Prescription Drug Information: Duloxetine (Page 3 of 9)

5.12 Clinically Important Drug Interactions

Both CYP1A2 and CYP2D6 are responsible for duloxetine metabolism.

Potential for Other Drugs to Affect Duloxetine

CYP1A2 Inhibitors — Co-administration of duloxetine with potent CYP1A2 inhibitors should be avoided [see Drug Interactions ( 7.1)] .

CYP2D6 Inhibitors — Because CYP2D6 is involved in duloxetine metabolism, concomitant use of duloxetine with potent inhibitors of CYP2D6 would be expected to, and does, result in higher concentrations (on average of 60%) of duloxetine [see Drug Interactions ( 7.2)] .

Potential for Duloxetine to Affect Other Drugs

Drugs Metabolized by CYP2D6 — Co-administration of duloxetine with drugs that are extensively metabolized by CYP2D6 and that have a narrow therapeutic index, including certain antidepressants (tricyclic antidepressants [TCAs], such as nortriptyline, amitriptyline, and imipramine), phenothiazines and Type 1C antiarrhythmics (e.g., propafenone, flecainide), should be approached with caution. Plasma TCA concentrations may need to be monitored and the dose of the TCA may need to be reduced if a TCA is co-administered with duloxetine. Because of the risk of serious ventricular arrhythmias and sudden death potentially associated with elevated plasma levels of thioridazine, duloxetine and thioridazine should not be co-administered [see Drug Interactions ( 7.9)] .

Other Clinically Important Drug Interactions

Alcohol — Use of duloxetine concomitantly with heavy alcohol intake may be associated with severe liver injury. For this reason, duloxetine should not be prescribed for patients with substantial alcohol use [see Warnings and Precautions ( 5.2) and Drug Interactions ( 7.15)] .

CNS Acting Drugs — Given the primary CNS effects of duloxetine, it should be used with caution when it is taken in combination with or substituted for other centrally acting drugs, including those with a similar mechanism of action [see Warnings and Precautions ( 5.12) and Drug Interactions ( 7.16)] .

5.13 Hyponatremia

Hyponatremia may occur as a result of treatment with SSRIs and SNRIs, including duloxetine. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported with duloxetine use and appeared to be reversible when duloxetine was discontinued. Geriatric patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs. Also, patients taking diuretics or who are otherwise volume depleted may be at greater risk [see Use in Specific Populations ( 8.5)] . Discontinuation of duloxetine should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted.

Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. More severe and/or acute cases have been associated with hallucination, syncope, seizure, coma, respiratory arrest, and death.

5.14 Use in Patients with Concomitant Illness

Clinical experience with duloxetine in patients with concomitant systemic illnesses is limited. There is no information on the effect that alterations in gastric motility may have on the stability of duloxetine’s enteric coating. In extremely acidic conditions, duloxetine, unprotected by the enteric coating, may undergo hydrolysis to form naphthol. Caution is advised in using duloxetine in patients with conditions that may slow gastric emptying (e.g., some diabetics).

Duloxetine has not been systematically evaluated in patients with a recent history of myocardial infarction or unstable coronary artery disease. Patients with these diagnoses were generally excluded from clinical studies during the product’s premarketing testing.

Hepatic Impairment

Avoid use in patients with chronic liver disease or cirrhosis [see Dosage and Administration ( 2.7), Warnings and Precautions ( 5.2), and Use in Specific Populations ( 8.9)].

Severe Renal Impairment

Avoid use in patients with severe renal impairment, GFR <30 mL/minute. Increased plasma concentration of duloxetine, and especially of its metabolites, occured in patients with end-stage renal disease (requiring dialysis) [see Dosage and Administration ( 2.7) and Use in Specific Populations ( 8.10)].

