The FDA originally gave Cymbalta the green light for treating major depression in 2004. The drug has also received FDA approval for nerve pain (neuropathy) triggered by diabetes. In addition, the FDA has granted duloxetine approval to treat anxiety, the discomfort of fibromyalgia and the musculoskeletal pain brought on by arthritis or lower back injury. It works by affecting the neurotransmitters serotonin and norepinephrine.
On the surface, duloxetine seems like an ideal drug. It will ease your pain and relieve any related depression. Not surprisingly, Cymbalta became very successful. Today, the generic duloxetine formulation is prescribed quite frequently. Millions of people take it daily.
Duloxetine Side Effects:
There is a long list of significant side effects associated with Cymbalta. You can find them at this link.
Powerful Stories from Readers:
Kent in Oregon has the worst of both worlds: Side Effects and Withdrawal Symptoms:
“I am a 50 year old college honors grad, U.S. Marine and a retired homicide detective. I began taking Cymbalta to combat the effects of stress and depression associated with my constant exposure to the worst society has to offer.
“I have been taking it for about 15 years and now have symptoms I would trade for those that put me on Cymbalta in the first place. Each time the Veteran’s Healthcare Administration has failed to send my refills in the mail, it takes just 48 hours for the most terrible withdrawal symptoms to reappear.
“I experience horrible shakiness, uncontrollable, inappropriate and sudden bursts of tears, irritability and snappy moodiness, appetite problems and more. The worst of all my withdrawal symptoms, however, are the electrical shorts or zapping sensations in my brain. It literally feels like it shoots across my head and makes my brain bounce and eyeballs wobble. I find that it progressively worsens day after day while I wait for VHA to do their job and send the next bottle of capsules.
“There are symptoms that I get from taking the capsules as well, including erectile dysfunction, appetite changes, severe dry mouth, and MAJOR tinnitus [ringing in the ears]. The worst two are massive anxiety and sweating anytime I am in public or have even the slightest thought of things that are stressful for me.
“As a cop, I always thought anxiety was something people made up and used to escape work, or some other unpleasant task. Now I know it’s very real and has completely destroyed my public life. Standing in ANY store checkout line is a guaranteed shirt-soaking, sweat-filled-eyeballs experience for me.
“At one time, I was an over-achiever and a rising star in my profession with national awards and recognition, but now I live alone, have lost my family, friends, my personal belongings and even my home. I’m now stuck on a drug my brain cannot live without in a system with no reasonable means for discontinuation whatsoever.”
Sweating is a recognized side effect of duloxetine, along with hot flashes.
Martha in Texas shared a similar experience:
“I’ve been on Cymbalta since 2010 for fibromyalgia. Stupid me! I’m the one who asked my doctor to put me on it, since I saw it advertised on TV. The commercial said that it helps with pain!
“I was tired of the hot flashes and my ears ringing! And feeling like I was a robot! I had a lot of ‘brain farts’ where my mind would stop with a blank and couldn’t get my words out. I decided it was time to get off of Cymbalta.
“Getting off Cymbalta is horrific! Like so many others, I too am experiencing light-headedness, dizziness, and brain zaps. I describe it…when my eyes move my hearing zings while my brain zaps. I’m so tired and can sleep 12 hours at a time. I just don’t feel like myself.
All of this is affecting my job performance. I really need help, and I don’t care what it takes. Somehow or other, I’m getting off this awful drug!”
How to Stop Duloxetine (Cymbalta):
First, and we cannot emphasize this enough, NEVER stop duloxetine on your own. This requires very careful medical supervision. The prescriber must be informed of any plans to stop this drug. That said, the official prescribing information does not provide health professionals or patients much detailed guidance on how to stop duloxetine (Cymbalta).
Many readers have reported that they have to work with their doctor to devise a plan to stop duloxetine. In some ways, Cymbalta has advantages over other antidepressants in this regard. That’s because it comes in a capsule with tiny drug “beads” inside. We have never taken the time to actually count the number of beads inside a capsule, but some folks say it can range from 100 to 300. This allows for very slow tapering as you will shortly read.
