Duloxetine 60 mg, 40 mg, 30 mg, and 20 mg are currently being marketed by various companies. Cymbalta, being the research brand, is manufactured and marketed by Lilly. Duloxetine is a potent inhibitor of serotonin and norepinephrine. It has little effect on dopamine receptors.

The following conditions are currently listed as being indicated for treatment with it:

• Fibromyalgia

• Generalized Anxiety disorder

• Diabetic neuropathy

• Major depressive disorder

• Chronic musculoskeletal pains

A brief summary of my patient who became a "Superwoman"

65 years of age female patient, Canadian-Pakistani, came for consultation regarding her diabetes. She, along with her husband, son, and daughter, visits Hunza valley each year for three months and celebrate the earth. During these three months, they totally avoid artificial foods. They have grown all kinds of fruits in their home at Hunza, which is on a mountain peak with a natural waterfall. They walk bare feet, pluck fruits from the trees to eat and enjoy nature. Along with diabetes, the patient also has hypertension, ischemic heart disease, hypothyroidism, Parkinson's disease, osteoarthritis, and osteoporosis. Her current medications included:

• a statin (atorvastatin),
• Aspirin,
• Thyroxine,
• metformin,
• sitagliptin,
• insulin aspart,
• Insulin glargine,
• Levodopa/ carbidopa,
• Valsartan,
• bisoprolol,
• Omeprazole, and
• calcium supplements.

Her blood sugars varied between 150 mg/dl and 250 mg/dl and she had glycated hemoglobin of 8.8% Apart from deranged blood sugars, she was complaining of fatigue, numbness, paraesthesia, low mood, and difficulty in getting up from bed early in the morning. Her Dexa scan (bone densitometry) suggested osteoporosis with a T-score of -3.5 at different levels.

Adding more drugs was a difficult decision ...

To avoid adding extra medicine for osteoporosis, I advised her a single injection of Zometa (Zoledronic acid), which is administered once every year. Other bisphosphonates are administered more frequently, for example:

• Alendronic acid is given daily or once a week
• Ibandronic acid is given monthly orally or 3-monthly when given intravenously
• Similarly, Risedronate is also administered monthly.

Her insulin dose was increased according to her blood sugar record. Duloxetine 60 mg tablet was added. She was advised to take the drug after breakfast. Another option for her neuropathic symptoms was to add Pregabalin or Gabapentin. However, these drugs could have added to more sedation and fatigue. Hence, I preferred to start her on duloxetine 60 mg. Duloxetine is primarily used as an antidepressant and most patients present with fatigue, lethargy, and palpitation when they are depressed. Thus, duloxetine improved her mood along with the neuropathic symptoms. Duloxetine (Cymbalta) also has analgesic properties and is therefore used to treat patients with fibromyalgia and non-specific skeletal pains.

What happened after three months?

After three months of stay in Hunza, the patient visited me again. Her son was very excited and his comments were:

" After so many years, for the first time, I saw my mom so active. She was like a superwoman". 

He was also insisting on to repeat injection Zometa (Zoledronic acid). Most of her symptoms like fatigue, lethargy, body aches, numbness, and paresthesias had improved. She was advised to continue duloxetine 60 mg along with all the other medications.

What is Duloxetine?

It is a selective and potent drug that inhibits the reuptake of norepinephrine and serotonin without affecting dopamine. It is primarily used for depression and diabetic patients with neuropathic symptoms.

Is duloxetine addictive?

Duloxetine does not cause addiction, however, rapid withdrawal of the drug may cause unpleasant symptoms.

What is the effect of duloxetine 60 mg on weight?

Unlike other antidepressants, and except for Bupropion, duloxetine has been found in studies to cause weight loss.

Common side effects of duloxetine

The most common side effects of duloxetine include:

• Nausea
• Vomiting
• heartburn
• vertigo
• dry mouth
• sleep disturbance
• anorexia
• blood pressure fluctuations

In conclusion ...

Duloxetine may cause mood elevation, improve neuropathic symptoms, and improve skeletal pains. Most diabetic patients have one or more of these symptoms and duloxetine may be indicated at some stage.

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