Glycemic Control in Patients with Diabetes

As observed in DPNP trials, duloxetine treatment worsened glycemic control in some patients with diabetes. In three clinical trials of duloxetine for the management of neuropathic pain associated with diabetic peripheral neuropathy [see Clinical Studies ( 14.4)] , the mean duration of diabetes was approximately 12 years, the mean baseline fasting blood glucose was 176 mg/dL, and the mean baseline hemoglobin A 1c (HbA 1c ) was 7.8%. In the 12-week acute treatment phase of these studies, duloxetine was associated with a small increase in mean fasting blood glucose as compared to placebo. In the extension phase of these studies, which lasted up to 52 weeks, mean fasting blood glucose increased by 12 mg/dL in the duloxetine group and decreased by 11.5 mg/dL in the routine care group. HbA 1c increased by 0.5% in the duloxetine group and by 0.2% in the routine care group.

5.15 Urinary Hesitation and Retention

Duloxetine is in a class of drugs known to affect urethral resistance. If symptoms of urinary hesitation develop during treatment with duloxetine, consideration should be given to the possibility that they might be drug-related.

In post marketing experience, cases of urinary retention have been observed. In some instances of urinary retention associated with duloxetine use, hospitalization and/or catheterization has been needed.

6 ADVERSE REACTIONS

The following serious adverse reactions are described below and elsewhere in the labeling:

  • Suicidal Thoughts and Behaviors in Children, Adolescents and Young Adults [see Boxed Warning and Warnings and Precautions ( 5.1)]
  • Hepatotoxicity [see Warnings and Precautions ( 5.2)]
  • Orthostatic Hypotension, Falls and Syncope [see Warnings and Precautions ( 5.3)]
  • Serotonin Syndrome [see Warnings and Precautions ( 5.4)]
  • Increased Risk of Bleeding [see Warnings and Precautions ( 5.5)]
  • Severe Skin Reactions [see Warnings and Precautions ( 5.6)]
  • Discontinuation Syndrome [see Warnings and Precautions ( 5.7)]
  • Activation of Mania/Hypomania [see Warnings and Precautions ( 5.8)]
  • Angle-Closure Glaucoma [see Warnings and Precautions ( 5.9)]
  • Seizures [see Warnings and Precautions ( 5.10)]
  • Increases in Blood Pressure [see Warnings and Precautions ( 5.11)]
  • Clinically Important Drug Interactions [see Warnings and Precautions ( 5.12)]
  • Hyponatremia [see Warnings and Precautions ( 5.13)]
  • Urinary Hesitation and Retention [see Warnings and Precautions ( 5.15)]

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The stated frequencies of adverse reactions represent the proportion of patients who experienced, at least once, one treatment-emergent adverse reaction of the type listed. A reaction was considered treatment-emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation.

Adverse Reactions in Adults

Adult Clinical Trial Database

The data described below reflect exposure to duloxetine delayed-release capsules in placebo-controlled adult trials for MDD (N=3779), GAD (N=1018), OA (N=503), CLBP (N=600), DPNP (N=906), and FM (N=1294). The age range in this pooled population was 17 to 89 years of age. In this pooled population, 66%, 61%, 61%, 43%, and 94% of adult patients were female; and 82%, 73%, 85%, 74%, and 86% of adult patients were Caucasian in the MDD, GAD, OA and CLBP, DPNP, and FM populations, respectively. Most patients received duloxetine delayed-release capsules dosages of a total of 60 to 120 mg per day [see Clinical Studies ( 14)] . The data below do not include results of the trial that evaluated the efficacy of duloxetine delayed-release capsules for the treatment of GAD in patients ≥ 65 years old (Study GAD-5) [see Clinical Studies ( 14.3)] ; however, the adverse reactions observed in this geriatric population were generally similar to adverse reactions in the overall adult population.

