View source for Duloxetine

{{Short description|Antidepressant medication used also for the treatment of anxiety and chronic pain}}
{{Distinguish|Dapoxetine|Dulcolax (disambiguation){{!}}Dulcolax}}
{{Use dmy dates|date=August 2025}}
{{cs1 config|name-list-style=vanc|display-authors=6}}
{{Infobox drug
| Verifiedfields = changed
| verifiedrevid = 460765928
| image = Duloxetine.svg
| image_class = skin-invert-image
| alt = 
| image2 = Duloxetine-hydrochloride-from-xtal-3D-bs-17.png
| image_class2 = bg-transparent
| alt2 = <!--Clinical data-->
| pronounce = {{IPAc-en|d|uː|ˈ|l|ɑː|k|s|ə|ˌ|t|i|n}} <br />
{{respell|doo|LAHK|sə|teen}}
| tradename = Cymbalta, others<ref name="Drugs.com-Duloxetine-Generics"/>
| Drugs.com = {{drugs.com|monograph|duloxetine}}
| MedlinePlus = a604030
| DailyMedID = Duloxetine
| pregnancy_AU = B3
| routes_of_administration = [[Oral administration|By mouth]]
| class = [[Serotonin–norepinephrine reuptake inhibitor]] (SNRI)
| ATC_prefix = N06
| ATC_suffix = AX21
| legal_AU = S4
| legal_BR = C1
| legal_BR_comment = <ref name="Diário Oficial da União-2023">{{cite web |author-link=Brazilian Health Regulatory Agency |date=31 March 2023 |title=RDC Nº 784 - Listas de Substâncias Entorpecentes, Psicotrópicas, Precursoras e Outras sob Controle Especial |trans-title=Collegiate Board Resolution No. 784 - Lists of Narcotic, Psychotropic, Precursor, and Other Substances under Special Control|url=https://www.in.gov.br/en/web/dou/-/resolucao-rdc-n-784-de-31-de-marco-de-2023-474904992 |url-status=live |archive-url=https://web.archive.org/web/20230803143925/https://www.in.gov.br/en/web/dou/-/resolucao-rdc-n-784-de-31-de-marco-de-2023-474904992 |archive-date=3 August 2023 |access-date=16 August 2023 |publisher=[[Diário Oficial da União]] |language=pt-BR |publication-date=4 April 2023}}</ref>
| legal_CA = Rx-only
| legal_UK = POM
| legal_US = Rx-only
| legal_US_comment = <ref name="Cymbalta FDA label" />
| legal_EU = Rx-only
| legal_EU_comment = <ref name="Cymbalta EPAR" /><ref name="Cymbalta PI">{{cite web | title=Cymbalta PI | website=Union Register of medicinal products | date=22 December 2004 | url=https://ec.europa.eu/health/documents/community-register/html/h296.htm | access-date=19 December 2024 | archive-date=19 December 2024 | archive-url=https://web.archive.org/web/20241219203448/https://ec.europa.eu/health/documents/community-register/html/h296.htm | url-status=live }}</ref><ref name="Yentreve EPAR" /><ref name="Yentreve PI">{{cite web | title=Yentreve PI | website=Union Register of medicinal products | date=13 August 2004 | url=https://ec.europa.eu/health/documents/community-register/html/h280.htm | access-date=19 December 2024 | archive-date=19 December 2024 | archive-url=https://web.archive.org/web/20241219160658/https://ec.europa.eu/health/documents/community-register/html/h280.htm | url-status=live }}</ref>

<!--Pharmacokinetic data-->| bioavailability = ~ 50% (32% to 80%)<ref name="pmid21366359"/>
| protein_bound = ~ 95%
| metabolism = [[Liver]], two P450 isozymes, [[CYP2D6]] and [[CYP1A2]]
| elimination_half-life = {{val|10|-|12|u=hours}}<ref name="pmid21366359"/><ref name="Cymbalta FDA label" />
| excretion = 70% in urine, 20% in feces

<!--Identifiers-->| index2_label = as HCl
| CAS_number_Ref = {{cascite|correct|CAS}}
| CAS_number = 116539-59-4
| CAS_number2_Ref = {{cascite|correct|CAS}}
| CAS_number2 = 136434-34-9
| PubChem = 60835
| IUPHAR_ligand = 202
| DrugBank_Ref = {{drugbankcite|correct|drugbank}}
| DrugBank = DB00476
| ChemSpiderID_Ref = {{chemspidercite|correct|chemspider}}
| ChemSpiderID = 54822
| UNII_Ref = {{fdacite|correct|FDA}}
| UNII = O5TNM5N07U
| UNII2_Ref = {{fdacite|correct|FDA}}
| UNII2 = 9044SC542W
| KEGG_Ref = {{keggcite|correct|kegg}}
| KEGG = D07880
| KEGG2_Ref = {{keggcite|correct|kegg}}
| KEGG2 = D01179
| ChEBI_Ref = {{ebicite|correct|EBI}}
| ChEBI = 36795
| ChEBI2_Ref = {{ebicite|correct|EBI}}
| ChEBI2 = 31526
| ChEMBL_Ref = {{ebicite|correct|EBI}}
| ChEMBL = 1175
| ChEMBL2_Ref = {{ebicite|correct|EBI}}
| ChEMBL2 = 1200328
| PDB_ligand = 29E

<!--Chemical data-->| IUPAC_name = (+)-(''S'')-''N''-Methyl-3-(naphthalen-1-yloxy)-3-(thiophen-2-yl)propan-1-amine
| C = 18
| H = 19
| N = 1
| O = 1
| S = 1
| smiles = CNCC[C@@H](C1=CC=CS1)OC2=CC=CC3=CC=CC=C32
| StdInChI_Ref = {{stdinchicite|correct|chemspider}}
| StdInChI = 1S/C18H19NOS/c1-19-12-11-17(18-10-5-13-21-18)20-16-9-4-7-14-6-2-3-8-15(14)16/h2-10,13,17,19H,11-12H2,1H3/t17-/m0/s1
| StdInChIKey_Ref = {{stdinchicite|correct|chemspider}}
| StdInChIKey = ZEUITGRIYCTCEM-KRWDZBQOSA-N
}}

<!-- Definition and medical uses -->
'''Duloxetine''', sold under the brand name '''Cymbalta''' among others,<ref name="Drugs.com-Duloxetine-Generics">{{cite web |title=Duloxetine |url=https://www.drugs.com/international/duloxetine.html |website=Drugs.com |access-date=24 December 2018 |archive-date=29 September 2018 |archive-url=https://web.archive.org/web/20180929233319/https://www.drugs.com/international/duloxetine.html |url-status=live }}</ref> is a medication used to treat [[major depressive disorder]], [[generalized anxiety disorder]], [[obsessive–compulsive disorder]], [[fibromyalgia]], [[neuropathic pain]], [[central sensitization]], and other types of chronic pain.<ref name="AHFS2018">{{cite web | title = Duloxetine | work = Monograph | url = https://www.drugs.com/monograph/duloxetine.html | publisher = The American Society of Health-System Pharmacists | access-date = 24 December 2018 | archive-date = 26 November 2018 | archive-url = https://web.archive.org/web/20181126162525/https://www.drugs.com/monograph/duloxetine.html | url-status = live }}</ref><ref name="International OCD Foundation-2024">{{Cite web |title=Medications for OCD |url=https://iocdf.org/about-ocd/treatment/meds/ |access-date=25 February 2024 |website=International OCD Foundation |language=en-US |archive-date=27 January 2024 |archive-url=https://web.archive.org/web/20240127115230/https://iocdf.org/about-ocd/treatment/meds/ |url-status=live }}</ref> It is taken [[by mouth]].<ref name=AHFS2018/>

<!-- Type and mechanism -->
Duloxetine is a [[serotonin–norepinephrine reuptake inhibitor]] (SNRI).<ref name="Pharmaceutical Press-2018">{{cite book|title=British national formulary: BNF 76|date=2018|publisher=Pharmaceutical Press|isbn=978-0-85711-338-2|pages=364–365|edition=76}}</ref> The precise mechanism for its [[antidepressant]] and [[anxiolytic]] effects is not known.<ref name=AHFS2018/>

<!-- Side effects -->
Common side effects include [[Xerostomia|dry mouth]], [[nausea]], [[constipation]], loss of appetite, [[Somnolence|drowsiness]], sexual problems, and [[Hyperhidrosis|increased sweating]].<ref name=":0">{{Cite web |title=Duloxetine: Uses, Side Effects, Dosage, Warnings |url=https://www.drugs.com/duloxetine.html |access-date=30 May 2025 |website=Drugs.com |language=en}}</ref> Severe side effects include an increased risk of [[suicide]], [[serotonin syndrome]], [[mania]], and [[liver problems]].<ref name=AHFS2018/> [[Antidepressant withdrawal syndrome]] may occur if stopped.<ref name=AHFS2018/> Use during the later part of [[pregnancy]] may increase the risk of bleeding or cause complications for the fetus.<ref name=":0" />

<!-- Society and culture -->
Duloxetine was approved for medical use in the United States<ref name=AHFS2018/><ref name="FDA Cymbalta Approval Package" /> and the European Union in 2004.<ref name="Cymbalta EPAR">{{cite web | title=Cymbalta EPAR | website=[[European Medicines Agency]] (EMA) | date=17 September 2018 | url=https://www.ema.europa.eu/en/medicines/human/EPAR/cymbalta | access-date=30 September 2020 | archive-date=20 October 2020 | archive-url=https://web.archive.org/web/20201020121232/https://www.ema.europa.eu/en/medicines/human/EPAR/cymbalta | url-status=live }}</ref><ref name="Yentreve EPAR" /> It is available as a [[generic medication]].<ref name="Pharmaceutical Press-2018"/> In 2023, it was the 31st most commonly prescribed medication in the United States, with more than 18{{nbsp}}million prescriptions.<ref name="Top300Drugs">{{cite web | title=Top 300 of 2023 | url=https://clincalc.com/DrugStats/Top300Drugs.aspx | website=ClinCalc | access-date=12 August 2025 | archive-date=12 August 2025 | archive-url=https://web.archive.org/web/20250812130026/https://clincalc.com/DrugStats/Top300Drugs.aspx | url-status=live }}</ref><ref>{{cite web | title = Duloxetine Drug Usage Statistics, United States, 2014 - 2023 | website = ClinCalc | url = https://clincalc.com/DrugStats/Drugs/Duloxetine | access-date = 13 August 2025 }}</ref>

