Duloxetine HCl

Dosages

1.  MDD - normal TDD is 40-60 mg.  40 = 20 mg BID; 60 mg = 30 mg BID or 60 mg QD

2.  Neuropathic pain - 60 mg QD

3.  GAD - Start w/ 30 mg QD x 1 wk then increase to 60 mg QD; Max  dose = 120 mg

MAOI to Cymbalta - 14 days

Cymbalta to MAOI - 5 days

Initial dose - 20 mg then gradually increase to a dose of 40 mg QD.

See effects in 4 weeks

Tx of depression & for the prevention of seasonal major depressive eisodes in pts w/seasonal affective disorder: 

IR - 100 mg BID then increase max 100 mg/day no sooner than q3d.  Usual dose - 100 mg TID.  Max 450 mg/day.  No single dose should > 150 mg

SR - 400 mg/day in 2 divided dose.  Target dose 300 mg/day

ER - 150 - 300 QD

Oral: 40-150 mg/day in divided doses or HS

Hospitalized pts: 300 mg/day

NOT RECOMMENDED FOR < 12 y/o

1. Depression: 75 mg/day in a single or divided doses taken w/ food.  May be increased to 150 mg/day or up to 225 mg/day.  Increase in increments up to 75 mg/day NLT 4 days.  Max: 375 mg for severe pts

2. GAD: Initial 37.5 mg/day; Maintenance 75-225 mg/day

3. SAD: Initial 75 mg QD.  Maintenance 75-225 mg/day

Hepatic impairment: reduce 50%

Renal impairment: reduce 25%

14 days btw MAO-I to Effexor

7 days btw Effexor to MAO-1

1. Depression: Start w/ 10 mg then increases q2wks. Normal daily dose - 10-40 mg. Max 80 mg After 13 wks of tx w/ 20 mg QD, pts may switched to Prozac Weekly 90 mg qwk. Initiated 7 days following the last dose.

2. OCD: 20 mg/day then increase q2wks. 20 mg/day should be given BID (AM & noon)

3. Bulimia nervosa: 60 mg QAM

4. Panic disorder: 10 mg/day then increase 20 mg/day after one wk. Max 60 mg

1. Depression & OCD: Start 50 then increase no sooner than weekly up to a max of 200 mg/day. Tx up to 16 weeks

2. Panic disorder & PTSD: Start w/ 25 mg QD then increase no sooner than weekly up to a msx of 200 mg/day

3. PMDD: Start w/ 50 mg/day. Changes up to a max of 150 mg/day

4. SAD: Start w/ 25 mg QD. After one week, increased to 50 mg QD

150 mg initially in divided doses. May be increased or decreased by 50 mg/day increments q3-4d

Max for outpt: 400 mg

Hospital inpts: 600 mg/day in divided doses

NOT RECOMMENDED FOR < 18 y/o

Mild, moderate & severe dementia of the Alzheimer's type

5 mg HS.  May be increased after 4-6 wks to 10 mg HS

1. Schizo:  25 mg BID then increase in increments of 25-50 mg q2-3d;  Maintenance dose:  300-400 mg QD (divided dose or ER); Max dose:  800 mg

2. Depressive episodes associated w/ bipolar disorde:  Day 1- 50 mg, Day 2- 100mg, Day 3-200 mg, Goal- 300 mg HS

3. Acute manic episodes associated w/ bipolar I disorder, as monotherapy or adjunct therapy to Li or Divalproex:  50 mg BID.  Increase dose 100 mg/day until 400 mg/day.  Max dose:  800 mg/day

Hepatic fx impairment:  25 mg/day then increase by 25 mg/day

1. Schizo:  Initial dose 10-15 mg QD then titrated up or down after 2 wks intervals to 10-30 mg.

2. Acute manic and mixed episodes associated w/ bipolar disorder:  15 mg QD

CYP3A4/2D6 inhibitors - reduced to 1/2 of the usual dose

CYP3A4 inducers - double the dose

1. Schizo:  Day 1- 1 mg BID, Day 2- 2 mg BID, Day 3- 3 mg BID.  Further dose adjustment in 1 week intervals.  Max dose - 16 mg

2. Short-term tx of acute manic or mixed episodes associated w/ Bipolar I Disorder:  Initial 2-3 mg QD;  NLT 24h in dose increments of 1 mg/day

