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Cymbalta-Pdoc adding an SNRI to my SSRI...????


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Ok guys, this might be the last time I post a meds question.......My pdoc is adding 20mg Cymbalta to my current cocktail.

The only SNRI I've ever tried is Effexor, and that didn't work out for me.......I don't know what time of day to take the Cymbalta it so it won't disturb my sleep?....Pdoc and pharmacist said just take it each day at the time that works best for me.

In general, does it tend to be activating or sedating for most people?......I have read that some people sleep fine on it, and some say it can cause insomnia.

Anybody have any experience with Cymbalta?

All thoughts welcome......Thanks so much...

  @basuraeuropea  @browri  @Iceberg

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Unfortunately it might be a “no way to tell until you try” situation. I couldn’t find anything official from the manufacturer. If you take it at night and it causes issues you’d probably know fairly quickly. Since it’s such a low dose I wouldn’t worry too much because switching from AM to PM or reverse shouldn’t be too difficult

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It's a peculiar drug in my experience. It does release some "happy" neurotransmitters I've always enjoyed it. Another very peculiar effect of it was it activated the language centers of my brain. Once I read 300 pages of a Sttephen King novvel after taking it.

 

Edited by the maze runner
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Thank you, @DogMan, @the maze runner, and @Iceberg........I did read in the PI sheet that it can possibly cause urinary issues......Also read that it could possibly cause increase in blood pressue, and possibly increase blood sugar.

I took first dose this morning, and feel slightly more anxious, and not tired at all......I suppose I'll see how my sleep goes tonight......I don't know if she plans on increasing the dose or not....20mg is a really low dose for this med.

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  • Cymbalta tends to be stimulating. I took it before bed when I took it historically, but I was also misdiagnosed and only taking that. My sleep wasn't great, but who's to say if it was the Cymbalta or the hypomania.
  • Cymbalta capsules are delayed release, meaning they don't start releasing until ~2 hours after you take it when it reaches the right spot in the small intestine, then I think they release over the course of the following ~4 hours. Another interesting tidbit is that Cymbalta's half-life is longer when it is taken at night.
  • Cymbalta is probably less likely to cause hypertension than venlafaxine or desvenlafaxine.
  • The adrenaline/nervous feelings will likely get better with time, and the hope is that your baseline anxiety is improved.

 

All things being said...probably best to take it in the morning so as not to disturb your sleep because I know that's difficult for you. Is the goal to replace the Lexapro or to use them together?

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9 hours ago, browri said:
  • Cymbalta tends to be stimulating. I took it before bed when I took it historically, but I was also misdiagnosed and only taking that. My sleep wasn't great, but who's to say if it was the Cymbalta or the hypomania.
  • Cymbalta capsules are delayed release, meaning they don't start releasing until ~2 hours after you take it when it reaches the right spot in the small intestine, then I think they release over the course of the following ~4 hours. Another interesting tidbit is that Cymbalta's half-life is longer when it is taken at night.
  • Cymbalta is probably less likely to cause hypertension than venlafaxine or desvenlafaxine.
  • The adrenaline/nervous feelings will likely get better with time, and the hope is that your baseline anxiety is improved.

 

All things being said...probably best to take it in the morning so as not to disturb your sleep because I know that's difficult for you. Is the goal to replace the Lexapro or to use them together?

Thanks @browri......I took first dose in the morning yesterday, and woke up once last night, for about an hour, before I went back to sleep......I took a dose this morning as well, so we'll see how it goes tonight.

I think pdocs goal is to use together with Lexapro, although I'm not quite sure yet......She mentioned using Zyprexa in place of the Risperdal, although I admit I'm pretty reluctant to use that.

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hi @CrazyRedhead. i am not convinced that it's widely regarded as being stimulating as stated by @browri (i think it was probably hypo popping up for him); somnolence is listed as one of the drug's most common side effects per the Eli Lilly PI sheet and that certainly has been my experience with the drug. i have found it super fatiguing at varying dosages where an excessive amount of sleep was needed daily. it did work well to control my anxiety disorders, but did not help a ton to control depression unless blunting all affect counts. several years later mirtazapine was added and that did help with depression/anhedonia, but the weight gain...oh, the weight gain.

i am glad that you are open to trying it. ❤️

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On 12/25/2022 at 1:55 AM, basuraeuropea said:

hi @CrazyRedhead. i am not convinced that it's widely regarded as being stimulating as stated by @browri (i think it was probably hypo popping up for him); somnolence is listed as one of the drug's most common side effects per the Eli Lilly PI sheet

This is genuinely true. I was very hypomanic at the time I last took duloxetine, and my experience with bupropion as an NRI since then would indicate that somnolence can be an issue with NRIs if you're bipolar but properly stabilized. Still.....more recently I found desvenlafaxine to be quite stimulating, and duloxetine is usually only more so than desvenlafaxine. So, your mileage may vary I guess.