==Medical uses==
[[File:2024-03-16 Duloxetine（SNRI）セロトニン・ノルアドレナリン,サインバルタ,デュロキセチン,再取り込み阻害薬DSCF7713.jpg|thumb|260px|left|Duloxetine 20mg sold under the name Cymbalta in Japan]]
The main uses of duloxetine are in [[major depressive disorder]], [[generalized anxiety disorder]], [[neuropathic pain]], chronic [[musculoskeletal pain]], and [[fibromyalgia]].<ref name="Cymbalta FDA label">{{cite web | title=Cymbalta- duloxetine hydrochloride capsule, delayed release | website=DailyMed | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2f7d4d67-10c1-4bf4-a7f2-c185fbad64ba | access-date=29 September 2020 | archive-date=13 August 2020 | archive-url=https://web.archive.org/web/20200813211636/https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=2f7d4d67-10c1-4bf4-a7f2-c185fbad64ba | url-status=live }}</ref><ref name=AHFS2018/><ref name="nice-2010">{{NICE|96|Neuropathic pain – pharmacological management|2010}}</ref><ref name="pmid21482920">{{cite journal | vauthors = Bril V, England J, Franklin GM, Backonja M, Cohen J, Del Toro D, Feldman E, Iverson DJ, Perkins B, Russell JW, Zochodne D | title = Evidence-based guideline: Treatment of painful diabetic neuropathy: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation | journal = Neurology | volume = 76 | issue = 20 | pages = 1758–65 | date = May 2011 | pmid = 21482920 | pmc = 3100130 | doi = 10.1212/WNL.0b013e3182166ebe }}</ref>

Duloxetine is recommended as a first-line agent for the treatment of chemotherapy-induced neuropathy by the [[American Society of Clinical Oncology]],<ref name="pmid24733808">{{cite journal | vauthors = Hershman DL, Lacchetti C, Dworkin RH, Lavoie Smith EM, Bleeker J, Cavaletti G, Chauhan C, Gavin P, Lavino A, Lustberg MB, Paice J, Schneider B, Smith ML, Smith T, Terstriep S, Wagner-Johnston N, Bak K, Loprinzi CL | title = Prevention and management of chemotherapy-induced peripheral neuropathy in survivors of adult cancers: American Society of Clinical Oncology clinical practice guideline | journal = Journal of Clinical Oncology | volume = 32 | issue = 18 | pages = 1941–1967 | date = June 2014 | pmid = 24733808 | doi = 10.1200/JCO.2013.54.0914 | s2cid = 11183183 | doi-access = free }}</ref> as a first-line therapy for fibromyalgia in the presence of mood disorders by the German Interdisciplinary Association for Pain Therapy,<ref name="pmid22760463">{{cite journal | vauthors = Sommer C, Häuser W, Alten R, Petzke F, Späth M, Tölle T, Uçeyler N, Winkelmann A, Winter E, Bär KJ | title = [Drug therapy of fibromyalgia syndrome. Systematic review, meta-analysis and guideline] | language = de | journal = Schmerz | volume = 26 | issue = 3 | pages = 297–310 | date = June 2012 | pmid = 22760463 | doi = 10.1007/s00482-012-1172-2 | s2cid = 1348989 }}</ref> as a Grade B recommendation for the treatment of diabetic neuropathy by the American Association for Neurology<ref name="pmid21484835">{{cite journal | vauthors = Bril V, England JD, Franklin GM, Backonja M, Cohen JA, Del Toro DR, Feldman EL, Iverson DJ, Perkins B, Russell JW, Zochodne DW | title = Evidence-based guideline: treatment of painful diabetic neuropathy--report of the American Association of Neuromuscular and Electrodiagnostic Medicine, the American Academy of Neurology, and the American Academy of Physical Medicine & Rehabilitation | journal = Muscle & Nerve | volume = 43 | issue = 6 | pages = 910–7 | date = June 2011 | pmid = 21484835 | doi = 10.1002/mus.22092 | hdl = 2027.42/84412 | s2cid = 15020212 | hdl-access = free }}</ref> and as a level A recommendation in certain neuropathic states by the [[European Federation of Neurological Societies]].<ref name="pmid20402746">{{cite journal | vauthors = Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen TS, Nurmikko T | title = EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision | journal = European Journal of Neurology | volume = 17 | issue = 9 | pages = 1113–e88 | date = September 2010 | pmid = 20402746 | doi = 10.1111/j.1468-1331.2010.02999.x | s2cid = 14236933  | doi-access = free }}</ref>

===Painful diabetic peripheral neuropathy===
A 2014 [[Cochrane (organisation)|Cochrane]] review concluded that duloxetine is beneficial in the treatment of diabetic neuropathy and fibromyalgia but that more comparative studies with other medicines are needed.<ref name="pmid24385423">{{cite journal | vauthors = Lunn MP, Hughes RA, Wiffen PJ | title = Duloxetine for treating painful neuropathy, chronic pain or fibromyalgia | journal = The Cochrane Database of Systematic Reviews | volume = 1 | issue = 1 | article-number = CD007115 | date = January 2014 | pmid = 24385423 | doi = 10.1002/14651858.CD007115.pub3 | pmc = 10711341 }}</ref> The French medical journal ''[[Prescrire]]'' concluded that duloxetine is no better than other available agents and has a greater risk of side effects.<ref name="pmid25121155">{{cite journal | title = Towards better patient care: drugs to avoid in 2014 | journal = Prescrire International | volume = 23 | issue = 150 | pages = 161–5 | date = June 2014 | pmid = 25121155 | url = http://english.prescrire.org/en/81/168/49342/0/NewsDetails.aspx | access-date = 28 June 2014 | archive-date = 14 July 2014 | archive-url = https://web.archive.org/web/20140714192809/http://english.prescrire.org/en/81/168/49342/0/NewsDetails.aspx | url-status = live }}</ref> Whereas duloxetine has shown efficacy in treating painful diabetic peripheral neuropathy by blocking late Nav 1.7 sodium ion channels and increasing norepinephrine, serotonin, and dopamine in the [[central nervous system]] (CNS) and while improving mean NPRS scores and achieving a ≥50% pain response in more patients compared to placebo, it has been associated with potentially serious adverse reactions including hepatotoxicity, serotonin syndrome, severe skin reactions, increased risk of bleeding, increased blood pressure and sexual dysfunction.<ref name="pmid38505500">{{cite journal |vauthors=Mallick-Searle T, Adler JA |title=Update on Treating Painful Diabetic Peripheral Neuropathy: A Review of Current US Guidelines with a Focus on the Most Recently Approved Management Options |journal=J Pain Res |volume=17 |issue= |pages=1005–1028 |date=2024 |pmid=38505500 |pmc=10949339 |doi=10.2147/JPR.S442595|doi-access=free }}</ref>

===Major depressive disorder===
Duloxetine was approved for the treatment of major depression in 2004.<ref name="Cymbalta FDA label" /><ref name="Cymbalta EPAR" />  A 2025 systematic review assessing the benefits and harms of duloxetine in depression found an average change of 1.81 points on the 53-point [[Hamilton Depression Rating Scale]] and a small beneficial effect on quality of life, effects below the review's predefined minimal clinically important differences. There was insufficient data to assess suicide or other serious adverse events. All results assessed were at a high risk of bias.<ref name="pmid39920066">{{cite journal |vauthors=Siddiqui F, Petersen JJ, Juul S, Kamp CB, Barbateskovic M, Moncrieff J, Horowitz MA, Maagaard M, Katakam KK, Gluud C, Jakobsen JC |title=Beneficial and harmful effects of duloxetine versus placebo, 'active placebo' or no intervention for adults with major depressive disorder: a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials |journal=[[BMJ Open]] |volume=15 |issue=2 |article-number=e082853 |date=February 2025 |pmid=39920066 |doi=10.1136/bmjopen-2023-082853 |doi-access=free|pmc=12056638 }}</ref> A 2012 Cochrane Review did not find greater efficacy of duloxetine compared to SSRIs and newer antidepressants. Additionally, the review found evidence that duloxetine has increased side effects and reduced tolerability compared to other antidepressants. It thus did not recommend duloxetine as a first-line treatment for major depressive disorder, given the (then) high cost of duloxetine compared to inexpensive off-patent antidepressants and lack of increased efficacy.<ref name="pmid23076926">{{cite journal | vauthors = Cipriani A, Koesters M, Furukawa TA, Nosè M, Purgato M, Omori IM, Trespidi C, Barbui C | title = Duloxetine versus other anti-depressive agents for depression | journal = The Cochrane Database of Systematic Reviews | volume = 2012 | article-number = CD006533 | date = October 2012 | issue = 10 | pmid = 23076926 | pmc = 4169791 | doi = 10.1002/14651858.cd006533.pub2 }}</ref> Duloxetine appears less tolerable than some other antidepressants.<ref name="pmid29477251">{{cite journal | vauthors = Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, Leucht S, Ruhe HG, Turner EH, Higgins JP, Egger M, Takeshima N, Hayasaka Y, Imai H, Shinohara K, Tajika A, Ioannidis JP, Geddes JR | title = Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis | journal = Lancet | volume = 391 | issue = 10128 | pages = 1357–1366 | date = April 2018 | pmid = 29477251 | pmc = 5889788 | doi = 10.1016/S0140-6736(17)32802-7 }}</ref> Generic duloxetine became available in 2013.<ref name="Swiatek-2013">{{cite journal |title=Loss of Cymbalta patent a major blow for Eli Lilly |journal=Indianapolis Star |date=13 October 2013 |vauthors=Swiatek J |url=http://www.indystar.com/story/money/2013/12/10/loss-of-cymbalta-patent-a-major-blow-for-eli-lilly/3956997/ |access-date=27 February 2015 |archive-date=15 January 2014 |archive-url=https://web.archive.org/web/20140115091916/http://www.indystar.com/story/money/2013/12/10/loss-of-cymbalta-patent-a-major-blow-for-eli-lilly/3956997/ |url-status=live }}</ref>