3. Tx of irritability associated w/ autistic disorderr, including sxs of aggression towards others, deliberate self-injuriousness, temper tantrums and quickly changing moods: 

0.25 mg/day - <20 kg

0.5 mg/day - >20 kg

Increase 0.25-0.5 mg q14d

1. Neuropathic pain associated w/ diabetic peripheral neuropathy:  50 mg TID may be increased to 300 mg/day after 1 week;  Max dose 100 mg TID in pts w/ CrCl 60 mL/min

2. Postherpetic neuralgia:  75 mg BID or 50 mg TID may be increased to 300 mg/day after 1 week; may be increased to 600 mg/day after 2-4 wks; max dose 100 mg TID in pts w/ CrCl 60 mL/min

3. Adjunctive therapy for adult pts w/ partial onset seizures:  75 mg BID or 50 mg TID may be increased to 600 mg/day

4. Management of fibromyalgia:  75 mg BID may be increased to 150 mg BID after 1 wk and may be further tolerated to 225 mg BID

When DC, taper gradually over 1 week

1. Adjunctive therapy in pediatric & adult pts w/ partial seizures or generalized seizures of Lennox-Gastaut syndrome & in primary generalized tonic-clonic seizures:  25-200 mg QD

2-12 y/o taking valporic acid - 0.15 mg/kg/day x 2 wks increase to 0.3 mg/kg/day x 2 wks to maintenance dose 1-5 mg/kg/day

2-12 y/o taking EIAED - 0.6 mg/kg/day x 2 wks increase to 1.2 mg/kg/day x 2 wks to maintenance dose 5-15 mg/kg/day

Adults - valporic acid - 25 mg EOD x 2 wks increase to 25 mg QD x 2 wks to maintenance dose 100-400 mg/day

Adults - EIAED - 50 mg/day x 2 wks increase to 100 mg/day x 2 weeks to maintenance dose 300-500 mg/day

2. Conversion to monotherapy in adults w/ parital seizures who are receiving tx w/ a single EIAED or valproate:  50 mg/day x 2 wks increase to 100 mg/day x 2 weeks to maintenance dose 300-500 mg/day

3. Maintance tx of Bipolar I Disorder to delay the time to occurrence of mood episodes:  Titrate up to 25 mg QD not taking EIAED (double dose if taken) or valproic acid (divide dose if taken).  Double the dose EOW up to 200 mg QD

1. Adjunctive therapy in the tx of partial sezures w/ and w/o secondary genralization in adults w/ epilepsy:

Day 1- 300 mg HS, Day 2- 300 mg BID, Day 3- 300 mg TID.  Effective dose 900-1800 mg.  Doses of 2400 mg can be tolerated.  DC over 1 week

CrCl:

>60 - 400 mg TID

30-60 - 300 BID

15-30 - 300 QD

<15 - 300 mg EOD

2. Adjunctive therapy in the tx of partial seizures in pediatric pts age 3-12 y/o:  10-15 mg/kg/day in 3 divided doses titrated to 25-35 mg/kg/day for pts > 5 y/o & up to 40 mg/kg/day for pts 3-4 y/o

3. Tx of postherpetic neuralgia in adults:  Day 1- 300 mg HS, Day 2- 300 mg BID, Day 3- 300 mg TID titrated up to 600 mg TID

Lennox-Gastaut Syndrome (petit mal variant), akinetic and myoclonic seizures, and in pts w/ absence seizures (petit mal) who have failed to respond to succinimides

Adults:  0.5 mg TID may be increased in increments of 0.5-1 mg q3d until seizures are controlled; Max dose - 20 mg

Infants & children:  0.01-0.05 mg/kg/day in 2-3 divided doses may be increased no more than 0.25-0.5 q3d until maintenance dose of 0.1-0.2 has been reached

1. Adjunctive and monotherapy for adults and pediatric pts ages 2-16 y/o w/ partial onset seizures, or primary generalized tonic-clonic seizures, and in pts > 2 y/o with seizures associated with Lennox-Gastaut syndrome:

Adults:  200-400 mg divided doses.  25-50 mg/day may be increased in increments of 25-50 mg per wk

2-16 y/o:  5-9 mg/kg/day divided doses.  25 mg (1-3 mg/kg) per PM titrated in increments of 1-3 mg/kg/wk