Adverse Reactions Leading to Treatment Discontinuation in Adult Placebo-Controlled Trials

Major Depressive Disorder

Approximately 8.4% (319/3779) of duloxetine -treated patients in placebo-controlled adult trials for MDD discontinued treatment due to an adverse reaction, compared with 4.6% (117/2536) of placebo-treated patients. Nausea (duloxetine 1.1%, placebo 0.4%) was the only adverse reaction reported as a reason for discontinuation and considered to be drug-related (i.e., discontinuation occurring in at least 1% of the duloxetine -treated patients and at a rate of at least twice that of placebo-treated patients).

Generalized Anxiety Disorder

Approximately 13.7% (139/1018) of the duloxetine -treated patients in placebo-controlled adult trials for GAD discontinued treatment due to an adverse reaction, compared with 5% (38/767) for placebo-treated patients. Common adverse reactions reported as a reason for discontinuation and considered to be drug-related (as defined above) included nausea (duloxetine 3.3%, placebo 0.4%), and dizziness (duloxetine 1.3%, placebo 0.4%).

Diabetic Peripheral Neuropathic Pain

Approximately 12.9% (117/906) of the duloxetine -treated patients in placebo-controlled adult trials for DPNP discontinued treatment due to an adverse reaction, compared with 5.1% (23/448) for placebo-treated patients. Common adverse reactions reported as a reason for discontinuation and considered to be drug-related (as defined above) included nausea (duloxetine 3.5%, placebo 0.7%), dizziness (duloxetine 1.2%, placebo 0.4%), and somnolence (duloxetine 1.1%, placebo 0 %).

Fibromyalgia

Approximately 17.5% (227/1294) of the duloxetine -treated patients in 3- to 6- month placebo-controlled adult trials for FM discontinued treatment due to an adverse reaction, compared with 10.1% (96/955) for placebo-treated patients. Adverse reactions reported as a reason for discontinuation and considered to be drug-related (as defined above) included nausea (duloxetine 2.0%, placebo 0.5%), headache (duloxetine 1.2%, placebo 0.3%), somnolence (duloxetine 1.1%, placebo 0%), and fatigue (duloxetine 1.1%, placebo 0.1%).

Chronic Pain due to Osteoarthritis

Approximately 15.7% (79/503) of the duloxetine -treated patients in 13-week, placebo-controlled adult trials for chronic pain due to OA discontinued treatment due to an adverse reaction, compared with 7.3% (37/508) for placebo-treated patients. Adverse reactions reported as a reason for discontinuation and considered to be drug-related (as defined above) included nausea (duloxetine 2.2%, placebo 1%).

Chronic Low Back Pain

Approximately 16.5% (99/600) of the duloxetine -treated patients in 13-week, placebo-controlled adult trials for CLBP discontinued treatment due to an adverse reaction, compared with 6.3% (28/441) for placebo-treated patients. Adverse reactions reported as a reason for discontinuation and considered to be drug-related (as defined above) included nausea (duloxetine 3%, placebo 0.7%), and somnolence (duloxetine 1%, placebo 0%).

Most Common Adverse Reactions in Adult Trials

The most commonly observed adverse reactions in duloxetine -treated patients (as defined above) were:

  • Diabetic Peripheral Neuropathic Pain: nausea, somnolence, decreased appetite, constipation, hyperhidrosis, and dry mouth.
  • Fibromyalgia: nausea, dry mouth, constipation, somnolence, decreased appetite, hyperhidrosis, and agitation.
  • Chronic Pain due to Osteoarthritis: nausea, fatigue, constipation, dry mouth, insomnia, somnolence, and dizziness.
  • Chronic Low Back Pain: nausea, dry mouth, insomnia, somnolence, constipation, dizziness, and fatigue.

The most commonly observed adverse reactions in duloxetine -treated patients in all the pooled adult populations (i.e., MDD, GAD, DPNP, FM, OA, and CLBP) (incidence of at least 5% and at least twice the incidence in placebo-treated patients) were nausea, dry mouth, somnolence, constipation, decreased appetite, and hyperhidrosis.