===Generalized anxiety disorder===
Duloxetine is more effective than placebo in the treatment of [[generalized anxiety disorder]] (GAD).<ref name="pmid19480470">{{cite journal | vauthors = Carter NJ, McCormack PL | title = Duloxetine: a review of its use in the treatment of generalized anxiety disorder | journal = CNS Drugs | volume = 23 | issue = 6 | pages = 523–41 | year = 2009 | pmid = 19480470 | doi = 10.2165/00023210-200923060-00006 | s2cid = 30897102 }}</ref> A review from the ''[[Annals of Internal Medicine]]'' lists duloxetine among the first line drug treatments along with [[citalopram]], [[escitalopram]], [[sertraline]], [[paroxetine]], and [[venlafaxine]].<ref name="pmid24297210">{{cite journal | vauthors = Patel G, Fancher TL | title = Generalized anxiety disorder | journal = Annals of Internal Medicine | volume = 159 | issue = 11 | pages = ITC6–1, ITC6–2, ITC6–3, ITC6–4, ITC6–5, ITC6–6, ITC6–7, ITC6–8, ITC6–9, ITC6–10, ITC6–11; quiz ITC6–12 | date = December 2013 | pmid = 24297210 | doi = 10.7326/0003-4819-159-11-201312030-01006 | s2cid = 42889106 }}</ref>

===Neuropathic pain===
Duloxetine was approved for the pain associated with diabetic [[peripheral neuropathy]] (DPN) by the US FDA.<ref name="pmid37670573">{{cite journal |vauthors=Jang HN, Oh TJ |title=Pharmacological and Nonpharmacological Treatments for Painful Diabetic Peripheral Neuropathy |journal=Diabetes Metab J |volume=47 |issue=6 |pages=743–756 |date=November 2023 |pmid=37670573 |pmc=10695723 |doi=10.4093/dmj.2023.0018 |url=}}</ref><ref name="pmid15927394">{{cite journal | vauthors = Goldstein DJ, Lu Y, Detke MJ, Lee TC, Iyengar S | title = Duloxetine vs. placebo in patients with painful diabetic neuropathy | journal = Pain | volume = 116 | issue = 1–2 | pages = 109–18 | date = July 2005 | pmid = 15927394 | doi = 10.1016/j.pain.2005.03.029 | s2cid = 10291281 }}</ref><ref name="pmid16266355">{{cite journal | vauthors = Raskin J, Pritchett YL, Wang F, D'Souza DN, Waninger AL, Iyengar S, Wernicke JF | title = A double-blind, randomized multicenter trial comparing duloxetine with placebo in the management of diabetic peripheral neuropathic pain | journal = Pain Medicine | volume = 6 | issue = 5 | pages = 346–56 | year = 2005 | pmid = 16266355 | doi = 10.1111/j.1526-4637.2005.00061.x | doi-access = free }}</ref> The response is achieved in the first two weeks on the medication. Duloxetine slightly increased the fasting [[serum glucose]].<ref name="U.S. Food and Drug Administration (FDA)-Application-Number-21-733-2004">{{cite web | url = https://www.fda.gov/cder/foi/nda/2004/021733s000_Cymbalta_medr.pdf | title =Application number 21-733. Medical review(s).| access-date = 14 April 2009 | date = 3 September 2004| publisher = U.S. [[Food and Drug Administration]] (FDA)}}{{dead link|date=May 2025|bot=medic}}{{cbignore|bot=medic}} </ref>

The comparative efficacy of duloxetine and established pain-relief medications for diabetic peripheral neuropathy is unclear. A systematic review noted that [[tricyclic antidepressant]]s ([[imipramine]] and [[amitriptyline]]), traditional [[anticonvulsant]]s and [[opioid]]s have better efficacy than duloxetine. Duloxetine, tricyclic antidepressants, and anticonvulsants have similar tolerability while opioids cause more side effects.<ref name="pmid17562735">{{cite journal | vauthors = Wong MC, Chung JW, Wong TK | title = Effects of treatments for symptoms of painful diabetic neuropathy: systematic review | journal = BMJ | volume = 335 | issue = 7610 | page = 87 | date = July 2007 | pmid = 17562735 | pmc = 1914460 | doi = 10.1136/bmj.39213.565972.AE }}</ref> Another review in ''Prescrire International'' considered the moderate pain relief achieved with duloxetine to be clinically insignificant and the results of the clinical trials unconvincing. The reviewer saw no reason to prescribe duloxetine in practice.<ref name="pmid17121211">{{cite journal | title = Duloxetine: new indication. Depression and diabetic neuropathy: too many adverse effects | journal = Prescrire International | volume = 15 | issue = 85 | pages = 168–72 | date = October 2006 | pmid = 17121211 }}</ref> The comparative data collected by reviewers in ''[[BMC Neurology]]'' indicated that amitriptyline, other tricyclic antidepressants, and venlafaxine may be more effective. The authors noted that the evidence in favor of duloxetine is much more solid, however.<ref name="pmid18673529">{{cite journal | vauthors = Sultan A, Gaskell H, Derry S, Moore RA | title = Duloxetine for painful diabetic neuropathy and fibromyalgia pain: systematic review of randomised trials | journal = BMC Neurology | volume = 8 | article-number = 29 | date = August 2008 | pmid = 18673529 | pmc = 2529342 | doi = 10.1186/1471-2377-8-29 | doi-access = free }}</ref> A Cochrane review concluded that the evidence in support of duloxetine's efficacy in treating painful diabetic neuropathy was adequate and that further trials should focus on comparisons with other medications.<ref name="pmid24385423"/> A crossover trial found that duloxetine, [[pregabalin]], and amitriptyline offered similar levels of pain relief.<ref name="NIHR-Evidence"/> Duloxetine also has similar effect on pain relief in diabetic neuropathic pain as [[gabapentin]].<ref name="pmid39065707">{{cite journal |vauthors=Valenzuela-Fuenzalida JJ, López-Chaparro M, Barahona-Vásquez M, Campos-Valdes J, Cordero Gonzalez J, Nova-Baeza P, Orellana-Donoso M, Suazo-Santibañez A, Oyanedel-Amaro G, Gutiérrez Espinoza H |title=Effectiveness of Duloxetine versus Other Therapeutic Modalities in Patients with Diabetic Neuropathic Pain: A Systematic Review and Meta-Analysis |journal=Pharmaceuticals (Basel) |volume=17 |issue=7 |date=June 2024 |page=856 |pmid=39065707 |pmc=11280092 |doi=10.3390/ph17070856 |doi-access=free |url=}}</ref> Comparing at various doses, the strongest effect on relieving diabetic neuropatic pain is on {{val|120|u=mg/d}} dose.<ref name="pmid39065707"/> [[Combination therapy|Combination treatment]] of duloxetine and pregabalin offered additional pain relief for people whose pain is not adequately controlled with one medication and was safe.<ref name="NIHR-Evidence">{{cite journal |date=6 April 2023 |title=Combination therapy for painful diabetic neuropathy is safe and effective |url=https://evidence.nihr.ac.uk/alert/combination-therapy-for-painful-diabetic-neuropathy-is-safe-and-effective/ |journal=NIHR Evidence |language=en |doi=10.3310/nihrevidence_57470 |s2cid=258013544 |url-access=subscription |access-date=28 April 2023 |archive-date=28 April 2023 |archive-url=https://web.archive.org/web/20230428104720/https://evidence.nihr.ac.uk/alert/combination-therapy-for-painful-diabetic-neuropathy-is-safe-and-effective/ |url-status=live }}</ref><ref name="pmid36007534">{{cite journal | vauthors = Tesfaye S, Sloan G, Petrie J, White D, Bradburn M, Julious S, Rajbhandari S, Sharma S, Rayman G, Gouni R, Alam U, Cooper C, Loban A, Sutherland K, Glover R, Waterhouse S, Turton E, Horspool M, Gandhi R, Maguire D, Jude EB, Ahmed SH, Vas P, Hariman C, McDougall C, Devers M, Tsatlidis V, Johnson M, Rice AS, Bouhassira D, Bennett DL, Selvarajah D | title = Comparison of amitriptyline supplemented with pregabalin, pregabalin supplemented with amitriptyline, and duloxetine supplemented with pregabalin for the treatment of diabetic peripheral neuropathic pain (OPTION-DM): a multicentre, double-blind, randomised crossover trial | journal = Lancet | volume = 400 | issue = 10353 | pages = 680–690 | date = August 2022 | pmid = 36007534 | pmc = 9418415 | doi = 10.1016/s0140-6736(22)01472-6 }}</ref>

Duloxetine is also an option for the management of neuropathic pain in [[multiple sclerosis]] patients.<ref name="pmid38421578">{{cite journal |vauthors=Shkodina AD, Bardhan M, Chopra H, Anyagwa OE, Pinchuk VA, Hryn KV, Kryvchun AM, Boiko DI, Suresh V, Verma A, Delva MY |title=Pharmacological and Non-pharmacological Approaches for the Management of Neuropathic Pain in Multiple Sclerosis |journal=CNS Drugs |volume=38 |issue=3 |pages=205–224 |date=March 2024 |pmid=38421578 |doi=10.1007/s40263-024-01072-5 |url=}}</ref>

===Fibromyalgia and chronic pain===
A review of duloxetine found that it reduced pain and fatigue, and improved physical and mental performance compared to placebo.<ref name="pmid19137126">{{cite journal | vauthors = Acuna C | title = Duloxetine for the treatment of fibromyalgia | journal = Drugs of Today | volume = 44 | issue = 10 | pages = 725–34 | date = October 2008 | pmid = 19137126 | doi = 10.1358/dot.2008.44.10.1269675 }}</ref>

The US [[Food and Drug Administration]] (FDA) approved the drug for the treatment of fibromyalgia in June 2008.<ref name="FDA-Fibromyalgia-2008">{{cite press release |url=http://newsroom.lilly.com/ReleaseDetail.cfm?ReleaseID=316740 |title=FDA Approves Cymbalta for the Management of Fibromyalgia |date=16 June 2008 |work=Eli Lilly Co. |access-date=17 June 2008 |archive-date=30 July 2008 |archive-url=https://web.archive.org/web/20080730063358/http://newsroom.lilly.com/ReleaseDetail.cfm?ReleaseID=316740 }}</ref><ref name="FDA-Drug-Approval-Package-022148">{{cite web | title=Drug Approval Package: Cymbalta (duloxetine hydrochloride) NDA #022148 | website=U.S. [[Food and Drug Administration]] (FDA) | url=https://www.accessdata.fda.gov/drugsatfda_docs/nda/2008/022148_cymbalta_toc.cfm | access-date=30 September 2020 | archive-date=31 October 2020 | archive-url=https://web.archive.org/web/20201031223436/https://www.accessdata.fda.gov/drugsatfda_docs/nda/2008/022148_cymbalta_toc.cfm }}</ref>

