Disclaimer: This is for informational purposes only. This does not replace the instructions you received from Dr. Anderson or any other practitioner,
constitute medical treatment, establishment of a patient-physician relationship, constitute any form of recommendation, prescription or medical
advice, or imply that the medication is appropriate or FDA approved for any condition. This information may be outdated and is not a complete
listing of instructions, doses, uses, or side effects. If this was prescribed to you, you must review this information with your pharmacist and
prescriber before starting the medication. Any medication may interfere with the ability to drive, concentrate, or operate machinery; patients must
be responsible for their own behavior and should not engage in any dangerous activity if there is any question of impairment. All medications have
side effects and drug interactions, some serious, some fatal. Let all of your practitioners and pharmacist know about every substance used. Alcohol,
herbals, or illegal drugs are not considered safe with these medications. Assume no medication is safe during pregnancy or while breast feeding. The
medication may interfere with birth control. Almost any medication can cause sleepiness, insomnia, dizziness, confusion, hallucinations, anxiety,
panic, constipation or diarrhea, headache, chest pain and nausea or vomiting, among others. These could cause physical injury, such as dizziness
causing one to fall down stairs. Many reduce blood pressure, which could cause fainting, dizziness, stroke, or other problems. Most medications
should NOT be stopped suddenly because of the risk of withdrawal. This is a supplement to the standardized drug information sheets.
Drug: DUOLOXETINE
Wayne E. Anderson, D.O.
A Medical Corporation
Chronic Intractable Pain Disorders
Headache & Facial Pain Disorders
Neurotoxin Therapy
FDA-approved uses: The pain of diabetic neuropathy, fibromyalgia,
chronic musculoskeletal pain due to chronic osteoarthritis and
chronic low back pain. Also, generalized anxiety disorder and major
depressive disorder.
Common off-label uses: Neuropathic pain and musculoskeletal
pain of causes other than the low back or arthritis. Neuropathy and
neuropathic pain from causes other than diabetes.
Alternatives: Non-medication modalities, pain interventions and
other medications that may work in a similar manner.
Board Certified Neurology
American Board of Psychiatry & Neurology
Board Certified Pain Medicine
American Board of Psychiatry & Neurology
in association with the
American Board of Anesthesiology
Subspecialty Certified Headache Medicine
United Council for Neurological
Subspecialties
Qualified Medical Evaluator
Member of the
California Pacific Neuroscience Institute
45 Castro Street Suite 225
San Francisco CA 94114
415.558.8584 tel
415.513.4521 fax
www.wayneanderson.net
How it works: This medication works by helping to prevent the
destruction of two of the nervous system’s important natural
chemicals: serotonin and norepinephrine. These neurotransmitters
are involved in reducing the perception of pain.
Side effects: Please see the standardized drug information sheet for
detailed information about risks, side effects, interactions, and other
important information. Common side effects include sleepiness,
dizziness, nausea and dry mouth are common side effects. Like most
medications, the liver helps remove the medication from the body.
Therefore, Cymbalta must be used carefully if there is any liver
disease. Like most pain medications, Cymbalta should not be used
with alcohol. There have been cases of liver problems with the
medication and it seems that the liver problems occur more
frequently in alcohol users. Cymbalta should not be used with
uncontrolled narrow-angle glaucoma. It should not be used with
MAO inhibitors. As with all antidepressants and other neuropathic
pain medications, there is a potential worsening of depression when
the medication is first started. All medications in this class may
worsen depression when first started, possibly resulting in suicide.
This is rare, but all patients should be aware of the risk and should let
the prescribing provider know immediately of any worsening of
depression.
Common doses: The FDA-approved doses begin at 20-30mg per day
and increase to 60mg per day. Many pain patients use 90mg to 120mg
per day. Those doses, although helpful, were not evaluated by the
FDA. Most patients start with 30mg per day. Some patients start with 20mg per day.
Time to effect: The time to effect depends on the use or uses for the medication. Neuropathic pain
may improve in a few weeks, but depression may improve in a few months.
Financial: Dr. Anderson has never received payment in exchange for prescribing a medication. Dr.
Anderson has no financial relationship with the company that manufactures duloxetine.
Insurance coverage: Many medications, especially in painful conditions, are off-label as discussed
above. Insurance companies do not need to cover medications used off label but typically do provide
coverage for most medications that have good scientific evidence. There is no guarantee that any
medication will be covered. However, this medication has quite a bit of scientific evidence and most
insurance companies do provide coverage.
Clinical and Scientific evidence: Some scientific evidence supportive of the use of the medication is
listed in this section. Of course, scientific information changes rapidly and the information listed may
become outdated or incorrect overnight. Duloxetine is a serotonin and norepinephrine reuptake
inhibitor that reduces the body’s destruction of these two natural neurotransmitters. These two
neurotransmitters are involved with pain perception. It is FDA approved for fibromyalgia, diabetic
neuropathy, a certain type of back pain, and depression. SSNRI medications are considered first-line
treatments for fibromyalgia-like neuropathic pain syndromes. The literature suggests that duloxetine
may have benefit in other types of chronic pain as well, especially if depression is present along with the
pain.
References:
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2.
3.
4.
5.
Buckhardt CS, Goldenberg D, Crofford L, Gerwin R, Gowens S, Jackson K, Kugel P, McCarberg W, Rudin N, Schanberg L, Taylor
AG, Taylor J, Turk D. Guideline for the management of fibromyalgia syndrome pain in adults and children. Glenview (IL):
American Pain Society (APS); 2005. Also at National Guideline Clearinghouse as Guideline for the management of fibromyalgia
syndrome pain in adults and children.
Management of fibromyalgia syndrome in adults. National Guideline Clearinghouse, Dept of Health and Human Services.
Häuser W, Petzke F, Uçeyler N, Sommer C. Comparative efficacy and acceptability of amitriptyline, duloxetine and milnacipran
in fibromyalgia syndrome: a systematic review with meta-analysis. Rheumatology (Oxford). 2010 Nov 14.
Lee YC, Chen PP. A review of SSRIs and SNRIs in neuropathic pain. Expert Opin Pharmacother. 2010 Dec;11(17):2813-25. Epub
2010 Jul 19.
Kroenke K, Krebs EE, Bair MJ. Pharmacotherapy of chronic pain: a synthesis of recommendations from systematic reviews. Gen
Hosp Psychiatry. 2009 May-Jun;31(3):206-19. Epub 2009 Mar 4.