Table 2 displays the incidence of adverse reactions in placebo-controlled trials for approved adult populations (i.e., MDD, GAD, DPNP, FM, OA, and CLBP) that occurred in 5% or more of duloxetine-treated patients and with an incidence greater than placebo-treated patients.

Table 2: Adverse Reactions: Incidence of 5% or More and Greater than Placebo in Placebo-Controlled Trials of Approved Adult Populations a

Adverse Reaction Percentage of Patients Reporting Reaction
Duloxetine (N=8100) Placebo (N=5655)
Nausea c 23 8
Headache 14 12
Dry mouth 13 5
Somnolence e 10 3
Fatigue b, c 9 5
Insomnia d 9 5
Constipation c 9 4
Dizziness c 9 5
Diarrhea 9 6
Decreased appetite c 7 2
Hyperhidrosis c 6 1
Abdominal Pain f 5 4

a Includes adults with MDD, GAD, DPNP, FM, and chronic musculoskeletal pain. The inclusion of an event in the table is determined based on the percentages before rounding; however, the percentages displayed in the table are rounded to the nearest integer.

b Also includes asthenia.

c Events for which there was a significant dose-dependent relationship in fixed-dose studies, excluding three MDD studies which did not have a placebo lead-in period or dose titration.

d Also includes initial insomnia, middle insomnia, and early morning awakening.

e Also includes hypersomnia and sedation.

f Also includes abdominal discomfort, abdominal pain lower, abdominal pain upper, abdominal tenderness, and gastrointestinal pain.

Adverse Reactions in Pooled MDD and GAD Trials in Adults

Table 3 displays the incidence of adverse reactions in MDD and GAD placebo-controlled adult trials that occurred in 2% or more of duloxetine -treated patients and with an incidence greater than placebo-treated patients.

Table 3: Adverse Reactions: Incidence of 2% or More and Greater than Placebo in MDD and GAD Placebo-Controlled Trials in Adults a,b

System Organ Class / Adverse Reaction Percentage of Patients Reporting Reaction
Duloxetine (N=4797) Placebo (N=3303)
Cardiac Disorders
Palpitations 2 1
Eye Disorders
Vision blurred 3 1
Gastrointestinal Disorders
Nausea c 23 8
Dry mouth 14 6
Constipation c 9 4
Diarrhea 9 6
Abdominal pain d 5 4
Vomiting 4 2
General Disorders and Administration Site Conditions
Fatigue e 9 5
Metabolism and Nutrition Disorders
Decreased appetite c 6 2
Nervous System Disorders
Headache 14 14
Dizziness c 9 5
Somnolence f 9 3
Tremor 3 1
Psychiatric Disorders
Insomnia g 9 5
Agitation h 4 2
Anxiety 3 2
Reproductive System and Breast Disorders
Erectile dysfunction 4 1
Ejaculation delayed c 2 1
Libido decreased i 3 1
Orgasm abnormal j 2 <1
Respiratory, Thoracic, and Mediastinal Disorders
Yawning 2 <1
Skin and Subcutaneous Tissue Disorders
Hyperhidrosis 6 2

a The inclusion of an event in the table is determined based on the percentages before rounding; however, the percentages displayed in the table are rounded to the nearest integer.

b For GAD, there were no adverse reactions that were significantly different between treatments in adults ≥65 years that were also not significant in the adults <65 years.

c Events for which there was a significant dose-dependent relationship in fixed-dose studies, excluding three MDD studies which did not have a placebo lead-in period or dose titration.

d Includes abdominal pain upper, abdominal pain lower, abdominal tenderness, abdominal discomfort, and gastrointestinal pain.

e Includes asthenia.

f Includes hypersomnia and sedation.

g Includes initial insomnia, middle insomnia, and early morning awakening.

h Includes feeling jittery, nervousness, restlessness, tension and psychomotor hyperactivity.

i Includes loss of libido.

j Includes anorgasmia.