It may be useful for [[chronic pain]] from [[osteoarthritis]].<ref name="pmid22314118">{{cite journal | vauthors = Citrome L, Weiss-Citrome A | title = A systematic review of duloxetine for osteoarthritic pain: what is the number needed to treat, number needed to harm, and likelihood to be helped or harmed? | journal = Postgraduate Medicine | volume = 124 | issue = 1 | pages = 83–93 | date = January 2012 | pmid = 22314118 | doi = 10.3810/pgm.2012.01.2521 | s2cid = 20599116 }}</ref><ref name="pmid24618328">{{cite journal | vauthors = Myers J, Wielage RC, Han B, Price K, Gahn J, Paget MA, Happich M | title = The efficacy of duloxetine, non-steroidal anti-inflammatory drugs, and opioids in osteoarthritis: a systematic literature review and meta-analysis | journal = BMC Musculoskeletal Disorders | volume = 15 | article-number = 76 | date = March 2014 | pmid = 24618328 | pmc = 4007556 | doi = 10.1186/1471-2474-15-76 | doi-access = free }}</ref>

In November 2010, the US [[Food and Drug Administration]] (FDA) approved duloxetine to treat chronic musculoskeletal pain, including discomfort from osteoarthritis and chronic lower back pain.<ref name="Food and Drug Administration-Press-Release-2010">{{cite press release |url = https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm232708.htm |title = FDA clears Cymbalta to treat chronic musculoskeletal pain |publisher = Food and Drug Administration |date = 4 November 2010 |website = U.S. [[Food and Drug Administration]] (FDA) |access-date = 19 August 2013 |archive-date = 7 August 2013 |archive-url = https://web.archive.org/web/20130807032223/http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm232708.htm }}</ref><ref name="FDA-Drug-Approval-Package-022516">{{cite web | title=Drug Approval Package: Cymbalta (duloxetine hydrochloride) NDA #022516 | website=U.S. [[Food and Drug Administration]] (FDA) | date=16 September 2011 | url=https://www.accessdata.fda.gov/drugsatfda_docs/nda/2010/022516_cymbalta_tocEDT.cfm | access-date=29 September 2020 | archive-date=5 April 2021 | archive-url=https://web.archive.org/web/20210405153136/https://www.accessdata.fda.gov/drugsatfda_docs/nda/2010/022516_cymbalta_tocEDT.cfm | url-status=live }}</ref>

===Stress urinary incontinence===
Duloxetine failed to receive US approval for [[stress incontinence|stress urinary incontinence]] amid concerns over liver toxicity and suicidal events; it was approved for this use in the [[United Kingdom|UK]], however, where it is recommended as an add-on medication in stress urinary incontinence instead of surgery.<ref name="NICE-urinary">{{NICE|40|Urinary incontinence|2006}}</ref>

The safety and utility of duloxetine in the treatment of incontinence have been evaluated in a series of meta-analyses and practice guidelines.
* A 2017 meta-analysis found that the harms are at least as great if not greater than the benefits.<ref name="pmid28246265">{{cite journal | vauthors = Maund E, Guski LS, Gøtzsche PC | title = Considering benefits and harms of duloxetine for treatment of stress urinary incontinence: a meta-analysis of clinical study reports | journal = CMAJ | volume = 189 | issue = 5 | pages = E194–E203 | date = February 2017 | pmid = 28246265 | pmc = 5289870 | doi = 10.1503/cmaj.151104 }}</ref>
* A 2013 [[meta-analysis]] concluded that duloxetine decreased incontinence episodes more than placebo with people about 56% more likely than placebo to experience a 50% decrease in episodes. Adverse effects were experienced by 83% of duloxetine-treated subjects and by 45% of placebo-treated subjects.<ref name="pmid23504618">{{cite journal | vauthors = Li J, Yang L, Pu C, Tang Y, Yun H, Han P | title = The role of duloxetine in stress urinary incontinence: a systematic review and meta-analysis | journal = International Urology and Nephrology | volume = 45 | issue = 3 | pages = 679–86 | date = June 2013 | pmid = 23504618 | doi = 10.1007/s11255-013-0410-6 | s2cid = 10788312 }}</ref>
* A 2012 review and practice guideline published by the [[European Association of Urology]] concluded that the clinical trial data provides Grade 1a evidence that duloxetine improves but does not cure urinary incontinence and that it causes a high rate of gastrointestinal side effects (mainly nausea and vomiting) leading to a high rate of treatment discontinuation.<ref name="uroweb-2014">{{cite web|url=http://www.uroweb.org/gls/pdf/20%20Urinary%20Incontinence_LR.pdf|title=www.uroweb.org|archive-url=https://web.archive.org/web/20140504105841/http://www.uroweb.org/gls/pdf/20%20Urinary%20Incontinence_LR.pdf|archive-date=4 May 2014}}</ref>
* The National Institute for Clinical and Health Excellence recommends (as of September 2013) that duloxetine not be routinely offered as first-line treatment, and that it only be offered as second-line therapy in women wishing to avoid therapy.  The guideline further states that women should be counseled regarding the drug's side effects.<ref name="Urinary incontinence Introduction CG171-2014">{{cite web|url=http://publications.nice.org.uk/urinary-incontinence-cg171|title=Urinary incontinence Introduction CG171|archive-url=https://web.archive.org/web/20140504105632/http://publications.nice.org.uk/urinary-incontinence-cg171|archive-date=4 May 2014}}</ref>

==Contraindications==
The following [[contraindication]]s are listed by the manufacturer:<ref name="Eli Lilly and Company-2010">{{cite web|url=http://www.cymbalta.com/learnaboutcymbalta/importantsafetyinformation.jsp|title=Eli Lilly and Company|access-date=15 May 2010|archive-date=13 April 2010|archive-url=https://web.archive.org/web/20100413180157/http://www.cymbalta.com/learnaboutcymbalta/importantsafetyinformation.jsp|url-status=live}}</ref>
* Hypersensitivity: duloxetine is contraindicated in patients with a known hypersensitivity to duloxetine or any of the inactive ingredients.
* [[Monoamine oxidase inhibitor]]s (MAOIs): concomitant use in patients taking MAOIs is contraindicated.
* Uncontrolled narrow-angle [[glaucoma]]: in [[clinical trials]], Cymbalta use was associated with an increased risk of [[mydriasis]] (dilation of the pupil); therefore, its use should be avoided in patients with uncontrolled narrow-angle [[glaucoma]], in which mydriasis can cause sudden worsening.
* [[Central nervous system]] (CNS) acting drugs: given the primary CNS effects of duloxetine, it should be used with caution when it is taken in combination with or substituted for other centrally acting drugs, including those with a similar mechanism of action.
* Duloxetine and [[thioridazine]] should not be co-administered.{{refn|group=note|name=first|Duloxetine moderately inhibits CYP2D6, decreasing the rate of metabolism and thereby increasing the concentration of thioridazine. This raises the patient's risk of lethal ventricular arrhythmias.<ref name="pmid17577103">{{cite journal | vauthors = Derby MA, Zhang L, Chappell JC, Gonzales CR, Callaghan JT, Leibowitz M, Ereshefsky L, Hoelscher D, Leese PT, Mitchell MI | title = The effects of supratherapeutic doses of duloxetine on blood pressure and pulse rate | journal = Journal of Cardiovascular Pharmacology | volume = 49 | issue = 6 | pages = 384–393 | date = June 2007 | pmid = 17577103 | doi = 10.1097/FJC.0b013e31804d1cce| s2cid = 2356196 | doi-access = free }}</ref>}}

In addition, the FDA has reported on life-threatening drug interactions that may be possible when co-administered with [[triptan]]s and other drugs acting on serotonin pathways leading to increased risk for [[serotonin syndrome]].<ref name="FDA-2013">{{cite web |url=https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124915.htm |title=Information for Healthcare Professionals: Duloxetine (marketed as Cymbalta) – Selective Serotonin Reuptake Inhibitors (SSRIs) or Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) and 5-Hydroxytryptamine Receptor Agonists (Triptans) |publisher=U.S. [[Food and Drug Administration]] (FDA) |date=14 August 2013 |access-date=18 September 2013 |archive-date=7 March 2013 |archive-url=https://web.archive.org/web/20130307052542/http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124915.htm }}</ref>

Duloxetine should also be avoided in hepatic impairment such as cirrhosis.<ref name="pmid37918778">{{cite journal |vauthors=Ma J, Björnsson ES, Chalasani N |title=The Safe Use of Analgesics in Patients with Cirrhosis: A Narrative Review |journal=Am J Med |volume=137 |issue=2 |pages=99–106 |date=February 2024 |pmid=37918778 |doi=10.1016/j.amjmed.2023.10.022 |s2cid=264888110 |url=}}</ref>

==Adverse effects==
[[Nausea]], [[somnolence]], [[insomnia]], and [[dizziness]] are the main [[side effects]], reported by about 10% to 20% of patients.<ref name="Cymbalta package insert-2004">Cymbalta package insert. Indianapolis, IN: Eli Lilly Pharmaceuticals; 2004, September.</ref>