2. Initial monotherapy tx of partial onset or primary generalized tonic-clonic seizures in pts > 10 y/o:

400 mg/day in divided doses may be titrated over a 6 wk period in 50-100 mg/day increments

3. Prophylaxis of migraine HA in adults

100 mg/day in 2 divided doses may be titrated over a 4 wk period in 25 mg/day increments

1. Simple (petit mal), complex absence, and complex partial seizures

Initial 15 mg/kg/day may be increased at 1 wk intervals byy 5-10 mg/kg/day until seizures are controlled up to max dose 60 mg/kg/day

2. Acute mania or mixed episodes associated with bipolar disorder, w/ or w/o psychotic features

250 mg TID or 25 mg/kg (ER); max dose 60 mg/kg

3. Prophylaxis of migraine HAs

250 mg BID or 1 ER tab; max dose 1000 mg given BID or QD in ER tab

1. Management of anxiety disorders or for the short-term relief of the sxs of anxiety

2-10 mg orally, IM, or IV intially repeat 3-4 h PRN.  Use tabletes orally 2-3x/day

2. Withdrawal sxs of acute alcoholism

10 mg orally, IM, or IV initially repeat injection in 3-4 h PRN.  Oral dsoe = 30-40 mg during 1st 24h.  REduce oral dose to 5 mg 3-4x/day PRN

3. Relief of skeletal muscle spasm

5-10 mg IM or IV initially, then 5-10 mg in 3-4 h PRN.  2-10 mg orally 3-4 x/day

4. Adjunct in convulsive disorders

4-40 mg/day in divided doses

5. Preoperative apprehension and anxiety

10 mg IM prior surgery

6. Endoscopy procedures

5-10 mg IM 30 min prior to surgery or IV titrated to desired response

7. Cardioversion

5-15 mg IV w/in 5-10 mins of procedure

8. Status epilepticus

5-10 mg rectally, IM, or IV initially repeat at 10-15 min intervals up to max dose of 30 mg .  May repeat therapy in 2-4 hours.  IV is preferred

1. Anxiety disorders or for the short term relief of sxs of anxiety or anxiety-associated depressive states

0.25-0.5 mg TID initially can be titrated to 4 mg/day in divided doses

2. Tx of panic disorder

0.5 mg TID may be increased at intervals of 3-4 d in increments of NMT 1 mg/day

3. Tx of panic disorder, w/ or w/o agoraphobia

0.5-1mg may be increased in 1 mg increments q3-4d

TDD 3-6 mg/day

Elderly initiated at 0.5 mg/day

DC by reducing 0.5 mg q3-4d

1. Anxiety disorders or for the short-term relief of the sxs of anxiety or anxiety-associated depressive states

2-6 mg in divided doses HS (varies btw 1-10 mg)

2. Insomnia due to anxiety or transient situational stress

2-4 mg HS

3. Preanesthetic medication

0.05 mg/dg up to 4 mg IM 2 h prior to procedure

4. Sedation and relief of anxiety

0.044 mg/kg up to 2 mg IV whichever is smaller

5. Status epilepticus

4 mg by slow (2 mg/min) IV infusion.  If seizures persist after 10-15 min, give a 2nd 4 mg dose

ATIVAN INJECTION IS NOT RECOMMENDED FOR CHILDREN < 18 y/o

Short-term tx of insomnia

In elderly, debilitated, or hepatic insufficiency - initial Ambien 5 mg or Ambien CR 6.35 mg

Acute, painful musculoskeletal conditions

250-350 mg TID HS

Mild to moderate pain w/ or w/o fever

1 TA Q4H PRN F PN.  May give 2 D-N50 TAS Q4H.  No more than 500 mg of propoxyphene napsylate/day

NOT RECOMMENDED FOR USE IN CHILDREN

Moderate or moderately severe pain

1 TA PO Q6H PRN.  Do not exceed 4 g/day of Acetaminophen

Moderate to severe pain where use of an opioid analegsic is appropriate for more than a few days