Adverse Reactions in the DPNP, FM, OA, and CLBP Adult Trials

Table 4 displays the incidence of adverse reactions that occurred in 2% or more of duloxetine -treated patients (determined prior to rounding) in the premarketing acute phase of DPNP, FM, OA, and CLBP placebo-controlled adult trials and with an incidence greater than placebo-treated patients.

Table 4: Adverse Reactions: Incidence of 2% or More and Greater than Placebo in DPNP, FM, OA, and CLBP Placebo-Controlled Trials a

System Organ Class / Adverse Reaction Percentage of Patients Reporting Reaction
Duloxetine (N=3303) Placebo (N=2352)
Gastrointestinal Disorders
Nausea 23 7
Dry Mouth b 11 3
Constipation b 10 3
Diarrhea 9 5
Abdominal Pain c 5 4
Vomiting 3 2
Dyspepsia 2 1
General Disorders and Administration Site Conditions
Fatigue d 11 5
Infections and Infestations
Nasopharyngitis 4 4
Upper Respiratory Tract Infection 3 3
Influenza 2 2
Metabolism and Nutrition Disorders
Decreased Appetite b 8 1
Musculoskeletal and Connective Tissue Musculoskeletal Pain e 3 3
Muscle Spasms 2 2
Nervous System Disorders
Headache 13 8
Somnolence b,f 11 3
Dizziness 9 5
Paraesthesia g 2 2
Tremor b 2 <1
Psychiatric Disorders
Insomnia b,h 10 5
Agitation i 3 1
Reproductive System and Breast Disorders
Erectile Dysfunction b 4 <1
Ejaculation Disorder j 2 <1
Respiratory, Thoracic, and Mediastinal Disorders
Cough 2 2
Skin and Subcutaneous Tissue Disorders
Hyperhidrosis 6 1
Vascular Disorders
Flushing k 3 1
Blood pressure increased l 2 1

a The inclusion of an event in the table is determined based on the percentages before rounding; however, the percentages displayed in the table are rounded to the nearest integer.

b Incidence of 120 mg/day is significantly greater than the incidence for 60 mg/day.

c Includes abdominal discomfort, lower abdominal pain, upper abdominal pain, abdominal tenderness and gastrointestinal pain.

d Includes asthenia.

e Includes myalgia and neck pain.

f Includes hypersomnia and sedation.

g Includes hypoaesthesia, facial hypoaesthesia, genital hypoaesthesia and oral paraesthesia.

h Includes initial insomnia, middle insomnia, and early morning awakening.

i Includes feeling jittery, nervousness, restlessness, tension and psychomotor hyperactivity.

j Includes ejaculation failure.

k Includes hot flush.

l Includes increased diastolic blood pressure, increased systolic blood pressure, diastolic hypertension, essential hypertension, hypertension, hypertensive crisis, labile hypertension, orthostatic hypertension, secondary hypertension, and systolic hypertension.

Effects on Male and Female Sexual Function in Adults with MDD

Changes in sexual desire, sexual performance and sexual satisfaction often occur as manifestations of psychiatric disorders or diabetes, but they may also be a consequence of pharmacologic treatment. Because adverse sexual reactions are presumed to be voluntarily underreported, the Arizona Sexual Experience Scale (ASEX), a validated measure designed to identify sexual adverse reactions, was used prospectively in 4 MDD placebo-controlled adult trials (Studies MDD-1, MDD-2, MDD-3, and MDD-4) [see Clinical Studies ( 14.2)] . The ASEX scale includes five questions that pertain to the following aspects of sexual function: 1) sex drive, 2) ease of arousal, 3) ability to achieve erection (men) or lubrication (women), 4) ease of reaching orgasm, and 5) orgasm satisfaction. Positive numbers signify a worsening of sexual function from baseline. Negative numbers signify an improvement from a baseline level of dysfunction, which is commonly seen in depressed patients.