In a trial for major depressive disorder (MDD), the most commonly reported treatment-emergent adverse events among duloxetine-treated patients were [[nausea]] (34.7%), [[dry mouth]] (22.7%), [[headache]] (20.0%) and [[dizziness]] (18.7%), and except for [[headache]], these were reported significantly more often than in the placebo group.<ref name="pmid16700869">{{cite journal | vauthors = Perahia DG, Kajdasz DK, Walker DJ, Raskin J, Tylee A | title = Duloxetine 60 mg once daily in the treatment of milder major depressive disorder | journal = International Journal of Clinical Practice | volume = 60 | issue = 5 | pages = 613–20 | date = May 2006 | pmid = 16700869 | pmc = 1473178 | doi = 10.1111/j.1368-5031.2006.00956.x }}</ref> In a long-term study of fibromyalgia patients receiving duloxetine, frequency and type of adverse effects was similar to that reported in the MDD trial above. Side effects tended to be mild-to-moderate, and tended to decrease in intensity over time.<ref name="pmid19454869">{{cite journal | vauthors = Chappell AS, Littlejohn G, Kajdasz DK, Scheinberg M, D'Souza DN, Moldofsky H | title = A 1-year safety and efficacy study of duloxetine in patients with fibromyalgia | journal = The Clinical Journal of Pain | volume = 25 | issue = 5 | pages = 365–75 | date = June 2009 | pmid = 19454869 | doi = 10.1097/ajp.0b013e31819be587 | s2cid = 12208795 }}</ref><ref name="Drugs.com-FDA-prescribing-information">{{cite news|url=https://www.drugs.com/pro/cymbalta.html|title=Cymbalta - FDA prescribing information, side effects and uses|work=Drugs.com|access-date=14 September 2018|archive-date=14 September 2018|archive-url=https://web.archive.org/web/20180914203656/https://www.drugs.com/pro/cymbalta.html|url-status=live}}</ref>

===Sexual dysfunction===
In four clinical trials of duloxetine for the treatment of MDD, [[sexual dysfunction]] occurred significantly more frequently in patients treated with duloxetine than those treated with placebo, and this difference occurred only in men.<ref name="pmid16964316">{{cite journal | vauthors = Nelson JC, Lu Pritchett Y, Martynov O, Yu JY, Mallinckrodt CH, Detke MJ | title = The safety and tolerability of duloxetine compared with paroxetine and placebo: a pooled analysis of 4 clinical trials | journal = Primary Care Companion to the Journal of Clinical Psychiatry | volume = 8 | issue = 4 | pages = 212–9 | date = 2006 | pmid = 16964316 | pmc = 1557468 | doi = 10.4088/pcc.v08n0404 }}</ref><ref name="Drugs.com-FDA-prescribing-information" /> Specifically, common side effects include difficulty becoming aroused, lack of interest in sex, and [[anorgasmia]] (trouble achieving orgasm). Loss of or decreased response to sexual stimuli and ejaculatory [[anhedonia]] are also reported.<ref name="pmid17627739">{{cite journal | vauthors = Clayton A, Kornstein S, Prakash A, Mallinckrodt C, Wohlreich M | title = Changes in sexual functioning associated with duloxetine, escitalopram, and placebo in the treatment of patients with major depressive disorder | journal = The Journal of Sexual Medicine | volume = 4 | issue = 4 Pt 1 | pages = 917–29 | date = July 2007 | pmid = 17627739 | doi = 10.1111/j.1743-6109.2007.00520.x }}</ref> Frequency of treatment-emergent sexual dysfunction were similar for duloxetine and SSRIs when compared in a 6-month observational study in depressed patients.<ref name="pmid22121997">{{cite journal | vauthors = Dueñas H, Brnabic AJ, Lee A, Montejo AL, Prakash S, Casimiro-Querubin ML, Khaled M, Dossenbach M, Raskin J | title = Treatment-emergent sexual dysfunction with SSRIs and duloxetine: effectiveness and functional outcomes over a 6-month observational period | journal = International Journal of Psychiatry in Clinical Practice | volume = 15 | issue = 4 | pages = 242–54 | date = November 2011 | pmid = 22121997 | doi = 10.3109/13651501.2011.590209 | s2cid = 23153099 }}</ref> Rates of sexual dysfunction in MDD patients treated with duloxetine versus [[escitalopram]] did not differ significantly at 4, 8, and 12 weeks of treatment, although the trend favored duloxetine (33.3% of duloxetine patients experienced sexual side effects compared to 43.6% of those receiving escitalopram and 25% of those receiving placebo).<ref name="pmid17627739"/>

===Increased sweating===
Duloxetine may also cause sweating more than usual ([[hyperhidrosis]]).<ref name="DuloxetineMayo-Clinic">{{cite web |url=https://www.mayoclinic.org/drugs-supplements/duloxetine-oral-route/side-effects/drg-20067247 |title=Duloxetine (Oral Route) Side Effects - Mayo Clinic |website=[[Mayo Clinic]] |access-date=1 October 2023 |archive-date=19 October 2023 |archive-url=https://web.archive.org/web/20231019032525/https://www.mayoclinic.org/drugs-supplements/duloxetine-oral-route/side-effects/drg-20067247 |url-status=live }}</ref><ref name="pmid25576334">{{cite journal |vauthors=Štuhec M |title=Excessive sweating induced by interaction between agomelatine and duloxetine hydrochloride: case report and review of the literature |journal=Wien Klin Wochenschr |volume=127 |issue=17–18 |pages=703–6 |date=September 2015 |pmid=25576334 |doi=10.1007/s00508-014-0688-0 |s2cid=184484229 |url=}}</ref>

The exact mechanism behind why duloxetine increases sweating is still not fully understood. However, a possible explanation is in duloxetine's action on the sympathetic nervous system. Sympathetic nerves control thermoregulation and sweating in humans; when increased levels of noradrenaline are present (as seen with SNRIs), this can stimulate sweat gland activity, leading to an increase in perspiration. Noradrenaline release may also cause increased serotonin availability that results from inhibiting reuptake. Such release enhances and further facilitates the activation of post-synaptic α-adrenoceptors by noradrenaline, which can stimulate sweat gland activity, leading to more significant amounts of copious liquid secretion mainly at higher duloxetine dosages above certain thresholds. The amount of sweating experienced may be influenced by the noradrenergic tone, which is determined by the interaction between noradrenergic and serotonergic neurons.<ref name="pmid19664885"/><ref>{{cite journal|url=https://opinvisindi.is/bitstream/handle/20.500.11815/4065/Journal_of_Sleep_Research_2022_Idiaquez_Hyperhidrosis_in_sleep_disorders_A_narrative_review_of_mechanisms_and.pdf|doi=10.1111/jsr.13660 |title=Hyperhidrosis in sleep disorders – A narrative review of mechanisms and clinical significance |date=2023 |journal=Journal of Sleep Research |volume=32 |issue=1 |article-number=e13660 |pmid=35706374 |hdl=20.500.11815/4065 | vauthors = Idiaquez J, Casar JC, Arnardottir ES, August E, Santin J, Iturriaga R }}</ref> Therefore, at higher serum doses or concentrations (above certain thresholds) resulting from therapeutic antidepressant treatment, patients may show more perspiration than at lower doses.<ref name="pmid19664885">{{cite journal |vauthors=Demling J, Beyer S, Kornhuber J |title=To sweat or not to sweat? A hypothesis on the effects of venlafaxine and SSRIs |journal=Med Hypotheses |volume=74 |issue=1 |pages=155–7 |date=January 2010 |pmid=19664885 |doi=10.1016/j.mehy.2009.07.011}}</ref>

===Discontinuation syndrome===
{{Further|SSRI discontinuation syndrome}}
During marketing of other [[Selective serotonin reuptake inhibitor|SSRIs]] and [[Serotonin–norepinephrine reuptake inhibitor|SNRIs]], there have been spontaneous reports of adverse events occurring upon discontinuation of these drugs, particularly when abrupt, including the following: [[Dysphoria|dysphoric mood]], irritability, agitation, dizziness, sensory disturbances (e.g., [[paresthesias]] such as [[brain zap]] electric shock sensations), anxiety, confusion, headache, lethargy, [[Labile affect|emotional lability]], [[insomnia]], [[hypomania]], [[tinnitus]], and seizures. {{source?|date=August 2025}} The [[Drug withdrawal|withdrawal]] syndrome from duloxetine resembles the [[SSRI discontinuation syndrome]].

When discontinuing treatment with duloxetine, the manufacturer recommends a gradual reduction in the dose, rather than abrupt cessation, 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.

In placebo-controlled clinical trials of up to nine weeks' duration of patients with MDD, a systematic evaluation of discontinuation symptoms in patients taking duloxetine following abrupt discontinuation found the following symptoms occurring at a rate greater than or equal to 2% and at a significantly higher rate in duloxetine-treated patients compared to those discontinuing from placebo: dizziness, nausea, headache, paresthesia, vomiting, irritability, and nightmare.<ref name="pmid16266753">{{cite journal | vauthors = Perahia DG, Kajdasz DK, Desaiah D, Haddad PM | title = Symptoms following abrupt discontinuation of duloxetine treatment in patients with major depressive disorder | journal = Journal of Affective Disorders | volume = 89 | issue = 1–3 | pages = 207–12 | date = December 2005 | pmid = 16266753 | doi = 10.1016/j.jad.2005.09.003 }}</ref>

In 2012 The [[Institute for Safe Medication Practices|Institute for Safe Medical Practices]] (ISMP) published a report: "Duloxetine and Serious Withdrawal Symptoms".{{cn|date=December 2024}} The report highlights early clinical studies which found "abrupt discontinuation showed that withdrawal effects occurred in 40-50% of patients, that 10% of those were severe and approximately half were not resolved when side effects monitoring had ended after one or two weeks". Withdrawal symptoms listed in 48 case reports (in the first quarter of 2012) included anger, crying, dizziness, and suicidal ideation. The report concluded there was insufficient information and a lack of clear warnings about the effects of discontinuing duloxetine and that in many cases withdrawal symptoms may be "severe, persistent, or both", adding "the prescribing information for physicians and pharmacists does not provide realistic schedules for tapering or a clear picture of the likely incidence of these reactions".