Official Prescribing Information:
The FDA requires the following wording in the package insert. This is the officially sanctioned information hammered out between the drug manufacturer and the Food and Drug Administration. See what you think:
“Discontinuation symptoms have been systematically evaluated in patients taking CYMBALTA. Following abrupt or tapered discontinuation in adult placebo-controlled clinical trials, the following symptoms occurred at 1% or greater and at a significantly higher rate in CYMBALTA-treated patients compared to those discontinuing from placebo: dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis [excess sweating], and fatigue.
“During marketing of other SSRIs and SNRIs (serotonin and norepinephrine reuptake inhibitors), there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric [bad] mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, hypomania, tinnitus, and seizures. Although these events are generally self-limiting, some have been reported to be severe.
“Patients should be monitored for these symptoms when discontinuing treatment with CYMBALTA. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate [see Dosage and Administration (2.7)].
2.7 Discontinuing CYMBALTA:
“Adverse reactions after discontinuation of CYMBALTA, after abrupt or tapered discontinuation, include: dizziness, headache, nausea, diarrhea, paresthesia, irritability, vomiting, insomnia, anxiety, hyperhidrosis, and fatigue. A gradual reduction in dosage rather than abrupt cessation is recommended whenever possible [see Warnings and Precautions (5.7)].”
FDA’s Guidance on How to Stop Duloxetine (Cymbalta)?
So, what do you make of the official prescribing information? Do you feel as if you might be caught on the cusp of a Catch 22 situation? The FDA and the company acknowledge that “intolerable symptoms” may occur upon “discontinuation of treatment” or even a “decrease in dose.” The solution: resume the previously prescribed dose. Then “continue decreasing the dose but at a more gradual rate.”
We did not find any actual guidance on how to stop duloxetine (Cymbalta) gradually. For one physician that might mean over a week. For another health professional, “gradual” might be interpreted as a month. But the company and the FDA seem to be very careful not to provide clear and concise recommendations. That means that physicians are pretty much on their own and that leaves patients vulnerable to all sorts of complications.
Withdrawal Stories from Patients:
Cindy in Dickson, Tennessee went through hell:
“I have been on Cymbalta for about 2 years. I recently ran out and didn’t have the money to refill my prescription. It’s been 6 days. My body hurts, I feel like I’m sweating from inside, upset stomach, whooshing in my head and brain zaps.
“Yesterday, which would have been day 5, I could barely move. I was very sick to my stomach and throwing up. I was going to refill it today cause I had 1 refill left but it expired on 5/19 so I couldn’t refill it.”
Angela in Palo Alto, California, had a similar experience:
“I’ve been on Cymbalta for the past 6 years for depression. My new insurance would not pay for my meds without a prior auth. I’ve been waiting for a month for my Dr. to handle the paperwork.
I’ve been so sick. Headaches, sweating, thoughts of killing myself, hostility, crying, not sleeping, feeling of everyone around me is gonna die, can’t think clearly, the runs, chest hurting, wheezing, and so much more! I finally got my thoughts right for me to look up Rx discount today. I’ll be getting my meds tomorrow. Thank God!
JoAnne in New Market, Ontario, adds:
“I came off Cymbalta two weeks ago. Oh My God! I don’t mind pain, but this is sick.
I have nausea, runs, stomach pain and headache.
“Well at least I don’t have thoughts of suicide. One minute I am cold and the next hot and feverish. Some times light hurts my eyes. I have gas, burping and farting.
“Then I have moments of wanting to just break down and cry for no reason at all. Chills. I am having a bad moment now. I just want to go to bed and stay there until it all passes and God I hope this passes soon. Shortness of breath. Please tell me it will end soon.”
There is no way to predict how long withdrawal symptoms will persist for any given individual. Some people tell us that after several weeks of unbearable symptoms, things gradually begin to smooth out. Others tell us it takes months. That is why it is essential never to do this on your own or suddenly.
Nancy in Florida was taking a different antidepressant: citalopram (Celexa). Here is what she reports:
“I was on citalopram for many years. More than one doctor tried to tell me that there were no side effects if you quit. More than one time I tried to go off but would have major crying spells and irritability.
