Interaction of Fluoxetine and Valproic Acid
Ms. A, a 26-year-old obese woman, was referred because of the weekly occurrence of generalized seizures and pseudoseizures. Treatment with valproic acid was initiated, and the dose was titrated up to 2000 mg/day. The patient's valproate serum levels were routinely monitored, and the level (78 mg/liter) was always within the therapeutic range (50–120 mg/liter). She did not receive other drugs. One year later Ms. A developed major depression with binge eating episodes. She was started on fluoxetine, 20 mg/day, and after a week the dose was increased to 40 mg/day. Partial control of symptoms was obtained within 1 month after initiation of fluoxetine, but her valproate serum level (126 mg/liter) had risen above the therapeutic range and remained essentially unchanged (131 mg/liter) 20 days later. The patient was informed about the pharmacological interaction, and she agreed to the withdrawal of fluoxetine. Subsequent serum level monitoring showed a gradual reduction of valproic acid levels (week 2: 105 mg/liter; week 3: 87 mg/liter). The patient continued to take the same dose of valproic acid, achieving good seizure control.
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