===Suicidality===
In the United States all antidepressants, including duloxetine carry a [[black box warning]] stating that antidepressants may increase the risk of suicide in persons younger than 25. This warning is based on statistical analyses conducted by two independent groups of FDA experts that found a 2-fold increase in the risk of suicidal ideation and behavior in children and adolescents, and a 1.5-fold increase in suicidality in the 18–24 age group.<ref name="Levenson">{{cite web| vauthors = Levenson M, Holland C| title = Antidepressants and Suicidality in Adults: Statistical Evaluation. (Presentation at Psychopharmacologic Drugs Advisory Committee; December 13, 2006)| website = [[Food and Drug Administration]]| access-date = 13 May 2007| url = https://www.fda.gov/ohrms/dockets/ac/06/slides/2006-4272s1-04-FDA.ppt| archive-date = 27 September 2007| archive-url = https://web.archive.org/web/20070927214932/https://www.fda.gov/ohrms/dockets/ac/06/slides/2006-4272s1-04-FDA.ppt}}</ref><ref name="Stone-2006">{{cite web | url = https://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-01-FDA.pdf | title = Clinical review: relationship between antidepressant drugs and suicidality in adults | access-date = 22 September 2007 | vauthors = Stone MB, Jones ML | date = 17 November 2006 | work = Overview for December 13 Meeting of Psychopharmacologic Drugs Advisory Committee (PDAC) | publisher = U.S. [[Food and Drug Administration]] (FDA) | pages = 11–74 | archive-date = 16 March 2007 | archive-url = https://web.archive.org/web/20070316092329/https://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-01-FDA.pdf }}</ref><ref name="Levenson-2006">{{cite web | url = https://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-01-FDA.pdf | title = Statistical Evaluation of Suicidality in Adults Treated with Antidepressants | access-date = 22 September 2007 | vauthors = Levenson M, Holland C | date = 17 November 2006 | work = Overview for December 13 Meeting of Psychopharmacologic Drugs Advisory Committee (PDAC) | publisher = U.S. [[Food and Drug Administration]] (FDA) | pages = 75–140 | archive-date = 16 March 2007 | archive-url = https://web.archive.org/web/20070316092329/https://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4272b1-01-FDA.pdf }}</ref>
To obtain [[statistically significant]] results the FDA combined the results of 295 trials of 11 antidepressants for psychiatric indications. As [[suicidal ideation]] and behavior in clinical trials are rare, the results for any drug taken separately usually do not reach statistical significance.

In 2005, the United States FDA released a public health advisory noting that there had been eleven reports of suicide attempts and three reports of suicidality within the mostly middle-aged women participating in the open-label extension trials of duloxetine for the treatment of stress urinary incontinence (SUI). The FDA described the potential role of confounding social stressors as "unclear". The suicide attempt rate in the SUI study population (based on 9,400 patients) was calculated to be 400 per 100,000 person-years. This rate is more than 2.5 times greater than the suicide attempt rate among middle-aged US women that has been reported in published studies, i.e., 150 to 160 per 100,000 person-years. In addition, one death from suicide was reported in a Cymbalta clinical pharmacology study in a healthy female volunteer without SUI. No increase in suicidality was reported in controlled trials of Cymbalta for depression or diabetic neuropathic pain.<ref name="FDA-Historical">{{cite web |url=https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm114970.htm |title=Historical Information on Duloxetine hydrochloride (marketed as Cymbalta) |website=U.S. [[Food and Drug Administration]] (FDA) |access-date=16 December 2019 |archive-date=22 July 2017 |archive-url=https://web.archive.org/web/20170722190849/https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm114970.htm }}</ref>

===Postmarketing reports===
Reported adverse events that were temporally correlated to duloxetine therapy include rash, reported rarely, and the following adverse events, reported very rarely: [[alanine aminotransferase]] increased, [[alkaline phosphatase]] increased, [[anaphylactic]] reaction, [[angioneurotic edema]], [[aspartate aminotransferase]] increased, [[bilirubin]] increased, [[glaucoma]], [[hepatotoxicity]], [[hyponatremia]], [[jaundice]], [[orthostatic hypotension]] (especially at the initiation of treatment), [[Stevens–Johnson syndrome]], [[syncope (medicine)|syncope]] (especially at initiation of treatment), and [[urticaria]].<ref name="RxList Monographs-Duloxetine-Side-Effects-2008">{{cite web | url = http://www.rxlist.com/cgi/generic/cymbalta_ad.htm | archive-url= https://web.archive.org/web/20080912150829/http://www.rxlist.com/cgi/generic/cymbalta_ad.htm | archive-date=12 September 2008 | title = Duloxetine Side Effects, and Drug Interactions | work = RxList Monographs }}</ref>

==Pharmacology==

===Mechanism of action===
{| class="wikitable floatright sortable" style="float:right;width:200px;margin:10px;"
|+Binding profile<ref name="pmid11750180">{{cite journal | vauthors = Bymaster FP, Dreshfield-Ahmad LJ, Threlkeld PG, Shaw JL, Thompson L, Nelson DL, Hemrick-Luecke SK, Wong DT | title = Comparative affinity of duloxetine and venlafaxine for serotonin and norepinephrine transporters in vitro and in vivo, human serotonin receptor subtypes, and other neuronal receptors | journal = Neuropsychopharmacology | volume = 25 | issue = 6 | pages = 871–80 | date = December 2001 | pmid = 11750180 | doi = 10.1016/S0893-133X(01)00298-6 | doi-access = free }} {{open access}}</ref><ref name="Li-2015">{{cite book|vauthors=Li JJ|url=https://books.google.com/books?id=qOHXCQAAQBAJ&q=duloxetine+0.7+ki&pg=PA127|title=Top Drugs: Their History, Pharmacology, and Syntheses|date=2015|publisher=Oxford University Press|isbn=978-0-19-936258-5|access-date=20 October 2020|archive-date=25 February 2024|archive-url=https://web.archive.org/web/20240225123331/https://books.google.com/books?id=qOHXCQAAQBAJ&q=duloxetine+0.7+ki&pg=PA127#v=snippet&q=duloxetine%200.7%20ki&f=false|url-status=live}}</ref>
|-
! Receptor !! K<sub>i</sub> (nM)
|-
| [[Serotonin transporter|SERT]] || 0.7~0.8
|-
| [[Norepinephrine transporter|NET]] || 7.5
|-
| [[Dopamine transporter|DAT]] || 240
|-
| [[5-HT2A receptor|5-HT<sub>2A</sub>]] || 504
|-
| [[5-HT2C receptor|5-HT<sub>2C</sub>]] || 916
|-
| [[5-HT6 receptor|5-HT<sub>6</sub>]] || 419
|}

Duloxetine inhibits the reuptake of serotonin and norepinephrine (NE) in the central nervous system. Duloxetine increases dopamine (DA) specifically in the prefrontal cortex, where there are few DA reuptake pumps, via the inhibition of NE reuptake pumps (NET), which is believed to mediate the reuptake of DA and NE.<ref name="Stahl-2013">{{cite book | vauthors = Stahl S | date = 2013 | title = Stahl's Essential Pharmacology | edition = 4th | publisher = Cambridge University Press | location = New York | pages = 305, 308, 309 }}</ref> Duloxetine has no significant affinity for dopaminergic, cholinergic, histaminergic, opioid, glutamate, and GABA reuptake transporters, however, and can therefore be considered to be a selective reuptake inhibitor at the 5-HT and NE transporters. Duloxetine undergoes extensive [[metabolism]], but the major circulating metabolites do not contribute significantly to the pharmacologic activity.<ref name="pmid16142213">{{cite journal | vauthors = Stahl SM, Grady MM, Moret C, Briley M | title = SNRIs: their pharmacology, clinical efficacy, and tolerability in comparison with other classes of antidepressants | journal = CNS Spectrums | volume = 10 | issue = 9 | pages = 732–47 | date = September 2005 | pmid = 16142213 | doi=10.1017/s1092852900019726| s2cid = 40022100 }}</ref><ref name="pmid15892657">{{cite journal | vauthors = Bymaster FP, Lee TC, Knadler MP, Detke MJ, Iyengar S | title = The dual transporter inhibitor duloxetine: a review of its preclinical pharmacology, pharmacokinetic profile, and clinical results in depression | journal = Current Pharmaceutical Design | volume = 11 | issue = 12 | pages = 1475–93 | year = 2005 | pmid = 15892657 | doi = 10.2174/1381612053764805 }}</ref>

In vitro binding studies using synaptosomal preparations isolated from rat cerebral cortex indicated that duloxetine was approximately 3 fold more potent at inhibiting [[Serotonin uptake inhibitors|serotonin uptake]] than [[norepinephrine]] uptake.<ref name="pmid28913467">{{cite journal | vauthors = Onuţu AH | title = Duloxetine, an antidepressant with analgesic properties - a preliminary analysis | journal = Romanian Journal of Anaesthesia and Intensive Care | volume = 22 | issue = 2 | pages = 123–128 | date = October 2015 | pmid = 28913467 | pmc = 5505372 }}</ref>

===Pharmacokinetics===
====Absorption====
Duloxetine is acid labile, and is formulated with an enteric coating to prevent degradation in the stomach. Duloxetine has good oral [[bioavailability]], averaging 50% after one 60&nbsp;mg dose.<ref name="pmid21366359"/> There is an average 2-hour lag until absorption begins with maximum plasma concentrations occurring about 6 hours post-dose. Food or bedtime administration has no significant impact on the C<sub>max</sub> of duloxetine, but delay time to reach peak concentration by 4 hours.<ref name="pmid15892657"/><ref name="pmid21366359"/> This delay is caused by reduced gastrointestinal motility, and reduce [[area under curve]] and half-life by only 11% and 18%, respectively; as such, no dose adjustments or time-of-day restrictions are necessary.<ref name="pmid21366359"/> Depending on condition being treated, duloxetine is taken once a day or twice a day.<ref name="Cymbalta FDA label" /><ref name="pmid21366359"//>

====Distribution====
Duloxetine is highly bound (>90%) to proteins in human plasma, binding primarily to [[albumin]] and [[α1-acid glycoprotein]]. [[Volume of distribution]] is about {{val|1640|u=liters}}.<ref name="pmid21366359"/><ref name="Cymbalta FDA label" />

====Metabolism====
Duloxetine undergoes predominately hepatic metabolism via two [[cytochrome P450]] isozymes, [[CYP2D6]] and [[CYP1A2]]. Circulating metabolites are pharmacologically inactive. Duloxetine is a moderate CYP2D6 inhibitor.<ref name="Cymbalta FDA label" />

====Elimination==== 
Duloxetine, administered in a single oral dose of {{val|20|u=mg}} or {{val|40|u=mg}} has plasma elimination half-life of {{val|10|-|12|u=hours}}<ref name="pmid21366359"/><ref name="Cymbalta FDA label" /> and its pharmacokinetics are dose proportional over the [[Therapeutic index|therapeutic range]].<ref name="Cymbalta FDA label" /> [[Steady-state concentration]] is usually achieved after 3 days.<ref name="pmid21366359"/><ref name="Cymbalta FDA label" /> Only trace amounts (<1%) of unchanged duloxetine are present in the urine and most of the dose (approx. 70%) appears in the urine as metabolites of duloxetine with about 20% excreted in the feces.<ref name="Cymbalta FDA label" />