“I finally got off of it by taking 2/3 of a pill for one month, then 1/2 of a pill for 1 month, then 1/3 of a pill for 1 month, then 1/4 of a pill for 1 month. Then I went to 1/4 of a pill every other day for a month, then every third day, etc. It was an incredibly slow process but did not cause any problems.”
Kassandra in Arizona had physician support:
“I am currently on duloxetine for my extreme nerve pain related to sciatica. When I asked my doctor about the reported difficulty of stopping duloxetine, she said that she would put me on a different drug while I reduced the duloxetine, and that it would reduce the side effects. She also said that it can take months to get off it completely, and should not be rushed.”
How to stop duloxetine (Cymbalta) from “Hopeful” in Indiana:
“Getting off of Cymbalta was the hardest physical thing I’ve ever done in my life. Many doctors don’t realize how difficult it is or that you have to taper – mine did not.
“I found A LOT of help online — my withdrawals were so difficult, I’m not sure I would have survived if I had not found all the online resources and other people’s stories of how difficult getting off of it was and the techniques they used.
“What I did, safely and carefully, was actually open the capsules and count the beads in order to taper down. (Cold turkey is horrible and was simply not do-able for me!) This counting of the ‘beads’ was detailed in many places online.
“I went down VERY slowly and this greatly minimized the horrors of cold turkey. I think I took 3 solid months to go off of it completely. I took a LONG time to phase off this drug. Even then, I had bad side effects and my brain didn’t ‘heal’ completely for 9 months. I had bad memory problems, extreme difficulty with logical thinking, exhaustion, physical aches, and more. BUT I DID get better finally; it was just a very long, painful journey.
“Now I continue to experiment and research and have had successes with natural alternatives to a prescription antidepressant. I understand deeply how much antidepressants are needed for some people, but after my terrible experience with going off of Cymbalta, I hope to not use one again. (And the fact that the manufacturer doesn’t make a tapering dose/pack is unbelievable given the bad results of cold turkey.) I have much sympathy for you and urge you to search online regarding how to best go off Cymbalta. I wish you well. Hang in there – it can be done!”
We are grateful for “Hopeful” in Indiana for her guidance. Many visitors to our website have successfully tapered off duloxetine by removing a few pellets from the capsule each day. Some have gone so far as to remove only one a day for awhile until the body adjusts. Because duloxetine comes in a capsule with tiny pellets or beads containing the active drug, it is actually possible to lower the dose very gradually over a period of many months. If symptoms show up, a slight increase in the dose may suppress the discomfort.
An Alternate Approach from a Physician:
We were contacted by a board-certified family physician who specializes in pain and addiction. He reports that:
“The best way to stop this drug is to put the patient on fluoxetine (Prozac) for one to two weeks. You then stop the Prozac. Prozac is so long lasting that it gradually decreases blood levels slowly enough so that the discontinuation syndrome doesn’t happen.
“This is simple and inexpensive. It is important, as you say in your article, that people do not stop this medication [duloxetine] on their own. However, it is not necessary to go through the ‘Chinese water torture’ by such a prolonged and unnecessary tapering regimen.
“Since most physicians do not know this simple trick, it is up to the patient to ask their physician to use the simple method.”
Once again, we recommend this be supervised by a physician who is knowledgeable and sympathetic. Some people may be successful with the prolonged tapering regimen described by “Hopeful.” Others may find the fluoxetine substitution for duloxetine a helpful strategy under close medical supervision.
There is an advantage to fluoxetine. Like duloxetine, it can be tapered slowly. For example, Prozac comes in pills as well as in a liquid formulation. Liquid fluoxetine comes in a strength of 20 mg/5ml. The physician can personalize the dose for each patient and reduce it very gradually over time. Because each person responds differently, we hope that the health professional who assists in this process is patient and understanding.
Here are some links to other articles to consider:
Stopping Duloxetine (Cymbalta) Suddenly Flipped her Out
Stopping Cymbalta Suddenly Triggered Emotional Roller Coaster Ride
Stopping Cymbalta Suddenly Led to Disaster
Reader Enraged by Advice about Stopping Cymbalta
Share your own duloxetine (Cymbalta) story in the comment section below: