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Cymbalta (duloxetine) is a type of antidepressant known as a serotonin and norepinephrine reuptake inhibitor (SNRI). It’s used to treat depression and anxiety as well as chronic pain conditions like fibromyalgia and nerve pain caused by diabetes.
SNRIs work similarly to selective serotonin reuptake inhibitors (SSRIs), but they also increase the amount of the neurotransmitter norepinephrine in the brain (SSRIs only increase serotonin). Because SNRIs like Cymbalta increase serotonin and norepinephrine, they interact differently with some foods and medicines. There are several over-the-counter and prescription medications—as well as some foods and herbal supplements—you should avoid combining with this antidepressant. Here’s how Cymbalta works and what you should not mix with it.
How Cymbalta works
Cymbalta blocks the reuptake, or absorption, of the neurotransmitters norepinephrine and serotonin in the body—effectively increasing the levels of serotonin and norepinephrine—says Joanna Lewis, Pharm.D., founder of The Pharmacist’s Guide. Both of these neurotransmitters, she adds, can play a role in depression. Increasing them may positively impact mood, alertness, energy, and other common depression symptoms. These beneficial effects can happen within the first two weeks of taking Cymbalta, increasing over the next four to eight weeks, she says.
Dr. Lewis says Cymbalta’s role in relieving nerve pain is less clear. Some data show an imbalance of serotonin and norepinephrine in central pain pathways plays a role in pain sensitivity. Cymbalta’s ability to increase the amount of these neurotransmitters in the body may be able to decrease nerve pain, says Dr. Lewis.
A 2020 review of studies, for example, indicated that Cymbalta is a safe and effective drug for treating neuropathic pain, fibromyalgia, generalized anxiety disorder, and major depressive disorder.
Foods to avoid while taking Cymbalta
There are many documented drug interactions with Cymbalta but no known food interactions, according to Inna Melamed, Pharm.D., functional medicine practitioner and author of Digestive Reset.
However, you should still monitor the amount of certain beverages you consume, like alcohol and coffee.
Drinking a lot of coffee (or other caffeinated beverages) with Cymbalta can increase duloxetine levels, which increases the risk of serotonin syndrome, says Dr. Melamed. This rare but potentially severe, life-threatening drug reaction may occur when serotonin levels are too high.
You don’t have to cut out coffee completely, but you should limit your overall caffeine intake to avoid adverse effects—and apply the same rule to how much alcohol you drink. If you drink caffeinated beverages or moderate amounts of alcohol, speak with your healthcare provider about a safe amount.
“Cymbalta can affect the liver, [so when combined with alcohol], it can produce a double negative effect,” Dr. Melamed says. It can increase the likelihood of liver problems, including liver damage. The prescribing information recommends that people who drink a substantial amount of alcohol should not take Cymbalta.
5 Cymbalta interactions
Since duloxetine increases norepinephrine and serotonin levels, there are medications you may need to avoid or be careful taking with Cymbalta. Tell your healthcare provider about all the medications you take, including prescription and OTC drugs, vitamins, and supplements so they can check for possible drug interactions. When taking Cymbalta, do not start any new medications unless your doctor approves.
1. NSAIDs
Cymbalta carries a risk of increased bleeding, says Dr. Melamed. Combining duloxetine with common NSAIDs like aspirin or ibuprofen can increase this risk since NSAIDs also are associated with a higher risk of gastrointestinal bleeding.
Talk to your prescribing healthcare provider about the risks of taking NSAIDs with Cymbalta—you may be instructed to take other pain relievers, like Tylenol (acetaminophen).
2. Other antidepressants
Many people take a combination of antidepressants for various medical conditions. You may take a tricyclic antidepressant (TCA) like nortriptyline to prevent migraines and an SNRI like Cymbalta for anxiety. This combination can cause serotonin syndrome, but you can take steps to minimize your risk of a drug reaction, like taking a lower dose of one drug and knowing the signs of serotonin syndrome.
Most other antidepressant medications, including SSRIs, MAOIs, and TCAs, increase serotonin levels. Taking Cymbalta, which also increases serotonin, with other antidepressants should only be done under the supervision of a healthcare professional.
3. Blood thinners
Anticoagulant medications like Coumadin (warfarin) reduce blood clotting to prevent and treat health conditions like heart attack, stroke, and deep vein thrombosis. Since Cymbalta increases your risk of bleeding, combining Cymbalta with blood thinners like warfarin may not be safe.
Research into the combination of Cymbalta and warfarin hasn’t overwhelmingly shown you shouldn’t take these two drugs together. It may be possible to combine them as long as you’re under the medical care of a healthcare provider, as there could still be a risk of bleeding.
4. Amphetamines and opioids
Amphetamines used to treat ADHD, like Adderall, can increase serotonin levels, as can opioid medications like fentanyl, says Dr. Lewis.
There’s an additional risk with opioids, Dr. Lewis notes: “Cymbalta works on a certain enzyme in the body, CYP2D6, [which] could block the conversion of opiates like hydrocodone and oxycodone to their active metabolite, meaning the opiates would not work as well.”
5. St. John’s wort
Most herbal supplements don’t increase serotonin levels. Still, the dietary supplement St. John’s wort, which is often thought of as a natural antidepressant, does—so it could lead to serotonin syndrome when taken with Cymbalta. Studies are mixed on the effectiveness of St. John’s wort for treating depression symptoms, and it should only be taken under the supervision of a healthcare professional when used for the treatment of depression, especially if you are taking other medications for depression.
When to see a doctor for Cymbalta side effects
Contact your doctor or seek emergency care if you have recently taken Cymbalta and experience the following common symptoms of serotonin syndrome: sudden agitation, rapid heart rate, increased body temperature, nausea, vomiting, diarrhea, high blood pressure, or sudden changes in blood pressure.
Antidepressants like Cymbalta come with black box warnings about the possibility of suicidal thoughts and behaviors. While this is unlikely, suicidal thoughts are more common in children and young adults. However, people of any age who take an antidepressant should be closely monitored by family and caregivers for any changes in mood and behavior—especially during the start of treatment and after any dosage change (increased or decreased dosage). If you or someone you know is taking Cymbalta and experiences worsening depression, thoughts of self-harm, panic attacks, difficulty sleeping, or any other sudden changes in behavior, seek emergency medical attention or call 988 to reach the Suicide and Crisis Lifeline.
The bottom line
Cymbalta isn’t known to cause food interactions. As long as you only consume moderate amounts of caffeinated beverages and alcohol, you likely won’t experience any adverse side effects of Cymbalta.
But Cymbalta has several OTC and prescription drug interactions because of the way it increases the levels of serotonin in your brain. This is not a full list of interactions, so be sure to talk with your healthcare provider or pharmacist before taking Cymbalta.