Smoking is associated with a decrease in duloxetine concentration.<ref name="pmid21366359">{{cite journal | vauthors = Knadler MP, Lobo E, Chappell J, Bergstrom R | title = Duloxetine: clinical pharmacokinetics and drug interactions | journal = Clinical Pharmacokinetics | volume = 50 | issue = 5 | pages = 281–294 | date = May 2011 | pmid = 21366359 | doi = 10.2165/11539240-000000000-00000 | s2cid = 207299455 }}</ref><ref name="pmid18651344">{{cite journal | vauthors = Fric M, Pfuhlmann B, Laux G, Riederer P, Distler G, Artmann S, Wohlschläger M, Liebmann M, Deckert J | title = The influence of smoking on the serum level of duloxetine | journal = Pharmacopsychiatry | volume = 41 | issue = 4 | pages = 151–155 | date = July 2008 | pmid = 18651344 | doi = 10.1055/s-2008-1073173 | s2cid = 22045964 }}</ref><ref name="medicines.org.uk-Duloxetine-60">{{cite web|url=https://www.medicines.org.uk/emc/product/1900/smpc|title=Duloxetine 60mg gastro-resistant capsules - Summary of Product Characteristics (SmPC) - (emc)|website=www.medicines.org.uk|access-date=21 March 2020|archive-date=21 March 2020|archive-url=https://web.archive.org/web/20200321015841/https://www.medicines.org.uk/emc/product/1900/smpc}}</ref>

==Research directions==
Major depressive disorder is believed to be due in part to an increase in pro-inflammatory cytokines within the central nervous system.<ref name="pmid25003554">{{cite journal |vauthors=Lotrich FE |title=Inflammatory cytokine-associated depression |journal=Brain Res |volume=1617 |issue= |pages=113–25 |date=August 2015 |pmid=25003554 |pmc=4284141 |doi=10.1016/j.brainres.2014.06.032 |url=}}</ref><ref name="pmid17433516">{{cite journal |vauthors=Kim YK, Na KS, Shin KH, Jung HY, Choi SH, Kim JB |title=Cytokine imbalance in the pathophysiology of major depressive disorder |journal=Prog Neuropsychopharmacol Biol Psychiatry |volume=31 |issue=5 |pages=1044–53 |date=June 2007 |pmid=17433516 |doi=10.1016/j.pnpbp.2007.03.004 |s2cid=22275879 |url=http://kumel.medlib.dsmc.or.kr/handle/2015.oak/33530}}</ref> Antidepressants including ones with a similar mechanism of action as duloxetine, i.e., serotonin metabolism inhibition, cause a decrease in proinflammatory [[cytokine]] activity and an increase in anti-inflammatory cytokines;<ref name="pmid22981313">{{cite journal |vauthors=Fornaro M, Rocchi G, Escelsior A, Contini P, Martino M |title=Might different cytokine trends in depressed patients receiving duloxetine indicate differential biological backgrounds |journal=J Affect Disord |volume=145 |issue=3 |pages=300–7 |date=March 2013 |pmid=22981313 |doi=10.1016/j.jad.2012.08.007 |url=}}</ref> this mechanism may apply to duloxetine in its effect on depression but research on cytokines specific to duloxetine therapy is insufficient.<ref name="pmid20646337">{{cite journal | vauthors = De Berardis D, Conti CM, Serroni N, Moschetta FS, Olivieri L, Carano A, Salerno RM, Cavuto M, Farina B, Alessandrini M, Janiri L, Pozzi G, Di Giannantonio M | title = The effect of newer serotonin-noradrenalin antidepressants on cytokine production: a review of the current literature | journal = International Journal of Immunopathology and Pharmacology | volume = 23 | issue = 2 | pages = 417–22 | year = 2010 | pmid = 20646337 | doi = 10.1177/039463201002300204 | s2cid = 656023 | doi-access = free }}</ref><ref name="pmid21796103">{{cite journal | vauthors = Hannestad J, DellaGioia N, Bloch M | title = The Effect of Antidepressant Medication Treatment on Serum Levels of Inflammatory Cytokines: A Meta-Analysis | journal = Neuropsychopharmacology | volume = 36 | issue = 12 | pages = 2452–59 | date = November 2011 | pmid = 21796103 | doi = 10.1038/npp.2011.132 | pmc = 3194072 }}</ref> Cytokines are immunoregulatory molecules that play a key role in the human immune response. Some cytokines are proinflammatory and contribute to the development of inflammation, while others are anti-inflammatory and help to control the proinflammatory response.<ref name="pmid10767254">{{cite journal |vauthors=Opal SM, DePalo VA |title=Anti-inflammatory cytokines |journal=Chest |volume=117 |issue=4 |pages=1162–72 |date=April 2000 |pmid=10767254 |doi=10.1378/chest.117.4.1162 |s2cid=2267250 |url=}}</ref> Duloxetine can reduce the production of pro-inflammatory cytokines such as [[Interleukin 1 beta|interleukin-1 beta]] (IL-1β), [[Tumor necrosis factor|tumor necrosis factor-alpha]] (TNF-α), and [[interleukin 6]] (IL-6) and may increase the production of anti-inflammatory cytokines such as [[interleukin 10]] (IL-10),<ref name="pmid22981313"/><ref name="pmid39392051">{{cite journal |vauthors=Suzuki E, Sueki A, Takahashi H, Ishigooka J, Nishimura K |title=Association between TNF-α & IL-6 level changes and remission from depression with duloxetine treatment |journal=Int J Neurosci |volume= |issue= |pages=1–6 |date=October 2024 |pmid=39392051 |doi=10.1080/00207454.2024.2414279 |url=}}</ref><ref name="pmid38877455">{{cite journal |vauthors=Gao W, Gao Y, Xu Y, Liang J, Sun Y, Zhang Y, Shan F, Ge J, Xia Q |title=Effect of duloxetine on changes in serum proinflammatory cytokine levels in patients with major depressive disorder |journal=BMC Psychiatry |volume=24 |issue=1 |article-number=449 |date=June 2024 |pmid=38877455 |pmc=11179362 |doi=10.1186/s12888-024-05910-0|doi-access=free }}</ref> however, mechanisms behind these effects are not well elucidated, there have been mixed findings regarding duloxetine's impact on cytokine production in different contexts, and the results are inconclusive.<ref name="pmid35791513">{{cite journal |vauthors=Zhu J, Chen J, Zhang K |title=Clinical effect of flunarizine combined with duloxetine in the treatment of chronic migraine comorbidity of depression and anxiety disorder |journal=Brain Behav |volume=12 |issue=8 |article-number=e2689 |date=August 2022 |pmid=35791513 |pmc=9392519 |doi=10.1002/brb3.2689 |url=}}</ref><ref name="pmid26556688">{{cite journal |vauthors=Maciukiewicz M, Marshe VS, Tiwari AK, Fonseka TM, Freeman N, Rotzinger S, Foster JA, Kennedy JL, Kennedy SH, Müller DJ |title=Genetic variation in IL-1β, IL-2, IL-6, TSPO and BDNF and response to duloxetine or placebo treatment in major depressive disorder |journal=Pharmacogenomics |volume=16 |issue=17 |pages=1919–29 |date=November 2015 |pmid=26556688 |doi=10.2217/pgs.15.136 |url=}}</ref><ref name="pmid31125145">{{cite journal |vauthors=Miyauchi T, Tokura T, Kimura H, Ito M, Umemura E, Sato Boku A, Nagashima W, Tonoike T, Yamamoto Y, Saito K, Kurita K, Ozaki N |title=Effect of antidepressant treatment on plasma levels of neuroinflammation-associated molecules in patients with somatic symptom disorder with predominant pain around the orofacial region |journal=Hum Psychopharmacol |volume=34 |issue=4 |article-number=e2698 |date=July 2019 |pmid=31125145 |doi=10.1002/hup.2698 |s2cid=163168228 |url=}}</ref><ref name="pmid34174336">{{cite journal |vauthors=Qiu W, Go KA, Wen Y, Duarte-Guterman P, Eid RS, ((Galea LAM)) |title=Maternal fluoxetine reduces hippocampal inflammation and neurogenesis in adult offspring with sex-specific effects of periadolescent oxytocin |journal=Brain Behav Immun |volume=97 |issue= |pages=394–409 |date=October 2021 |pmid=34174336 |doi=10.1016/j.bbi.2021.06.012 |s2cid=235620244 |url=}}</ref>

Duloxetine is being investigated for its potential to decrease opioid use in the perioperative period because duloxetine administration can help reduce opioid consumption and mitigate the risk of opioid-related side effects and dependence. In total hip arthroplasty (THA) or total knee arthroplasty (TKA), duloxetine is researched to provide pain relief; studies demonstrated that it can reduce pain for several weeks post-surgery without an increased risk of adverse drug events, suggesting that duloxetine could be a valuable component of a multimodal management regimen for patients undergoing THA or TKA.<ref name="pmid38481321"/> Also, duloxetine can reduce postoperative nausea and vomiting after THA or TKA, which are common side effects of anesthesia and opioids: this additional benefit could improve patient comfort and satisfaction, potentially enhancing recovery outcomes.<ref name="pmid38481321">{{cite journal |vauthors=Lin Y, Jiang M, Liao C, Wu Q, Zhao J |title=Duloxetine reduces opioid consumption and pain after total hip or knee arthroplasty: a meta-analysis of randomized controlled trials |journal=J Orthop Surg Res |volume=19 |issue=1 |article-number=181 |date=March 2024 |pmid=38481321 |pmc=10936099 |doi=10.1186/s13018-024-04648-5 |doi-access=free |url=}}</ref>

