Combination Therapy with Strattera and Cymbalta

Introduction to Combination Therapy

The American Academy of Child and Adolescent Psychiatry recommends that healthcare providers can prescribe Strattera (atomoxetine) with Cymbalta (duloxetine), but this combination requires careful monitoring due to a significant drug-drug interaction that increases atomoxetine exposure and potential adverse effects 1, 2

Duloxetine is a CYP2D6 inhibitor, which significantly alters atomoxetine pharmacokinetics, and when these medications are combined, atomoxetine exposure increases, and its half-life extends 1, 2

The American Academy of Child and Adolescent Psychiatry suggests measuring blood pressure and pulse at baseline, after each dose adjustment, and at least monthly during maintenance when combining Strattera and Cymbalta 1, 2
Monitoring for sustained clinical hypertension is necessary, as both drugs can cause this 1, 2

The American Academy of Child and Adolescent Psychiatry recommends monitoring for hepatic symptoms, as duloxetine carries a risk of hepatic failure, presenting as abdominal pain, hepatomegaly, elevated transaminases 1, 2, 3
Discontinuing duloxetine immediately if jaundice or clinically significant liver dysfunction develops is advised 1, 2, 3

Common overlapping adverse effects of Strattera and Cymbalta include nausea and vomiting, decreased appetite and potential weight loss, dry mouth, headache, dizziness, and insomnia 1, 2, 5
Serious adverse effects requiring immediate attention include serotonin syndrome risk, suicidal ideation, severe skin reactions with duloxetine, and behavioral activation, agitation, hypomania, or mania 1, 2, 3

The American College of Obstetricians and Gynecologists notes that limited data exist for both medications in pregnancy, and atomoxetine shows a possible increased risk for spontaneous abortion and preterm birth 6, 7, 8
Duloxetine may increase the risk of persistent pulmonary hypertension of the newborn when used after 20 weeks gestation 5
No published studies exist for atomoxetine during breastfeeding, and caution is advised, while duloxetine is present in breast milk at low levels 5, 6, 7, 8
Duloxetine requires dose adjustment in renal impairment and should be avoided in severe renal impairment 4