Cymbalta (duloxetine) is a serotonin-norepinephrine reuptake inhibitor or SNRI introduced to the pharmaceutical market by Eli Lilly in the early 2000s. Consumers and healthcare professionals were not fully informed about the frequency and severity of the withdrawal effects. Eli Lilly conducted multiple studies in which 44% of short-term users and 51% of long-term users experienced withdrawal effects.

Tapering Cymbalta can be tricky as it comes in 20mg, 30mg, and 60mg capsules that contain beads/pellets. There is no liquid form of Cymbalta available and it’s not possible to compound it into a liquid. For full prescribing information: http://pi.lilly.com/us/cymbalta-pi.pdf.

For the drug’s protection, each bead inside the gelatin capsule has a polymer barrier or enteric coating to protect the drug from stomach acid. Therefore if the pellets are dissolved in water, the active ingredient will be destroyed.

The pellets cannot be crushed – the drug would not make it into your system and will be destroyed as soon as it reaches your stomach acid. This will cause immediate withdrawal.

The bead counting method can only be done if you are prescribed brand-name Cymbalta or the generic capsules containing 100s of tiny beads.

Important: You should be using all the same brand whether it’s generic or brand-name as well as the same capsule dose. You cannot mix 40mg and 60mg capsules as the beads contain a different amount of the active ingredient. These 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.

Contents:

• The Gradual Taper
• Dividing Cymbalta into capsules
• Tapering Generic Cymbalta
• The Micro-Taper
• Switching/Bridging to Prozac

Any taper with a neurologically active drug should be done slowly, over the course of a couple of months at a minimum. With Cymbalta, slow and steady will win the race against withdrawal symptoms.

You will want to start by removing 10% of your original dose per month. This 10% will be calculated on your LAST dose (The amount of the reduction gets progressively smaller). You may need to increase or reduce the percentage depending on how you are tolerating the taper.

Example:

Let’s say the dose you’re on is 60mg a capsule with the average beads count being 200 (this is an estimate please count the capsules yourself).

The taper dosage will be as follows:

• Month 1: 180 beads
• Month 2: 162 beads
• Month 3: 142 beads
• Month 4: 128 beads
• …

Until you hit the minimum number of beads.

Put unused beads into a clean, dry, and sealed prescription bottle marked with the dosage of the original capsule and expiration date. You may need these later. WARNING: Do NOT mix beads of different dosages in the same container.

NOTE: When taking your loose beads, they can be funneled into gelatin capsules for easy swallowing. Swallowing the beads themselves has a possibility of causing throat irritation.

Note: some people report success with dividing capsules into smaller amounts.

The technique:

1. Purchase empty gelatin (or vegetarian) capsules on Amazon or a health food store. Get the largest size you can find, normally 000 or 00 work best as they will be easier to handle. Please see the image below for sizing (for alternatives to gelatin capsules please see step 8):
   
2. Open all the gelatin capsules you intend to use
3. Carefully open your Cymbalta capsule by pulling both ends and twisting. The capsule should split in the middle.
4. Pour the contents of the capsule (little white beads) into a creased black or dark piece of paper for easy visibility when counting.
5. Use a knife or other thin, straight object and divide the beads into two, three, or four groups by eye. If you are sensitive, you may want to count beads or use a digital scale to measure the dosage more precisely.
6. With an empty gelatin capsule, carefully scoop up the first pile of beads and close the capsule. Repeat with all the piles of beads.
7. Put the capsules of the reduced dose into a clean medicine bottle marked with the dose of Cymbalta.
8. NOTE: If you prefer to not use gelatin capsules, you can put the beads into apple juice or apple sauce after following the steps above. It has been scientifically demonstrated that the Cymbalta pellets survive being put into apple juice or applesauce but NOT 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.”

The generic form of Cymbalta can come in capsules with beads like the brand-name, or 4 to 12 “mini-tablets”. From Lupin Pharmaceuticals.

“Duloxetine is available as delayed-release capsules:

• 20 mg: Size ’4′ capsules with a 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 the 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….”

These “mini-tablets” should NOT be split or dissolved to make liquid, much like the brand-name. These are suggestions for gradual tapering:

