Can duloxetine (Cymbalta) and levetiracetam (Keppra) cause dizziness?

Duloxetine and Levetiracetam Can Both Cause Dizziness

Yes, both duloxetine (Cymbalta) and levetiracetam (Keppra) can cause dizziness as a side effect, and the risk may be increased when these medications are used together.

Duloxetine-Related Dizziness

Duloxetine, a selective serotonin norepinephrine reuptake inhibitor (SSNRI), is known to cause several side effects including dizziness:

• The Mayo Clinic guidelines indicate that duloxetine may cause dizziness as a common adverse effect 1
• Dizziness is particularly notable when:
  • Starting treatment
  • Increasing dosage
  • Missing doses or discontinuing treatment

Duloxetine's discontinuation syndrome is characterized by dizziness, vertigo, sensory disturbances, and imbalance among other symptoms 1

Levetiracetam-Related Dizziness

Levetiracetam (Keppra) is an antiepileptic medication that can also cause dizziness:

• In overdose cases, levetiracetam has been reported to cause sedation and respiratory depression 2
• While not as extensively documented for its dizziness profile as duloxetine, levetiracetam's mechanism of action on the central nervous system can contribute to dizziness symptoms

Potential Mechanisms for Dizziness

The dizziness experienced with these medications may be related to:

1. Vestibular effects: SSRIs and SNRIs like duloxetine affect serotonin levels in the vestibular nucleus complex, which can disrupt balance perception 3

2. Central nervous system effects: Both medications act on the central nervous system through different mechanisms:

   • Duloxetine inhibits serotonin and norepinephrine reuptake
   • Levetiracetam binds to synaptic vesicle protein SV2A and affects neurotransmitter release

Combination Risk Factors

When using these medications together, consider:

• Additive effects: Both medications can independently cause dizziness, potentially leading to additive or synergistic effects when combined
• Drug interactions: While no specific pharmacokinetic interaction is documented between these two medications, their combined neurological effects may increase dizziness risk
• Individual susceptibility: Elderly patients and those with pre-existing vestibular issues may be more susceptible to dizziness from either or both medications

Management Recommendations

If dizziness occurs while taking these medications:

1. Dosing adjustments:

   • Start duloxetine at a low dose (30 mg once daily) and increase gradually to minimize side effects 1
   • Consider slower titration of levetiracetam if dizziness is problematic

2. Timing considerations:

   • Take medications consistently at the same time each day
   • Avoid abrupt discontinuation of either medication, particularly duloxetine, as this can cause significant dizziness 1

3. Monitoring:

   • Be particularly vigilant for dizziness during the first few weeks of treatment and during dose adjustments
   • Assess fall risk, especially in elderly patients

Important Precautions

• Never abruptly discontinue either medication, as this can worsen dizziness, particularly with duloxetine
• Monitor for other neurological symptoms that may accompany dizziness, such as drowsiness, confusion, or coordination problems
• Consider alternative medications if dizziness is severe or persistent despite management strategies

Dizziness from these medications typically improves with continued use as the body adjusts to the medication, but persistent or severe dizziness should prompt medical evaluation.