10-20 mg BID

Moderate to moderately severe pain

1-2 TAS or 3 TSPS PO Q4T6H PRN F PN.  Should not exceed 4g/day of Acetaminophen

1. Moderate to moderately severe pain

IR tablets:  50-100 mg Q4T6H PRN.  Do not exceed 400  mg/day

2. Moderate to moderately severe pain in pts who require around the clock tx for an extended period of time

ER tablets:  100 mg/day may be titrated up 100 mg q5d to max dose 300 mg/day

1. Mild to moderate pain, primary dysmenorrhea, acute tendinitis, and bursitis

500 mg initialy followed by 250 mg Q6T8H PRN

2. RA, OA, and ankylosing spondylitis

250-500 mg BID

3. Acute Gout

750 mg initially followed by 250 mg Q8H PRN

NOT RECOMMENDED IN PEDIATRIC

1. Mild to Moderate pain and primary dysmenorrhea

400 mg Q4T6H

2. RA, OA

1200-3200 mg in 3-4 divided doses

3. JA

30-40 mg/kg/day in 3-4 divided doses

1. OA and RA

7.5 mg QD to Max dose of 15 mg QD

2. Pauciarticular and polyarticular course JRA

>2 y/o:  0.125 mg/kg QD up to max dose 7.5 mg

Skeletal muscle spasms

15 mg/day - 5 mg TID or 15 mg ER tab may be increased to 30 mg/day - 10 mg TID or 30 mg ER tab

Do not use for periods longer than 3 weeks or more than 60 mg/day

NOT RECOMMENDED FOR CHILDREN < 15 y/o

1. Adjunctive therapy to diet to reduce elevated LDL-C, Total-C, TGs and Apo B, and to increase HDL-C in adult pts w/ primary hypercholesterolemia or mixed dyslipidemia (Fredrickson Types IIa and IIb)

145 mg QD WF

2. Adjunctive therapy to diet for tx of adult pts w/ hyperTG (Fredrickson Types IV and V)

48-145 mg QD WF

3. Tx of ts w/ renal impairment:  48 mg QD WF

1.  Fredrickson Type IV, primary dysbetalipoproteinemia (Fredrickson type III), increase HDL-C in pts w/ hypercholesterlemia (heterozygous familial & nonfamilial) and mixed dyslipidemia (Type IIa & IIb)

10 mg QD initially; 5 mg for predisposing factors for myopathy; 20 mg for LDL-C > 190 mg/dL); maintenance - 5-40 mg QD

2. Homozygous familial hypercholesterolemia as an adjunct to other lipid-lowering txs

20 mg QD; max dose 40 mg QD

3. Adjunct to diet to slow the progession of atherosclerosis

10-20 mg QD

1. Frederickson Type IIa, IIb, III, & IV, multiple CHD riskfactorss to reduce the risk of MI, angina, and revascularization procedures

10 mg QD w/ or w/o meals.  Doage range - 10-80 mg/day

2. Reduce the risk of non-fatal MI, fatal or nonfatal stroke, angina, revascularization, & hospitalization for CHF

10-80 mg/day

3. Homozygous familial hypercholesterolemia

10-80 mg/day

4. Boys & Girls 10-17 w/ heerozygous familial hypercholesterolemia if adequate diet therapy remains > 190 or > 160 AND there is a family hx of premature CVD or 2 or more CVD risk factors

10 mg /day titrate up to 20 mg/day in 4 week intervals

1. Fredrickson Type IIa & IIb

20 mg w/ evening meal increase dosage at 4 wk intervals to max therapeutic response

2. Slow progression of coronary atherosclerosis in CHD pts

20-80 mg /day in a single or divided doses

3. Primary prevention of CHD in pts w/o symptomatic CVD who have avg to moderately elevated TC and LDL & below avg of HDL

10 mg/day in evening titrate to max 40 mg/day in 4 week interval

4. Boys & Girls 10-17 w/ heerozygous familial hypercholesterolemia if adequate diet therapy remains > 190 or > 160 AND there is a family hx of premature CVD or 2 or more CVD risk factors

1. Frederickson Type IIa, IIb, III, & IV

5-10 mg QPM.  Adjust dose at intervals of 4 weeks to max 80 mg/day.  Usual dose 10-40 mg

2. Homozygous familial hypercholesterolemia

80 mg in divided doses

3. Boys & Girls 10-17 w/ heterozygous familial hypercholesterolemia if adequate diet therapy remains > 190 or > 160 AND there is a family hx of premature CVD or 2 or more CVD risk factors

10 mg/day in evening and titrate max 40 mg/day in 4 week interval