Switched from Fetzima to Cymbalta

[LittleAnn]

My doctor just switched me from 80 mg Fetzima to 30 mg Cymbalta due to change in insurance. I'm concerned that he switched me to too low of a dose to be comparable to the dosage of Fetzima I was taking (which worked great, by the way, so I'm very upset I had to switch to something else). I'm afraid of my fibro and depression symptoms coming back like they were before my treatment. Shouldn't he have switched me over to 60 mg?

[panic_down_under]

My doctor just switched me from 80 mg Fetzima to 30 mg Cymbalta due to change in insurance.

Welcome to No More Panic,

It is outrageous that an insurance company bean counter can decide what medications someone may take. Simply outrageous!

Shouldn't he have switched me over to 60 mg?

Antidepressant drug equivalence is an imprecise science and made more difficult in this case because Cymbalta is primarily a serotonin reuptake inhibitor whereas Fetzima is a stronger norepinephrine/noradrenaline reuptake inhibitor. Therefore, only broad guesstimates can be made, but I think 60mg duloxetine would have been nearer the ballpark.

I'm wondering whether your insurance would pay for Savella (milnacipran) instead? It is the out of patent parent drug to Fetzima (levomilnacipran). Fetzima is mostly a patent extending exercise and consists of the active isomer of milnacipran making them nearly the same drug.

In addition to whether insurance will pay you might have to convince your doctor to prescribe it as the FDA only approves it for fibromyalgia. This doesn't mean it can't be prescribed off-label, but some doctors are less keen than others to do so.

[MyNameIsTerry]

Could he be treating it like a switch therefore stopping one and tapering up the other?

Another possibility is to test how you respond. Switching between meds in the same class can still mean unexpected results where some patients tolerate one and not the other.

Duloxetine at 30mg is really doing nothing for the "N" element. It's usually a starting dose to allow a taper upwards. That's how I started.

[panic_down_under]

Duloxetine at 30mg is really doing nothing for the "N" element.

Yes, and that is going to be a bigger problem than any serotonin reuptake differences because levomilnacipran is a much more potent NE reuptake inhibitor than duloxetine, according to one study 27 times more, and 80mg levomilnacipran was a fairly hefty dose.

Imho, LittleAnn's doctor should have considered adding nortriptyline to maintain the NE inhibition and then weaned her off it over a month or so, but that requires experience many doctors lack in the SSRI era. Even some psychiatrists are uncomfortable venturing outside the SSRI/SNRI bubble. Desipramine instead of duloxetine would have been another option.

[LittleAnn]

Thank you all for your replies. Yes, having insurance dictate what you can and can't take, how often, etc. is beyond frustrating! Fetzima would have been $1,000 out of pocket. I have heard of Savella and was thinking my doctor would have wanted to switch me to that one since I have fibromyalgia as well as the depression, but I was wrong. Regarding the Cymbalta, he wanted me to switch right over, and he didn't indicate that I would be increasing the dosage anytime soon since he wrote 2 months of 30mg. I was already feeling brain zaps last night, but I'm going to give this a fair try before I say it's not working out. I will check out the insurance drug list to see if Savella is one of the covered ones in case I end up unhappy with Cymbalta and need to switch.