Adding topiramate to lithium.
- Lithium is eliminated by the kidney for about 95%. Changes in the rate of excretion can cause unwanted effects.
- Topiramate induces CYP3A4 and is an inhibitor of CYP2C19.
- This combination of drugs may have possible synergistic effects. However, this combination will also have additive side effects. Dose adaptation will be recommended for this combination.
- Start topiramate according to the general dosing advice.
- Elevated and toxic lithium levels have been reported with higher (800 mg/d) doses of topiramate, but not with 500 mg/d. 
- Pharmacologic response and serum lithium levels should be monitored closely in particular after change of dosage or discontinuation of topiramate.
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