If you’re taking…

• 20mg, 30mg, or 40mg (two 20mg capsules) daily: switch to brand-name Cymbalta or generic duloxetine containing beads and utilize the bead counting method above.
• 50mg (20mg + 30mg) daily: reduce the dose by one “mini-tablet” from the 30mg capsule (5mg, or 10%) for a month or longer (everyone reacts differently), then switch to brand-name Cymbalta or generic capsules containing beads. Continue the taper with the bead counting method above.
• 60mg (one capsule) daily: reduce by one “mini-tablet” (5mg, or 10%) per month or longer (everyone reacts differently) until you are down to 50mg daily. Switch to brand-name Cymbalta or generic capsules containing beads. Continue the taper with the bead counting method above.
• 60mg or more (up to the maximum dose of 80mg) daily: start by reducing by one mini-tablets (5 mg or 10%) per month or longer (everyone reacts differently) until you are at 45mg per day. Switch to brand-name Cymbalta or generic capsules containing beads. Continue the taper with the bead counting method above.
• NOTE: You are able to combine generic beads or mini-tablets with brand-name Cymbalta. This would cost less than using brand-name Cymbalta for the entirety of your taper allowing the prescription of 60mg brand-name Cymbalta capsules to last longer. You will be taking part in brand-name Cymbalta beads and the rest in the generic “mini-tablets”.

Example: If you’re 30mg generic Cymbalta/duloxetine capsules contain 6 mini-tablets, each tablet contains around 5mg of duloxetine. You will want to reduce 10% from 30mg to 27mg. You will be able to take 5 mini-tablets (25mg) and add 2 mg in Cymbalta brand-name beads. If the brand-name Cymbalta capsule contains 200 beads, that would equal out to roughly 0.3mg of duloxetine per-bead. You would take 7 beads (2.1mg) along with the 5 mini-tablets that would equal out to a daily dose of 27.1mg. When you reach 5 mini-tablets (25mg) daily, drop it to 4 mini-tablets and start working in the Cymbalta brand-name by 10% each month or longer (depending on the individual).

WARNING: Always make sure you count the total number of beads contained in your capsules, only use this information as an example.

The smallest possible dose of brand-name Cymbalta is one bead. Many people have stated online that they have had more success tapering Cymbalta one bead at a time. This is what we call a micro-taper and it seems to be a more tolerated method when tapering this drug. With this taper, you can try reducing the dose more frequently. For example, removing one bead from the gelatin capsule a week to test the waters at first and increase if your nervous system allows.

Steps to micro-taper:

• Decide on the number of beads you will remove. It is highly suggested to start with removing one bead.
• Reduce a new capsule by one bead. Take this new dose for a week.
• After the first week, if you feel no withdrawal symptoms, you may reduce the micro amount more often, such as every 4-5 days
  Note: you may want to “hold” at a certain dose after a couple of months to allow your nervous system to rest and adjust to the decrease of Cymbalta in your body.
• This may work for a while, depending on your sensitivity you may start feeling withdrawal symptoms. This is when you should integrate the “hold” and stay at the same dose for a couple of weeks and integrate more of these holds as the taper progresses.
• Keep a journal of any symptoms and/or changes in mood. This allows you to see any patterns and withdrawal symptoms that might unfold.
• As with any tapering schedule, it is vital to recognize withdrawal symptoms as soon as possible and slow the taper as soon as they appear.

Switching to Prozac or “bridging” is another well-known method when tapering off an SNRI and has been known to be used with tapering Effexor.

Many doctors suggest at a “normal” dose of Cymbalta (30-40mg) they switch to 10mg Prozac with a week overlap. Meaning, you will take both medications for a week and then drop the Cymbalta on day 8 and continue taking Prozac. Prozac is not withdrawal-free, although, given Prozac’s long half-life, tapering should be quite a bit easier than counting Cymbalta’s beads. Prozac can also be obtained in liquid form.

As Cymbalta is an SNRI and Prozac (Fluoxetine) is an SSRI, taking both together can run you the risk of serotonin syndrome, since their impact on serotonin can be additive. This will make it tricky to switch over from Cymbalta to Prozac.

Guides such as this one recommend tapering off the SNRI initially, then incorporating the fluoxetine – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919171/.

Another helpful guide is based on the Maudsley (UK) recommendations and advises a careful cross-taper with low-dose fluoxetine – https://ww2.health.wa.gov.au/~/media/Files/Corporate/general documents/WATAG/WAPDC/Antidepressant-switching-strategies-March-2013.pdf.

Here’s a Canadian doctors’ report also suggesting a cross-taper that appears like it has the same sources – http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/depress_appd.pdf.

The article above recommends this useful web site for changing psychiatric drugs https://www.switchrx.com. The site recommends a swap of 30mg duloxetine to fluoxetine by cross-tapering.

Note: that the maximum dose of Prozac while taking any amount of Cymbalta is 10mg.

Sources:

1. http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm103473.pdf
2. http://pi.lilly.com/us/cymbalta-pi.pdf
3. http://www.ncbi.nlm.nih.gov/pubmed/18691989
4. http://medlibrary.org/lib/rx/meds/duloxetine-3/
5. http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/depress_appd.pdf
6. https://ww2.health.wa.gov.au/~/media/Files/Corporate/general documents/WATAG/WAPDC/Antidepressant-switching-strategies-March-2013.pdf