Healthcare Provider

Study Objectives:

The Cymbalta Pregnancy Registry is a prospective, observational study that enrolls pregnant women prescribed Cymbalta by their health care provider and follows maternal, fetal, and infant outcomes following exposure to Cymbalta during pregnancy. Data collected from this study will be shared with the Food and Drug Administration and may be added to Cymbalta labeling to provide prescribers with additional prescribing and consulting information.

The objective is to estimate the risk of major congenital anomalies among pregnancies exposed to Cymbalta, as well as recognized spontaneous abortions, stillbirths, elective terminations, minor congenital anomalies, and any serious adverse pregnancy outcomes; the potential impact while breast-feeding is also examined.

Healthcare Provider Participation Steps:

Step 1: Inform patient of Registry so patient can provide consent to initiate enrollment.

Step 2: Fill out registration forms to complete enrollment.

Step 3: Fill out outcome data forms at specified intervals and provide to Registry.

Indication

Important Safety Information for Cymbalta©

Warning: Suicidal Thoughts and Behaviors — Antidepressants increased the risk of suicidal thoughts and behavior in children, adolescents, and young adults in short-term studies. These studies did not show an increase in the risk of suicidal thoughts and behavior with antidepressant use in patients over age 24; there was a reduction in risk with antidepressant use in patients aged 65 and older. In patients of all ages who are started on antidepressant therapy, monitor closely for worsening, and for emergence of suicidal thoughts and behaviors. Advise families and caregivers of the need for close observation and communication with the prescriber.

Contraindications

  • The use of MAOIs intended to treat psychiatric disorders with Cymbalta or within 5 days of stopping treatment with Cymbalta is contraindicated because of an increased risk of serotonin syndrome. The use of Cymbalta within 14 days of stopping an MAOI intended to treat psychiatric disorders is also contraindicated. Starting Cymbalta in a patient who is being treated with MAOIs such as linezolid or intravenous methylene blue is also contraindicated because of an increased risk of serotonin syndrome.

Warnings and Precautions

  • Suicidal Thoughts and Behaviors in Children, Adolescents and Young Adults
    All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially within the first few months of treatment and when changing the dose. Consider changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse or includes symptoms of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, or suicidality that are severe, abrupt in onset, or were not part of the patient's presenting symptoms. If discontinuing treatment, the medication should be tapered. Families and caregivers of patients being treated with antidepressants for any indication should be alerted about the need to monitor patients. Prescriptions for Cymbalta should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose.
    Screening patients for bipolar disorder: Prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. Cymbalta is not approved for use in treating bipolar depression.
  • Hepatic failure, sometimes fatal, has been reported in patients treated with Cymbalta. Cymbalta should be discontinued in patients who develop jaundice or other evidence of clinically significant liver dysfunction and should not be resumed unless another cause can be established.
  • Because it is possible that Cymbalta and alcohol may interact to cause liver injury or that Cymbalta may aggravate pre-existing liver disease, Cymbalta should not be prescribed to patients with substantial alcohol use or evidence of chronic liver disease.
  • Orthostatic hypotension, falls, and syncope have been reported with therapeutic doses of Cymbalta. Syncope and orthostatic hypotension tend to occur within the first week of therapy but can occur at any time during Cymbalta treatment, particularly after dose increases. The risk of falling appears to be related to the degree of orthostatic decrease in blood pressure as well as other factors.
    • In an analysis of patients from all placebo-controlled trials, patients treated with Cymbalta reported a higher rate of falls compared to patients treated with placebo. The risk of blood pressure decreases may be greater in patients taking concomitant medications that induce orthostatic hypotension (such as antihypertensives) or potent CYP1A2 inhibitors, and in patients taking Cymbalta above 60 mg. daily. Consideration should be given to dose reduction or discontinuation of Cymbalta in patients who experience symptomatic orthostatic hypotension, falls and/or syncope during Cymbalta therapy.
    • Risk of falling also appeared to be proportional to a patient's underlying risk for falls and appeared to increase steadily with age. As elderly patients tend to have a higher underlying risk for falls due to a higher prevalence of risk factors such as use of multiple medications, medical comorbidities and gait disturbances, the impact of increasing age by itself is unclear. Falls with serious consequences including bone fractures and hospitalizations have been reported.
  • Development of a potentially life-threatening serotonin syndrome has been reported with SNRIs and SSRIs, including Cymbalta, alone but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, St. John's Wort) and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue). Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Monitor patients for the emergence of serotonin syndrome. The concomitant use of Cymbalta with MAOIs intended to treat psychiatric disorders is containdicated. Cymbalta should also not be started in a patient being treated with MAOIs such as linezolid or intravenous methylene blue. If it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in a patient taking Cymbalta, discontinue Cymbalta before initiating treatment with the MAOI. If concomitant use of Cymbalta with other serotonergic drugs is clinically warranted, patients should be made aware of a potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases. Discontinue treatment with Cymbalta and any concomitant serotonergic agents immediately if the above events occur and initiate supportive symptomatic treatment.
  • SSRIs and SNRIs, including Cymbalta, may increase the risk of bleeding events. Patients should be cautioned about the risk of bleeding associated with concomitant use of Cymbalta and NSAIDs, aspirin, warfarin, or other drugs that affect coagulation.
  • Severe skin reactions, including erythema multiforme and Stevens-Johnson Syndrome, can occur with Cymbalta. Cymbalta should be discontinued at the first appearance of blisters, peeling rash, mucosal erosions, or any other sign of hypersensitivity, if no other etiology can be identified.
  • On abrupt or tapered discontinuation, spontaneous reports of adverse events, some of which may be serious, have been reported during the marketing of SSRIs and SNRIs. A gradual reduction in dose rather than abrupt cessation is recommended when possible.
  • Cymbalta should be used cautiously in patients with a history of mania.
  • Angle-Closure Glaucoma: The pupillary dilation that occurs following use of many antidepressant drugs including Cymbalta may trigger an angle closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy.
  • Cymbalta should be prescribed with care in patients with a history of seizure disorder.
  • In adult clinical trials across indications relative to placebo, treatment with Cymbalta was associated with mean increases of 0.5 mm Hg in systolic blood pressure and 0.8 mm Hg in diastolic blood pressure compared to mean decreases of 0.6 mm Hg systolic and 0.3 mm Hg diastolic in placebo-treated patients. There was no significant difference in the frequency of sustained (3 consecutive visits) elevated blood pressure. Blood pressure should be measured prior to initiating treatment and periodically measured throughout treatment.
  • Co-administration of Cymbalta with potent CYP1A2 inhibitors or thioridazine should be avoided.
  • SSRIs and SNRIs, including Cymbalta, have been associated with cases of clinically significant hyponatremia that appeared to be reversible when Cymbalta was discontinued. Elderly patients may be at greater risk of developing hyponatremia with SSRIs and SNRIs.
  • The effect that alterations in gastric motility may have on the stability of the enteric coating of Cymbalta is unknown. As duloxetine is rapidly hydrolyzed in acidic media to naphthol, caution is advised in using Cymbalta in patients with conditions that may slow gastric emptying (e.g., some diabetics).
  • Avoid using Cymbalta in patients with chronic liver disease or cirrhosis or patients with end-stage renal disease (requiring dialysis) or severe renal impairment (creatinine clearance <30 mL/min).
  • As observed in DPNP trials, Cymbalta treatment worsens glycemic control in some patients with diabetes. In the extension phases (up to 52 weeks) of the DPNP studies, an increase in HbA1c in both the Cymbalta (0.5%) and the routine care groups (0.2%) was noted.
  • Cymbalta is in a class of drugs known to affect urethral resistance. If symptoms of urinary hesitation during Cymbalta treatment, this effect may be drug-related. In postmarketing experience, urinary retention has been obseved.