In these trials, duloxetine -treated male patients experienced significantly more sexual dysfunction, as measured by the total score on the ASEX and the ability to reach orgasm, than placebo-treated male patients (see Table 5). duloxetine -treated female patients did not experience more sexual dysfunction than placebo-treated female patients as measured by ASEX total score. Healthcare providers should routinely inquire about possible sexual adverse reactions in duloxetine -treated patients.

Table 5: Mean Change in ASEX Scores by Gender in MDD Placebo-Controlled Adult Trials

Male Patients a Female Patients a
Duloxetine (n=175) Placebo (n=83) Duloxetine (n=241) Placebo (n=126)
ASEX Total (Items 1 to 5) 0.56 b -1.07 -1.15 -1.07
Item 1 — Sex drive -0.07 -0.12 -0.32 -0.24
Item 2 — Arousal 0.01 -0.26 -0.21 -0.18
Item 3 — Ability to achieve erection (men); Lubrication (women) 0.03 -0.25 -0.17 -0.18
Item 4 — Ease of reaching orgasm 0.40 c -0.24 -0.09 -0.13
Item 5 — Orgasm satisfaction 0.09 -0.13 -0.11 -0.17

a n=Number of patients with non-missing change score for ASEX total.

b p=0.013 versus placebo.

c p<0.001 versus placebo.

Vital Sign Changes in Adults

In placebo-controlled clinical trials across approved adult populations for change from baseline to endpoint, duloxetine treated patients had mean increases of 0.23 mm Hg in systolic blood pressure (SBP) and 0.73 mm Hg in diastolic blood pressure (DBP) compared to mean decreases of 1.09 mm Hg in SBP and 0.55 mm Hg in DBP in placebo-treated patients. There was no significant difference in the frequency of sustained (3 consecutive visits) elevated blood pressure [see Warnings and Precautions ( 5.3, 5.11)] .

Duloxetine treatment, for up to 26 weeks in placebo-controlled trials across approved adult populations, typically caused a small increase in heart rate for change from baseline to endpoint compared to placebo of up to 1.37 beats per minute (increase of 1.20 beats per minute in duloxetine -treated patients, decrease of 0.17 beats per minute in placebo-treated patients).

Laboratory Changes in Adults

Duloxetine treatment in placebo-controlled clinical trials across approved adult populations, was associated with small mean increases from baseline to endpoint in ALT, AST, CPK, and alkaline phosphatase; infrequent, modest, transient, abnormal values were observed for these analytes in duloxetine -treated patients when compared with placebo-treated patients [see Warnings and Precautions ( 5.2)] . High bicarbonate, cholesterol, and abnormal (high or low) potassium, were observed more frequently in duloxetine treated patients compared to placebo-treated patients.

Other Adverse Reactions Observed During the Clinical Trial Evaluation of Duloxetine in Adults

Following is a list of adverse reactions reported by patients treated withduloxetine in clinical adult trials. In clinical trials of all approved adult populations, 34,756 patients were treated with duloxetine. Of these, 27% (9337) took duloxetine for at least 6 months, and 12% (4317) took duloxetine for at least one year. The following listing is not intended to include reactions (1) already listed in previous tables or elsewhere in labeling, (2) for which a drug cause was remote, (3) which were so general as to be uninformative, (4) which were not considered to have significant clinical implications, or (5) which occurred at a rate equal to or less than placebo.

Reactions are categorized by body system according to the following definitions: frequent adverse reactions are those occurring in at least 1/100 patients; infrequent adverse reactions are those occurring in 1/100 to 1/1000 patients; rare reactions are those occurring in fewer than 1/1000 patients.

