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Orthostatic Hypotension and SyncopeOrthostatic hypotension and syncope have been reported with therapeutic doses ofduloxetine. Syncope and hypotension tend to occur within the first week of therapy butcan occur at any time during duloxetine treatment, particularly after dose increases. Therisk of blood pressure decreases may be greater in patients taking concomitantmedications that induce orthostatic hypotension (such as antihypertensives) or are potentCYP1A2 inhibitors and in patients taking doses above 60 mg daily. Consideration shouldbe given to discontinuing CYMBALTA in patients who experience symptomaticorthostatic hypotension and/or syncope during therapy.Electrocardiogram ChangesECGs were obtained from 321 duloxetine-treated patients with MDD and 169 placebotreatedpatients in 8-week clinical trials. The rate-corrected QT interval in duloxetinetreatedpatients in an 8-week study did not differ from that seen in placebo-treatedpatients. In summary, the data suggest no arrhythmogenic potential with duloxetine. Noclinically significant differences were observed for QT, PR and QRS intervals betweenduloxetine-treated and placebo-treated patients.Discontinuing TreatmentAs with other drugs effective in the treatment of major depressive disorder, whendiscontinuing CYMBALTA after more than 1 week of therapy, it is generallyrecommended that the dose be tapered to minimise the risk of discontinuation symptoms(see DOSAGE AND ADMINISTRATION). The most commonly reported symptomsfollowing abrupt discontinuation of duloxetine in clinical trials have included dizziness,nausea, headache, paraesthesia, fatigue, vomiting, irritability, nightmares, insomnia,diarrhoea, anxiety, hyperhidrosis, vertigo, somnolence and myalgia.Serotonin SyndromeDevelopment of serotonin syndrome may occur in association with treatment with SSRlsand SNRls, particularly when given in combination with MAOls or other serotonergicagents. Symptoms and signs of serotonin syndrome include rapid onset of neuromuscularexcitation (hyperreflexia, incoordination, myoclonus, tremor), altered mental status(confusion, agitation, hypomania) and autonomic dysfunction (diaphoresis, diarrhoea,fever, shivering and rapidly fluctuating vital signs). Treatment with CYMBALTA shouldbe discontinued if such events occur and supportive symptomatic treatment initiated.Caution is advisable if CYMBALTA is used concomitantly with serotonergicantidepressants like SSRIs, SNRIs, tricyclic antidepressants like clomipramine oramitriptyline, St John’s Wort (Hypericum perforatum), triptans, tramadol, pethidine ortryptophan.Effect on Ability to Drive or Operate MachineryIn controlled studies duloxetine has not been shown to impair psychomotor performance,cognitive function or memory. However, as any psychoactive drug may impairCymbalta PI Nov 2012 v8.0 16