Cymbalta comes in 20 mg, 30 mg, and 60 mg capsules. Full prescribing information: http://pi.lilly.com/us/cymbalta-pi.pdf
Cymbalta is tricky to taper. It does not come in liquid form and cannot be compounded into a liquid. To protect the drug, each bead inside the gelatin capsule has an enteric coating to protect the drug from stomach acid, which would destroy the drug. (It is absorbed further down in the digestive tract.) The pellets cannot be dissolved in any liquid without destroying the active ingredient.
You cannot crush the pellets (see http://survivinganti...ndpost__p__3021 ) or dissolve them in a solution -- the drug would never get into your system, it would be destroyed in your stomach and you would have immediate cold-turkey withdrawal.
Of course, the range of dosages from the manufacturer is inadequate for very gradual tapering.
Like all psychiatric drugs, do not skip doses or alternate doses to taper Cymbalta. Its half-life is very short, about 12 hours. It is metabolized via the liver enzymes P450 1A2 (substrate, inhibitor) and 2D6 (inhibitor).
See Doctor is shocked at severe Cymbalta withdrawal symptoms and testimony by Dr. Joseph Glenmullen regarding Cymbalta withdrawal syndrome: http://www.baumhedlu...taClassCert.pdf (PDF)
Reduce by 10% per month to start
As with any neurologically active drug, a conservative taper is the safest way to go off Cymbalta. Some people find they can go faster and some people find they have to go slower -- they can only tolerate decreases of a fraction of a milligram at a time.
A conservative taper for Cymbalta, like other psychiatric drugs is: Reduce by 10% per month, calculated on the last dosage. (The amount of the reduction gets progressively smaller.)
See Why taper by 10% of my dosage?
Cymbalta CANNOT be compounded into a liquid or dissolved in a liquid
The pellets in the capsule cannot be dissolved in a liquid; this would destroy the active ingredient.
High-dosage Cymbalta: Using different dosages to decrease to 40mg
If you are taking as much as 120mg Cymbalta, see this topic for an example of how to taper to 40mg using existing capsule dosages and a few compounded prescriptions: http://survivinganti...balta/?p=129252
To taper from a dosage of 40mg, you're going to have to either open up 20mg capsules and count beads, or get custom compounded dosages.
The bead-counting method
Like Effexor XR, some people have tapered by opening the Cymbalta capsule and taking out the beads to gradually reduce the dosage. (See http://survivinganti...ndpost__p__2985 for the technique.)
You can do this if you have brand-name Cymbalta or generic capsules containing hundreds of tiny beads rather than 4-12 "mini-tablets" (see below).
The number of tiny beads in each Cymbalta capsule will vary within a given dosage, across dosages, and from different manufacturers. The capsules are filled by weight. To find an average number of beads per capsule, you will have to carefully count the beads in several capsules. Then you can estimate how many beads amount to 10% of the dosage and manage your taper accordingly by keeping notes on paper showing the number of beads removed and equivalent Cymbalta dosage.
Take out 10% of the beads at each step of the taper. Put unused beads into a clean, dry, capped prescription bottle marked with the dosage of the original capsule and expiration date. You might want to use them later. Do NOT mix beads from capsules of different dosages, such as 30mg and 60mg.
NOTE When you are taking loose beads, put them in an empty capsule to swallow them. Gelatin capsules and vegetarian capsules are available at health food store. The FDA reports here http://www.fda.gov/d...s/ucm103473.pdf there have been some instances of the beads causing throat irritation when swallowed without a capsule.
Dividing Cymbalta beads into empty gelatin capsules
To make counting of the beads easier, this technique may work with Cymbalta, see details at
Opening capsules and weighing beads
Eventually, as you remove more and more beads, it may become too confusing and time-consuming to count out them. You may wish to weigh them instead, see Using a digital scale to measure doses and Counting beads in a capsule versus weighing.
Dividing Cymbalta beads into apple juice or applesauce
Follow the instructions above for dividing the beads in a capsule and put your reduced dose apple juice or applesauce.
It has been scientifically demonstrated that the Cymbalta pellets survive being put into apple juice or applesauce but NOT chocolate pudding:
Clin Ther. 2008 Jul;30(7):1300-8.
In vitro stability, potency, and dissolution of duloxetine enteric-coated pellets after exposure to applesauce, apple juice, and chocolate pudding.
Results from this study found that the enteric coating of duloxetine pellets mixed with applesauce or apple juice was not negatively affected. The pellets were stable at room temperature for < or = 2 hours and should quantitatively allow delivery of the full capsule dose, provided that the pellet integrity is maintained (ie, not crushed, chewed, or otherwise broken). Therefore, mixing duloxetine pellets with applesauce or apple juice appears to be an acceptable vehicle for administration. However, exposing the pellets to chocolate pudding damaged the pellets' enteric coating, suggesting that pudding may be an unacceptable vehicle for administration.
