Duloxetine

How it works

It inhibits the reuptake of serotonin and noradrenaline in the central nervous system, enhancing descending inhibitory pain pathways and modulating mood and anxiety circuits.

Prescribing in practice

• It can raise blood pressure and should not be started in uncontrolled hypertension; monitor blood pressure, and avoid combination with other serotonergic drugs or recent monoamine oxidase inhibitor use because of serotonin syndrome risk.
• Avoid in significant hepatic impairment and in severe renal impairment, and stop gradually to reduce discontinuation symptoms.
• Monitor for suicidal ideation, particularly in younger adults and early in treatment, and counsel on increased bleeding risk when combined with antiplatelets or anticoagulants.

Monitoring

Monitor mood and suicidality, blood pressure, hepatic function if symptoms arise, and for serotonergic or bleeding adverse effects.

Counselling the patient

• Do not stop suddenly, as this can cause dizziness, electric-shock sensations and mood changes.
• Report worsening mood or thoughts of self-harm, especially in the first weeks.
• Seek urgent advice for agitation, fever, tremor or confusion suggesting serotonin toxicity.

Evidence & guidelines

Regulatory and NICE depression and neuropathic pain guidance support duloxetine as an established treatment option in its licensed indications.