3 replies to this topic

[fishinghat]

https://www.ncbi.nlm...pubmed/26022117
Cymbalta causing oral lesions.

http://neuro.psychia...opsych.12110265
Long-term duloxetine withdrawal syndrome and management in a depressed patient.
I will try to post this article. It has an interesting approach to handling Cymbalta withdrawal.
 
LETTERS
Long-Term Duloxetine
Withdrawal Syndrome and Management in a Depressed Patient

To the Editor: Serotonin and norepinephrine reuptake inhibitors (SNRIs),
such as venlafaxine,1 have been reported to be associated with withdrawal
syndromes. However, duloxetine related withdrawal syndrome is infrequently
mentioned. We want to report on a depressed patient who experienced a long-term duloxetine withdrawal syndrome and relief after gradual tapering procedures.

Case Report
“Miss B” was a depressed patient (depressed mood, anhedonia, anergia, binge eating, and suicide ideation) with partial remission of symptoms under duloxetine treatment (60 mg/day) for 1 year. However, she disliked the side effects of duloxetine (dizziness and
sedation). Therefore, duloxetine was abruptly switched to bupropion 150 mg/day. She started to feel more energy, but with intermittent severe nausea, unexplained fear, and di zziness after quitting duloxetine for 1 day. She still had withdrawal symptoms once-to-twice every week in the following 6 months after the switch. She took duloxetine 30 mg
only while feeling withdrawal discomfort in the next 3 months, and then took 15 mg (discarding half the dose of the 30-mg capsule) in the same way for the last month. She took 10 months to recover from longterm and intermittent duloxetine withdrawal syndrome. No residual withdrawal syndrome was noted since that time.

Discussion
Venlafaxine has a higher selectivity of serotonin receptor (30-fold versus norepinephrine) than duloxetine (10-fold).2 Perahia et al. reported that discontinuation-emergent adverse effects of duloxetine happened in around 44.3% of patients, versus 22.9% in a placebo group. They found that duloxetine withdrawal syndrome included dizziness, nausea,
headache, paresthesia, vomiting, irritability, and nightmares,3 which were similar to the symptoms of this patient. Duloxetine withdrawal syndrome is similar to that seen in
discontinuation of SNRIs and serotoninergic-related antidepressants. 3 A 10-fold selectivity for serotonin receptor of duloxetine might explain duloxetine withdrawal syndrome
in this patient and why it is not so frequent as with venlafaxine, which has 30-fold higher affinity.2 In a current literature search, duloxetine withdrawal syndrome is just mentioned in a few reports.3,4 Besides, a relatively longer half-life of duloxetine (12 hours)5 than the short half-life (5 hours) of venlafaxine,6 and possible genotype polymorphism of Asian people,6 might explain why the long-term and intermittent duloxetine withdrawal syndrome happened in this patient. A gradual tapering-down of duloxetine dose (not an abrupt switch) or occasional re-use of duloxetine while withdrawing might be helpful for this kind of long-term duloxetine withdrawal syndrome.

Yi-Cheng Hou, MSc
Chien-Han Lai, M.D.
Department of Nutrition,
Taipei Tzu Chi Hospital,
Buddhist Tzu Chi Medical
Foundation, New Taipei City,
Taiwan, ROC
Corresponding author:
Chien-Han Lai, M.D.
Department of Psychiatry,
Cheng Hsin General Hospital,
Taipei City, Taiwan, ROC
e-mail: stephenlai99@gmail.com

References
1. Agelink MW, Zitzelsberger A, Klieser E:
Withdrawal syndrome after discontinuation
of venlafaxine. Am J Psychiatry 1997;
154:1473–1474
2. Montgomery SA: Tolerability of serotonin
norepinephrine reuptake inhibitor
antidepressants. CNS Spectr 2008; 13
(Suppl 11):27–33
3. Perahia DG, Kajdasz DK, Desaiah D, et al:
Symptoms following abrupt discontinuation
of duloxetine treatment in patients
with major depressive disorder. J Affect
Disord 2005; 89:207–212
4. Abdy NA, Gerhart K: Duloxetine
withdrawal syndrome in a newborn. Clin
Pediatr (Phila) 2012; 52:976–977
5. Carter NJ, McCormack PL: Duloxetine:
a review of its use in the treatment of
generalized anxiety disorder. CNS Drugs
2009; 23:523–541
6. Baboolal NS: Venlafaxine withdrawal
syndrome: report of seven cases in Trinidad.
J Clin Psychopharmacol 2004; 24:229–231
E4 http://neuro.psychiatryonline.orgJ Neuropsychiatry Clin Neurosci 26:1, Winter 2014

https://www.ncbi.nlm...les/PMC4713700/
Effects of duloxetine on microRNA expression profile in frontal lobe and hippocampus in a mouse model of depression
Our data showed that miRNA expression profile in frontal lobe and hippocampus was affected by duloxetine in mice model of depression. The effect was especially pronounced in the hippocampus, suggesting that hippocampus might be the action site of duloxetine, which presumably worked by regulating the expression of miRNA levels.
(This study shows the direct effect of Cymbalta on miRNA (used in translating DNA code) in the hippocampus (one of the emotional centers in the brain). This could help expplain the extreme number of symptoms developed during withdrawal.

[gail]

Miss B case is real interesting here. Thanks for the article.

[Carleeta]

Thank you Fishinghat.......absolutely phenomenal article. 

[zivcha]

Thanks alot FH.