  • Cardiac DisordersFrequent: palpitations; Infrequent: myocardial infarction, tachycardia, and Takotsubo cardiomyopathy.
  • Ear and Labyrinth DisordersFrequent: vertigo; Infrequent: ear pain and tinnitus.
  • Endocrine DisordersInfrequent: hypothyroidism.
  • Eye DisordersFrequent: vision blurred; Infrequent: diplopia, dry eye, and visual impairment.
  • Gastrointestinal DisordersFrequent: flatulence; Infrequent: dysphagia, eructation, gastritis, gastrointestinal hemorrhage, halitosis, and stomatitis; Rare: gastric ulcer.
  • General Disorders and Administration Site ConditionsFrequent: chills/rigors; Infrequent: falls, feeling abnormal, feeling hot and/or cold, malaise, and thirst; Rare: gait disturbance.
  • Infections and InfestationsInfrequent: gastroenteritis and laryngitis.
  • InvestigationsFrequent: weight increased, weight decreased; Infrequent: blood cholesterol increased.
  • Metabolism and Nutrition DisordersInfrequent: dehydration and hyperlipidemia; Rare: dyslipidemia.
  • Musculoskeletal and Connective Tissue DisordersFrequent: musculoskeletal pain; Infrequent: muscle tightness and muscle twitching.
  • Nervous System DisordersFrequent: dysgeusia, lethargy, and paraesthesia/hypoesthesia; Infrequent: disturbance in attention, dyskinesia, myoclonus, and poor quality sleep; Rare: dysarthria.
  • Psychiatric DisordersFrequent: abnormal dreams and sleep disorder; Infrequent: apathy, bruxism, disorientation/confusional state, irritability, mood swings, and suicide attempt; Rare: completed suicide.
  • Renal and Urinary Disorders Frequent: urinary frequency; Infrequent: dysuria, micturition urgency, nocturia, polyuria, and urine odor abnormal.
  • Reproductive System and Breast DisordersFrequent: anorgasmia/orgasm abnormal; Infrequent: menopausal symptoms, sexual dysfunction, and testicular pain; Rare: menstrual disorder.
  • Respiratory, Thoracic and Mediastinal DisordersFrequent: yawning, oropharyngeal pain; Infrequent: throat tightness.
  • Skin and Subcutaneous Tissue DisordersFrequent: pruritus; Infrequent: cold sweat, dermatitis contact, erythema, increased tendency to bruise, night sweats, and photosensitivity reaction; Rare: ecchymosis .
  • Vascular DisordersFrequent: hot flush; Infrequent: flushing, orthostatic hypotension, and peripheral coldness

Adverse Reactions Observed in Placebo-Controlled Clinical Trials in Pediatric Patients

Pediatric Clinical Trial Database

The data described below reflect exposure to duloxetine (N=567) in pediatric patients aged 7 to 18 years of age from two 10-week, placebo-controlled trials in patients with MDD (N=341) (Studies MDD-6 and MDD-7), one 10-week placebo-controlled trial in GAD (N=135) (Study GAD-6), and a 13-week trial in fibromyalgia (N=91). Duloxetine is not approved for the treatment of MDD in pediatric patients [see Use in Specific Populations ( 8.4)] . Of the duloxetine -treated patients in these studies, 36% were 7 to 11 years of age (64% were between 12 to 18 years old), 55% were female, and 69% were Caucasian. Patients received 30 to 120 mg of duloxetine per day during placebo-controlled acute treatment studies. In the pediatric MDD, GAD, and fibromyalgia trials up to 40 weeks long, there were 988 duloxetine -treated pediatric patients aged 7 to 17 years of age (most patients received 30-120 mg per day) – 35% were 7 to 11 years of age (65% were 12 to 17 years old) and 56% were female.

Most Common Adverse Reactions in Pediatric Trials

The most common adverse reactions (≥5% in duloxetine -treated patients and at least twice the incidence of placebo-treated patients) in all pooled pediatric populations (MDD, GAD, and fibromyalgia) were decreased weight, decreased appetite, nausea, vomiting, fatigue, and diarrhea.

Adverse Reactions in Pediatric Patients Aged 7 to 17 Years Old with MDD and GAD

The adverse reaction profile observed in clinical trials in pediatric patients aged 7 to 18 years old with MDD and GAD was consistent with the adverse reaction profile observed in adult clinical trials. The most common (≥5% and twice placebo) adverse reactions observed in these pediatric clinical trials included: nausea, diarrhea, decreased weight, and dizziness.