On 12/23/2022 at 8:52 PM, CrazyRedhead said:

Thanks @browri......I took first dose in the morning yesterday, and woke up once last night, for about an hour, before I went back to sleep......I took a dose this morning as well, so we'll see how it goes tonight.

Fortunately, duloxetine takes about 3 days to reach steady state. So you'll know pretty quickly if there are any side effects. But keep in mind of course that some of those dissipate with time.

On 12/23/2022 at 8:52 PM, CrazyRedhead said:

I think pdocs goal is to use together with Lexapro, although I'm not quite sure yet......She mentioned using Zyprexa in place of the Risperdal, although I admit I'm pretty reluctant to use that.

Yeah, I can understand the reluctance. I personally had the typical issues with lipids and glucose and increased weight with olanzapine, but it's a dream for anxiety and depression. Quite sedating so a wonderful bedtime med. If you have issues sleeping, olanzapine is where it's at. It's a shame it causes metabolic dysfunction for so many people because it's actually really effective for calming rumination. Even 2.5mg of this stuff goes a long way.

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36 minutes ago, browri said:

This is genuinely true. I was very hypomanic at the time I last took duloxetine, and my experience with bupropion as an NRI since then would indicate that somnolence can be an issue with NRIs if you're bipolar but properly stabilized. Still.....more recently I found desvenlafaxine to be quite stimulating, and duloxetine is usually only more so than desvenlafaxine. So, your mileage may vary I guess.

in contrast to duloxetine, desvenlafaxine is clinically documented as being more stimulating with very common or common side effects including: insomnia, feeling jittery, anxiety, decreased appetite, and nervousness per the PI sheets released by pfizer and ranbaxy pharmaceuticals.

clearly they are two different drugs, but i wouldn't bank on duloxetine causing for additional anxiety in the long run, @CrazyRedhead. i hope it works out for you.

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4 hours ago, basuraeuropea said:

in contrast to duloxetine, desvenlafaxine is clinically documented as being more stimulating with very common or common side effects including: insomnia, feeling jittery, anxiety, decreased appetite, and nervousness per the PI sheets released by pfizer and ranbaxy pharmaceuticals.

clearly they are two different drugs, but i wouldn't bank on duloxetine causing for additional anxiety in the long run, @CrazyRedhead. i hope it works out for you.

Well yeah but insomnia (9% vs 5% for placebo) and decreased appetite (7% vs 2% for placebo) are both prominent adverse effects of duloxetine (Cymbalta PI, page 12, Table 2), albeit not ones that typically caused discontinuation. Typically with duloxetine, one discontinues in the beginning because one can never develop a tolerance to the startup nausea.

@CrazyRedhead This isn't to say necessarily that duloxetine will or won't be stimulating. On the one hand, it activates the adrenergic system, but it does so more centrally (in the brain) than venlafaxine or desvenlafaxine, which have a more generalized (central+peripheral) effect. This is likely why venlafaxine/desvenlafaxine have the higher risk of hypertension vs duloxetine, and as @basuraeuropea pointed out, this is likely why venlafaxine/desvenlafaxine can still have some of the peripheral effects like jitteriness or nervousness despite being the lesser NRI of the two.

Despite the fact that norepinephrine reuptake inhibition is assumed to be stimulating, its effects are variable depending on where it occurs in the nervous system. In the peripheral nervous system, activation of alpha-2 adrenergic receptors leads to an increase in the release of GABA and thus has an inhibitory effect on the neurotransmission of pain signals back to the brain. This is how duloxetine, milnacipran/levomilnacipran are believed to mediate their effects in neuropathic pain. Venlafaxine/desvenlafaxine's lower affinity for the norepinephrine transporter likely makes them unsuitable for this purpose.

This also isn't to say that venlafaxine and desvenlafaxine aren't potent antidepressants. If you're really curious, go to the Wiki page for venlafaxine and then levothyroxine and then overlay the venlafaxine chemical structure against levothyroxine and you will find they are very similar. Amphetamine shares a similar structure to venlafaxine and thyroid hormones. In fact, thyroid hormones were used as the basis for the construction of the venlafaxine molecule. Development of duloxetine started not too longer after fluoxetine was released to the public. Duloxetine with EliLilly and Venlafaxine with Wyeth (now Pfizer).

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