Duloxetine

INTRODUCTION

Indications

Major depressive disorder. Diabetic peripheral neuropathic pain. Generalized anxiety disorder. Fibromyalgia. Unlabeled Use: Stress urinary incontinence.

Action

Inhibits serotonin and norepinephrine reuptake in the CNS. Both antidepressant and pain inhibition are centrally mediated. Therapeutic Effects: Decreased depressive symptomatology. Decreased neuropathic pain. Decreased symptoms of anxiety. Decreased pain.

Adverse Reactions/Side Effects

CNS: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, SUICIDAL THOUGHTS, fatigue, drowsiness, insomnia, activation of mania, dizziness, nightmares. EENT: blurred vision, ↑ intraocular pressure. CV: ↑ blood pressure. GI: HEPATOTOXICITY, ↓ appetite, constipation, dry mouth, nausea, diarrhea, ↑ liver enzymes, gastritis, vomiting. F and E: hyponatremia. GU: dysuria, abnormal orgasm, erectile dysfunction, ↓ libido, urinary retention. Derm: ↑ sweating, pruritus, rash. Neuro: tremor. Misc: SEROTONIN SYNDROME.

PHYSICAL THERAPY IMPLICATIONS

Examination and Evaluation

• Be alert for increased depression and suicidal thoughts and ideology, especially when initiating drug treatment, and in children and teenagers. Notify physician or other mental health care professional immediately if patient exhibits worsening depression or expresses thoughts of suicide.

• Watch for signs of neuroleptic malignant syndrome, including hyperthermia, diaphoresis, generalized muscle rigidity, altered mental status, tachycardia, changes in blood pressure (BP), and incontinence. Symptoms typically occur within 4–14 days after initiation of drug therapy, but can occur at any time during drug use. Report these signs to the physician immediately.

• Monitor and immediately report signs of serotonin syndrome, including hyperthermia, rigidity, myoclonus, and autonomic instability with fluctuating vital signs and extreme agitation that may proceed to delirium and coma. Patients should not take duloxetine with other drugs that increase serotonin levels (e.g., MAO inhibitors).

• Be alert for new seizures or increased seizure activity, especially at the onset of drug treatment. Document the number, duration, and severity of seizures, and report these findings immediately to the physician.

• Be alert for signs of hepatotoxicity, including anorexia, abdominal pain, severe nausea and vomiting, yellow skin or eyes, fever, sore throat, malaise, weakness, facial edema, lethargy, and unusual bleeding or bruising. Report these signs to the physician immediately.

• Inform physician if patient demonstrates other mood changes such as anxiety, nervousness, restlessness, or other signs of increased mania.

• When used to treat fibromyalgia, diabetic neuropathy, or other chronic pain syndromes, assess pain levels periodically to help document drug efficacy.

• Assess levels of drowsiness and dizziness (See Appendix C), especially in older adults. Determine if these side effects might impair gait, balance, and other functional activities.

• Assess BP and compare to normal values (See Appendix F). Report a sustained increase in BP (hypertension).

• Monitor signs of low sodium levels (hyponatremia), including headache, confusion, lethargy, irritability, decreased consciousness, and neuromuscular abnormalities (muscle weakness and cramps). Report ...