==History==
[[File:Cymbalta60mg.png|thumb|Cymbalta (duloxetine) 60mg]]
Duloxetine was created by [[Eli Lilly and Company]] researchers. David Robertson; David Wong, a co-inventor of [[fluoxetine]]; and Joseph Krushinski are listed as inventors on the [[patent application]] filed in 1986 and granted in 1990.<ref name="Robertson-1990">{{cite web |url=http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=4956388.PN.&OS=PN/4956388&RS=PN/4956388 |title=United States Patent 4,956,388: 3-Aryloxy-3-substituted propanamines |vauthors=Robertson DW, Wong DT, Krushinski JH |date=11 September 1990 |publisher=USPTO |access-date=17 May 2008 |archive-date=7 January 2016 |archive-url=https://web.archive.org/web/20160107015057/http://patft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PALL&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.htm&r=1&f=G&l=50&s1=4956388.PN.&OS=PN%2F4956388&RS=PN%2F4956388 }}</ref>  The first publication on the invention of the [[racemic]] form of duloxetine known as LY227942, was made in 1988.<ref name="pmid2850421">{{cite journal | vauthors = Wong DT, Robertson DW, Bymaster FP, Krushinski JH, Reid LR | title = LY227942, an inhibitor of serotonin and norepinephrine uptake: biochemical pharmacology of a potential antidepressant drug | journal = Life Sciences | volume = 43 | issue = 24 | pages = 2049–57 | year = 1988 | pmid = 2850421 | doi = 10.1016/0024-3205(88)90579-6 }}</ref> The (+)-[[enantiomer]], assigned LY248686, was chosen for further studies, because it inhibited serotonin reuptake in rat synaptosomes to twice the degree of the (–)-enantiomer. This molecule was subsequently named duloxetine.<ref name="pmid14643350">{{cite journal | vauthors = Bymaster FP, Beedle EE, Findlay J, Gallagher PT, Krushinski JH, Mitchell S, Robertson DW, Thompson DC, Wallace L, Wong DT | title = Duloxetine (Cymbalta), a dual inhibitor of serotonin and norepinephrine reuptake | journal = Bioorganic & Medicinal Chemistry Letters | volume = 13 | issue = 24 | pages = 4477–80 | date = December 2003 | pmid = 14643350 | doi = 10.1016/j.bmcl.2003.08.079 }}</ref>

In 2001, Lilly filed a [[New Drug Application]] (NDA) for duloxetine with the US [[Food and Drug Administration]]. In 2003, however, the FDA "recommended this application as not approvable from the manufacturing and control standpoint" because of "significant cGMP (current [[Good Manufacturing Practice]]) violations at the finished product manufacturing facility" of Eli Lilly in Indianapolis. Additionally, "potential liver toxicity" and [[QT interval|QTc interval]] prolongation appeared as a concern. The FDA experts concluded that "duloxetine can cause hepatotoxicity in the form of transaminase elevations. It may also be a factor in causing more severe liver injury, but there are no cases in the NDA database that clearly demonstrate this. Use of duloxetine in the presence of ethanol may potentiate the deleterious effect of ethanol on the liver." The FDA also recommended "routine [[blood pressure]] monitoring", since there was a dose-dependent increase in elevated blood pressure readings, including at the new highest recommended dose of 120&nbsp;mg "where 24% of patients had one or more [elevated] blood pressure readings of 140/90 vs. 9% of placebo patients."<ref name="FDA-2003">{{cite report |url=https://www.accessdata.fda.gov/drugsatfda_docs/nda/2004/021427_s000_Cymbalta_AdminCorres.pdf |title=Approval package for: application number NDA 721-427. Administrative/Correspondence #2 |year=2003 |publisher=U.S. [[Food and Drug Administration]] (FDA) |access-date=18 May 2008 |archive-date=12 February 2017 |archive-url=https://web.archive.org/web/20170212091852/http://www.accessdata.fda.gov/drugsatfda_docs/nda/2004/021427_s000_Cymbalta_AdminCorres.pdf }} {{PD-notice}}</ref><ref name="FDA Cymbalta Approval Package">{{cite web | title=Drug Approval Package: Cymbalta (Duloxetine Hydrochloride) NDA #021427 | website=U.S. [[Food and Drug Administration]] (FDA) | date=24 December 1999 | url=https://www.accessdata.fda.gov/drugsatfda_docs/nda/2004/021427_s000_Cymbalta.cfm | access-date=29 September 2020 | archive-date=24 September 2020 | archive-url=https://web.archive.org/web/20200924060238/https://www.accessdata.fda.gov/drugsatfda_docs/nda/2004/021427_s000_Cymbalta.cfm }}</ref>

After the manufacturing issues were resolved, the [[Hepatotoxicity|liver toxicity]] warning included in the prescribing information, and the follow-up studies showed that duloxetine does not cause QTc interval prolongation, duloxetine was approved by the FDA for depression and diabetic neuropathy in 2004.<ref name="FDA-News-2009">{{cite web |url=https://www.fda.gov/bbs/topics/news/2004/NEW01113.html |title=FDA news |website=[[Food and Drug Administration]] |access-date=16 December 2019 |archive-date=13 May 2009 |archive-url=https://web.archive.org/web/20090513072618/http://www.fda.gov/bbs/topics/news/2004/NEW01113.html }}</ref> In 2007, [[Health Canada]] approved duloxetine for the treatment of depression and diabetic peripheral neuropathic pain.<ref name="Health-Canada-2008">{{cite web|title=Summary Basis of Decision (SBD): Cymbalta|url=http://www.hc-sc.gc.ca/dhp-mps/prodpharma/sbd-smd/drug-med/sbd_smd_2008_cymbalta_110028-eng.php|publisher=Health Canada|date=5 May 2008|access-date=27 February 2015|archive-url=https://web.archive.org/web/20150301073033/http://www.hc-sc.gc.ca/dhp-mps/prodpharma/sbd-smd/drug-med/sbd_smd_2008_cymbalta_110028-eng.php|archive-date=1 March 2015}}</ref>

Duloxetine was approved for use of stress urinary incontinence (SUI) in the EU in 2004.<ref name="Yentreve EPAR">{{cite web | title=Yentreve EPAR | website=[[European Medicines Agency]] (EMA) | date=17 September 2018 | url=https://www.ema.europa.eu/en/medicines/human/EPAR/yentreve | access-date=30 September 2020 | archive-date=24 September 2020 | archive-url=https://web.archive.org/web/20200924025504/https://www.ema.europa.eu/en/medicines/human/EPAR/yentreve | url-status=live }}</ref> In 2005, Lilly withdrew the duloxetine application for stress urinary incontinence (SUI) in the US, stating that discussions with the FDA indicated "the agency is not prepared at this time to grant approval ... based on the data package submitted." A year later Lilly abandoned the pursuit of this indication in the US market.<ref name="TheStreet.com-2006">{{cite web |url=http://www.thestreet.com/_googlen/stocks/pharmaceuticals/10268662.html?cm_ven=GOOGLEN&cm_cat=FREE&cm_ite=NA |title=Lilly Won't Pursue Yentreve for U.S.  |date=15 February 2006 |publisher=TheStreet.com |access-date=18 May 2008 |archive-url=https://web.archive.org/web/20090202114300/http://www.thestreet.com/_googlen/stocks/pharmaceuticals/10268662.html?cm_ven=GOOGLEN&cm_cat=FREE&cm_ite=NA |archive-date=2 February 2009 }}</ref><ref name="pmid16002878">{{cite journal | vauthors = Lenzer J | title = FDA warns that antidepressants may increase suicidality in adults | journal = BMJ | volume = 331 | issue = 7508 | page = 70 | date = July 2005 | pmid = 16002878 | pmc = 558648 | doi = 10.1136/bmj.331.7508.70-b }}</ref>

The FDA approved duloxetine for the treatment of generalized anxiety disorder in February 2007.<ref name="News-Medical-2007">{{cite web|url=http://www.news-medical.net/?id=22194|title=FDA approves antidepressant Cymbalta (duloxetine HCl) for treatment of generalized anxiety disorder|date=26 February 2007|work=News-Medical|access-date=25 December 2013|archive-date=15 January 2009|archive-url=https://web.archive.org/web/20090115204249/http://www.news-medical.net/?id=22194|url-status=live}}</ref>

Cymbalta generated sales of nearly {{US$|5 billion}} in 2012, with $4 billion of that in the US, but its patent protection terminated 1 January 2014. Lilly received a six-month extension beyond 30 June 2013, after testing for the treatment of depression in adolescents, which may produce {{US$|1.5 billion}} in added sales.<ref name="Staton-2012">{{cite web|url=http://www.fiercepharma.com/story/lilly-could-net-15b-plus-cymbalta-extension/2012-07-09|title=Lilly could net $1.5B-plus from Cymbalta extension| vauthors = Staton T |date=9 July 2012|work=FiercePharma|access-date=25 December 2013|archive-date=30 October 2013|archive-url=https://web.archive.org/web/20131030202603/http://www.fiercepharma.com/story/lilly-could-net-15b-plus-cymbalta-extension/2012-07-09}}</ref><ref name="Palmer-2013">{{cite web|url=http://www.fiercepharma.com/story/eli-lilly-lay-hundreds-sales-cymbalta-nears-edge-patent-cliff/2013-04-11|title=Eli Lilly to lay off hundreds in sales as Cymbalta nears edge of patent cliff| vauthors = Palmer E |date=11 April 2013|work=FiercePharma|access-date=25 December 2013|archive-date=11 December 2013|archive-url= https://web.archive.org/web/20131211204149/http://www.fiercepharma.com/story/eli-lilly-lay-hundreds-sales-cymbalta-nears-edge-patent-cliff/2013-04-11}}</ref>

The first generic duloxetine was marketed by an Indian pharmaceutical company [[Dr. Reddy's Laboratories]].<ref name="Anson-2013">{{cite web|url=http://americannewsreport.com/nationalpainreport/generic-cheaper-versions-cymbalta-approved-8822633.html|title=Generic Cheaper Versions of Cymbalta Approved| vauthors = Anson P |date=12 December 2013|work=National Pain Report|access-date=2 January 2014|archive-date=2 January 2014 |archive-url=https://web.archive.org/web/20140102195512/http://americannewsreport.com/nationalpainreport/generic-cheaper-versions-cymbalta-approved-8822633.html}}</ref>

== See also ==
* [[List of antidepressants]]

== Explanatory notes ==
{{reflist|group=note}}

== References ==
{{Reflist}}

{{Antidepressants}}
{{Neuropathic pain and fibromyalgia pharmacotherapies}}
{{Monoamine reuptake inhibitors}}
{{Eli Lilly and Company}}
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[[Category:Serotonin–norepinephrine reuptake inhibitors]]
[[Category:CYP2D6 inhibitors]]
[[Category:Drugs developed by Eli Lilly and Company]]
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[[Category:Secondary amines]]
[[Category:Wikipedia medicine articles ready to translate]]
[[Category:Antidepressants]]