Reinstatement

Terms

Cymbalta = Cymbalta or generic duloxetine, the same drug
Reinstatement = to begin taking a consistent daily dose of the drug again within 2-3 weeks of stopping it
Late reinstatement = to begin taking a VERY LOW consistent daily dose of the drug again after it has been stopped or taken inconsistently for longer than 2-3 weeks
Stabilize = to be (mostly) free from withdrawal symptoms
Bridging = to add another antidepressant while removing Cymbalta – never recommended
Withdrawal = the painful symptoms you may get after discontinuation or reduction, where reinstating may possibly reverse the symptoms
Protracted Acute Withdrawal Syndrome (PAWS, P.A.W.S., PWS) = bad, long-lasting withdrawal symptoms that settle in after the 2- to 3-week reinstatement window, and which cannot be reversed by going back on the drug. Protracted withdrawal may last 18-36 months, and a rare few suffer longer. There is nothing known to reverse protracted withdrawal. It just takes time for it to run its course. Be patient and work on recovering through good nutrition and other healthy lifestyle changes. Typically, people in PAWS do recover – we just don’t know what an individual’s timeframe will be, because everyone reacts so differently.
Every-other-day tapering = taking the drug on alternating days – never recommended, as it puts you in constant withdrawal
YoYoing = changing your dose up and down over a short period of time

Late Reinstatement

Reported “lived experience” and new information from researcher Anders Sørensen PhD, tell us that some people do have success when reinstating later than two to three weeks. Each case is different. We call a reinstatement after two to three weeks “LATE reinstatement.” The dosing for late reinstatement is much lower than a reinstatement done at two to three weeks after stopping your dose abruptly. After that, we never recommend going back to your full dose as it may be too dangerous. Late reinstatement may be tricky as it is not an exact science. Please contact our Facebook support group Cymbalta Hurts Worse. A moderator will be better able to guide you with late reinstatement depending upon your particular situation. The information below may or may not apply to you if you choose to try a late reinstatement.

Reinstatement Within 2-3 Weeks

If you have stopped taking Cymbalta/duloxetine abruptly, reinstatement typically works best to stop withdrawals when done within a 2- or 3-week window. This may not be safe if another psychiatric drug has been added, depending on the specifics. Please contact Cymbalta Hurts Worse to discuss this with a moderator. If you are successful, you would stabilize on one dose for a time and then taper slowly down from there. After the 3-week reinstatement window, the further out you get the more difficult reinstatement can be. If it doesn’t help, then you are left to deal with whatever withdrawal symptoms occur. There is no known “cure” for protracted withdrawal once it settles in. It just takes time – months, possibly years – to resolve on its own. Reinstatement or late reinstatement could do one of three things:

Possibly reverse the withdrawal.
Nothing…and then you’d be still in withdrawal and still needing to gradually taper off the drug.
Produce an unpredictable outcome that could make withdrawal worse or cause other unpredictable damages, such as akathisia, dystonia, seizures, dangerous impulses, induced suicidal, homicidal or violent thoughts and actions, or more.

Reinstatement after going cold turkey (CT) or rapid discontinuation

If you have stopped Cymbalta cold turkey (CT), decreased rapidly or alternated days, have NOT introduced another drug, and are within 2 or 3 weeks of your last dose, you might be able to reverse the withdrawal by going back to your dose of two weeks ago (or the daily average if having skipped days).
Large changes in doses, either up or down are not recommended, so the drug should be stepped back up in increments over several days.
After reinstatement, wait until you are fully stabilized, meaning at least 3 weeks with no withdrawal symptoms. Then you can begin a gradual taper. This will give your body and brain time to adjust and level out and will give you time to make preparations Some people stabilize within a few hours and others might take a few days, but the person should hold on one dose for at least 3 weeks after stabilization before thinking of starting a taper.
If another antidepressant has been added (bridging), it is too risky to recommend reinstatement unless the new drug has been taken for a VERY limited amount of time and can still be stopped. Adding another antidepressant while rapidly removing Cymbalta does not guarantee that there will be no withdrawal symptoms. Many people still experience bad, long-lasting withdrawal even when bridging. Once another drug has been introduced it interferes with the ability to reinstate and stabilize. Also, note that taking more than one serotonin-affecting drug increases the risk of serotonin syndrome. Serotonin syndrome can go quickly from mild to deadly.

Reinstatement after alternating days or yoyoing

We can recommend reinstating to the average of your dose.
- Example 1: If you alternated 60-30, the average for reinstatement would be 45 mg.
- Example 2: If you alternated days, meaning you took 30 mg every other day, you would calculate the average of 30 and 0 to get 15 mg for your daily reinstatement dose.
- Example 3: If you took 30 mg every third day, you would calculate the average of 30, 0, and 0 to get 10 mg for your daily reinstatement dose.
When someone has been alternating days for longer than 2-3 weeks, or has yoyoed the drug, and then goes into withdrawal, reinstating is tricky: It may stop the withdrawal; it may do nothing; or it could make withdrawal worse. If you have been alternating or yoyoing for less time, going to a consistent daily dose is more apt to work smoothly.
Why is alternating or yoyoing a problem? Because Cymbalta has a short half-life and was designed to be taken every day. Alternating every other day throws the body into withdrawal every other day and causes instability.

Have you reinstated?

After reinstating, hold at a consistent daily dose until you feel stable (see below) and then hold at the same dose at least 3 weeks before beginning your taper. Take that time to read through the tapering guidelines and other information on this website, and prepare for your taper. What does “stabilizing” or “being stable” mean? Some people think stable means without symptoms. But for many of us, stable is as good as it gets, and not perfection. Most people who are tapering have had enough adverse effects to know what it’s like to miss a dose. We understand stable as being the baseline – where you were before the event that caused the destabilization. Occasionally, someone will reinstate and even after a very long time – months to a year – they find they just can’t stabilize. In that case, we recommend a small reduction of less than 3% of the most recent dose and some people may consider dropping by only one bead at a time. It may also be necessary to do much longer holds at each dose reduction.

Reinstating does not come without risks

Reinstating does not come without risks, and reinstating outside the window is particularly risky. Ideally it should be done under the care of a knowledgeable physician, however, many do not understand how severe or long-lasting the withdrawal from Cymbalta can be, or how to properly taper or reinstate the drug. THE MOST DANGEROUS TIMES WITH ANTIDEPRESSANTS ARE WHEN STOPPING, STARTING, CHANGING DOSES, OR ADDING AND TAKING AWAY OTHER DRUGS. Making large increases can be just as dangerous as making large decreases. When reinstating, gradually step back up to your last dose.

View “The David Carmichael Story.” He is a member of our group, and he reinstated outside the window several months later at a full dose without his doctor’s knowledge and became homicidal.

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