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Venlafaxine discontinuation syndrome in the from of tinnitus exacerbation: case report A 61-year-old man developed antidepressant discontinuation syndrome with exacerbation of pre-existing tinnitus following withdrawal of venlafaxine. Additionally, therapy with lithium also contributed to the exacerbation of pre-existing tinnitus. The man, who had bipolar disorder (diagnosed at the age of 59-year) and chronic tinnitus (for two years), was hospitalised following a mixed state associating irritability, impulsivity, emotional lability. At the time of admission, he was on sodium valproate 1600 mg/day and venlafaxine extended release 150mg in the morning for about 11 months. Venlafaxine was started more than a year after the onset of tinnitus. On admission, a clinical progression of his condition was noted. Hence, therapeutic adjustments were made to his medications. The dose of venlafaxine was reduced initially to 112.5 mg/day for 8 days, then to 75 mg/day, addition of quetiapine at a gradually increasing dose up to 300 mg/day, in combination with a slight increase in the dose of sodium valproate to 1700 mg/day. However, this strategy failed (failure of quetiapine, venlafaxine and sodium valproate). Thereafter, the man’s therapy with venlafaxine was immediately discontinued, while the dose of quetiapine was reduced to 100 mg/day over 4 days before it’s discontinuation. At the same time, he was started on extended-release lithium at a dose of 400 mg/day for 8 days, which was then escalated to 800 mg/day, alongside sodium valproate at the same dose. Approximately 5 days after the cessation of venlafaxine, he complained of a marked exacerbation of pre-existing tinnitus. The tinnitus became more intense and pulsatile in nature. This phenomenon accompanied by acute anxiety attacks, dizziness, nausea, irritability and a highly emotional state with fits of tears, although he described his mood as neutral. Based on these symptoms, several aetiologies were initially suggested including lithium-induced intracranial hypertension, serotonin syndrome, the loss of the therapeutic effect of venlafaxine on tinnitus upon its cessation or antidepressant discontinuation syndrome/withdrawal. Following discussion, he was restarted on venlafaxine at a dose of 75mg. Over the next five days, he showed clear improvement in the symptoms and tinnitus returned to its previous level. Based on these findings, antidepressant (venlafaxine) discontinuation syndrome with exacerbation of pre-existing tinnitus was considered. Therapy with lithium also thought to have contributed to the exacerbation of pre-existing tinnitus. Following overall improvement of his clinical status, he was discharged home on venlafaxine 75 mg/day, lithium 800 mg/day, sodium valproate at 1700 mg/day and alimemazine. Meyer G, et al. Tinnitus and venlafaxine discontinuation syndrome. Therapies : 2020. Available from: URL: http://doi.org/10.1016/j.therap.2020.06.009 [French; summarised 803497795 from a translation]

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