Use in Specific Populations

  • Pregancy and Nursing Mothers: Use only if the potential benefit justifies the potential risk to the fetus or child.
  • Pediatric Use: In pediatric patients aged 7 to 17 years with Generalized Anxiety Disorder, efficacy was demonstrated in one placebo controlled trial. The safety and effectiveness in pediatric patients less than 7 years of age have not been established.
  • Geriatric Use: In an analysis of data from all placebo controlled trials, patients treated with Cymbalta reported a higher rate of falls compared to patients treated with placebo. The increased risk appears to be proportional to a patients underlying risk for falls. Underlying risk appears to increase steadily with age. As elderly patients tend to have a higher prevalence of risk factors for falls such as medications, medical comorbidities, and gait disturbances, the impact of increasing age by itself on falls during treatment with Cymbalta is unclear. Falls with serious consequences including bone fractures and hospitalizations have been reported.

Most Common Adverse Events

  • The most commonly reported adverse events (≥5% and at least twice placebo) for Cymbalta vs placebo in adult controlled clinical trials were: nausea* (23% vs 8%), dry mouth (13% vs 5%), somnolence (10% vs 3%), constipation* (9% vs 4%), decreased appetite* (7% vs 2%), and increased sweating* (6% vs 1%).

    *Events for which there was a significant dose-dependent relationship in fixed-dose studies, excluding three MDD studies that did not have a placebo lead-in period or dose titration.
  • The adverse drug reaction profile observed in pediatric clinic trials (children and adolescents) was consistent with the adverse drug reaction profile observed in adult clinical trials. The specific adverse drug reactions observed in adult patients can be expected to be observed in pediatric patients (children and adolescents) [see Adverse Reactions (6.5)]. The most common (≥5% and twice placebo) adverse reactions observed in pediatric clinical trials include: nausea (18% vs 8%), vomiting (9% vs. 4%), diarrhea (6% vs 3%), decreased weight (14% vs. 6%), decreased appetite (10% vs. 5%), and dizziness (8% vs 4%).
  • In placebo-controlled clinical trials in adults, the overall discontinuation rates due to adverse events were: MDD: 8% vs 5%; GAD: 14% vs 5%; DPNP: 13% vs 5%; FM: 18% vs 10%; OA: 16% vs 7%; CLBP: 17% vs 6%.

    The common adverse events reported as a reason for discontinuation and considered to be drug related were: MDD: nausea (1.1% vs 0.4%). GAD: nausea (3.3% vs 0.4%), dizziness (1.3% vs 0.4%). DPNP: nausea (3.5% vs 0.7%), dizziness (1.2% vs 0.4%), somnolence (1.1% vs 0%). FM: nausea (2.0% vs 0.5%), headache (1.2% vs 0.3%), somnolence (1.1% vs 0%), fatigue (1.1% vs 0.1%). OA: nausea (2.2% vs 1.0%). CLBP: nausea (3.0% vs 0.7%), somnolence (1.0% vs 0%).

See Prescribing Information, including Boxed Warning about antidepressants and suicidality, and Medication Guide

DD HCP ISI 27OCT2016