Have a compounding pharmacy make up capsules of smaller dosages
For precise dosing, a compounding pharmacy will accurately weigh the doses and put the right number of beads into capsules for you. See http://survivinganti...ndpost__p__3001
Tapering generic Cymbalta (duloxetine) capsules containing "mini-tablets"
The generic forms of Cymbalta may contain beads, like brand-name Cymbalta, or 4 to 12 "mini-tablets" rather than beads. From Lupin Pharmaceuticals http://medlibrary.or...s/duloxetine-3/
Duloxetine is available as delayed-release capsules:
- 20 mg: Size ’4′ capsules with green cap and green body imprinted with “LU” on cap and “Q01″ in black ink on body, containing four white to off white mini tablets.
- 30 mg: Size ’3′ capsules with dark blue cap and white body imprinted with “LU” in white ink on cap and “Q02″ in black ink on body, containing six white to off white mini tablets.
- 60 mg: Size ’1′ capsules with dark blue cap and green body imprinted with “LU” in white ink on cap and “Q03″ in black ink on body, containing twelve white to off white mini tablets.
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....
The "mini-tablets" cannot be split or dissolved to make a liquid. Suggestions for gradual tapering:
- If you are taking 20mg, 30mg, or 40mg (two 20mg capsules) per day, switch to brand-name Cymbalta or a generic containing tiny beads rather than mini-tablets. Use the bead-counting method.
- If you are taking 50mg (20mg plus 30mg) per day, reduce by one mini-tablet from the 30mg capsule (5mg, or 10%) initially for a month, then switch to brand-name Cymbalta or a generic containing beads rather than mini-tablets. Use the bead-counting method.
- If you are taking one 60mg capsule per day, reduce by one mini-tablet (5mg) per month for 2 months until you are taking 50mg per day, then switch to brand-name Cymbalta or a generic containing beads rather than mini-tablets. Use the bead-counting method.
- If you are taking one 60mg capsule plus any of the other dosages per day (at least 80mg), reduce by one mini-tablet (5mg) from the 60mg capsule per month until you get to 45mg total daily dosage, then switch to brand-name Cymbalta or a generic containing beads rather than mini-tablets. Use the bead-counting method.
You can combine brand-name Cymbalta or generic beads with generic duloxetine mini-tablets to taper. (This would cost less than using brand-name Cymbalta for your entire taper. A prescription for 60mg brand-name Cymbalta capsules will go further.) You could take part of your dosage in brand-name Cymbalta beads and the rest of your daily dosage in generic mini-tablets. For example: If your 30mg generic duloxetine capsules contain 6 mini-tablets, each mini-tablet contains about 5mg duloxetine. Let's say you want to reduce 10% from 30mg to 27mg. You can take 5 mini-tablets (25mg) and add 2mg in beads to it. If a 60mg capsule of brand-name Cymbalta contains 200 beads, each bead contains about 0.3mg duloxetine; you would take 7 beads (2.1mg) to total a daily dose of 27.1mg. (BE SURE TO COUNT THE TOTAL NUMBER OF BEADS IN YOUR CAPSULES -- THEY CAN VARY FROM THIS EXAMPLE.) When you are down to 5 mini-tablets (25mg) per day, take 4 mini-tablets and the rest in beads to reduce another 10%, and so forth.
Reduce by micro-taper
The very smallest dose of brand-name Cymbalta is one bead. Some people find they can better tolerate a reduction of one bead at a time rather than a 10% decrease. You may be able to make reductions of one bead more frequently; try reducing by one bead a week for a while to see what your tolerance is. See http://survivinganti...or-5-decreases/
Do not reduce by one additional bead per day. This is too fast, you may develop withdrawal symptoms before you know what's happening.
Here is an example of a micro-taper from cymbaltawithdrawal.com http://www.cymbaltaw...ywhere/?p=50499
Switch to Prozac
Like its fellow SNRI Effexor, withdrawal from Cymbalta can be very difficult. Recently, I asked a knowledgeable doctor about how he switches patients to Prozac.
He said if the dosage of Cymbalta is "normal" -- 30mg-40mg -- he would switch to 10mg Prozac with a week of overlap. In other words, take both medications for a week and then drop the Cymbalta.
Later, taper off Prozac. He acknowledged Prozac can have its withdrawal problems, but given Prozac's long half-life, gradual tapering should be much easier than tapering off Cymbalta. And, at least Prozac comes in a liquid.
He confirmed that Cymbalta cannot be compounded because the pellets are enteric-coated to get the medication past the stomach acid, which destroys it. Other than the Prozac switch, he said counting pellets is the only way to taper.
See more about the Prozac switch http://survivinganti...ng-with-prozac/
NOTE Also see
Edited by Altostrata, 13 January 2016 - 10:04 AM.