Table 6 provides the incidence of adverse reactions in MDD and GAD pediatric placebo-controlled trials that occurred in greater than 2% of patients treated with duloxetine and with an incidence greater than patients treated with placebo. Duloxetine is not approved in the treatment of MDD in pediatric patients [see Use in Specific Populations ( 8.4)].

Table 6: Adverse Reactions: Incidence of 2% or More and Greater than Placebo in Three 10-week Pediatric Placebo-Controlled Trials in MDD and GAD a

System Organ Class/Adverse Reaction Percentage of Pediatric Patients Reporting Reaction
Duloxetine Placebo
(N=476) (N=362)
Gastrointestinal Disorders
Nausea 18 8
Abdominal Pain b 13 10
Vomiting 9 4
Diarrhea 6 3
Dry Mouth 2 1
General Disorders and Administration Site Conditions
Fatigue c 7 5
Investigations
Decreased Weight d 14 6
Metabolism and Nutrition Disorders
Decreased Appetite 10 5
Nervous System Disorders
Headache 18 13
Somnolence e 11 6
Dizziness 8 4
Psychiatric Disorders
Insomnia f 7 4
Respiratory, Thoracic, and Mediastinal Disorders
Oropharyngeal Pain 4 2
Cough 3 1

a Duloxetine is not approved for the treatment of pediatric MDD [see Use in Specific Populations ( 8.4)] .The inclusion of an event in the table is determined based on the percentages before rounding; however, the percentages displayed in the table are rounded to the nearest integer.

b Also includes abdominal pain upper, abdominal pain lower, abdominal tenderness, abdominal discomfort, and gastrointestinal pain.

c Also includes asthenia.

d Frequency based on weight measurement meeting potentially clinically significant threshold of ≥3.5% weight loss (N=467 duloxetine; N=354 Placebo).

e Also includes hypersomnia and sedation.

f Also includes initial insomnia, insomnia, middle insomnia, and terminal insomnia.

Other adverse reactions that occurred at an incidence of less than 2% and were reported by more duloxetine-treated patients than placebo-treated patients in pediatric MDD and GAD clinical trials included: abnormal dreams (including nightmare), anxiety, flushing (including hot flush), hyperhidrosis, palpitations, pulse increased, and tremor (duloxetine is not approved to treat pediatric patients with MDD).

The most commonly reported symptoms following discontinuation of duloxetine in pediatric MDD and GAD clinical trials included headache, dizziness, insomnia, and abdominal pain [see Warnings and Precautions ( 5.7)] .

Growth (Height and Weight) in Pediatric Patients 7 to 17 Years Old with GAD and MDD

Decreased appetite and weight loss have been observed in association with the use of SSRIs and SNRIs. Duloxetine -treated pediatric patients in clinical trials experienced a 0.1kg mean decrease in weight at 10 weeks, compared with a mean weight gain of approximately 0.9 kg in placebo-treated pediatric patients. The proportion of patients who experienced a clinically significant decrease in weight (≥3.5%) was greater in the duloxetine group than in the placebo group (16% and 6%, respectively). Subsequently, over the 4- to 6-month uncontrolled extension periods, duloxetine -treated patients on average trended toward recovery to their expected baseline weight percentile based on population data from age- and sex-matched peers.

In studies up to 9 months, duloxetine -treated pediatric patients experienced an increase in height of 1.7 cm on average (2.2 cm increase in patients 7 to 11 years of age and 1.3 cm increase in patients 12 to 17 years of age). While height increase was observed during these studies, a mean decrease of 1% in height percentile was observed (decrease of 2% in patients 7 to 11 years of age and increase of 0.3% in patients 12 to 17 years of age). Weight and height should be monitored regularly in pediatric patients treated with duloxetine [see Use in Specific Populations ( 8.4)].

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