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DANIELLE C. EZZO, PHARM.D., BCPS, is Assistant Clinical Professor, College of Pharmacy and Allied Health Professions, St. John’s University (SJU), Queens, NY, and Clinical Coordinator of Ambulatory Care, Long Island Jewish Medical Center, New Hyde Park, NY. PRITI N. PATEL, PHARM.D., BCPS, is Assistant Clinical Professor, College of Pharmacy and Allied Health Professions, and Director, Drug Information Center, SJU.

Address correspondence to Dr. Ezzo at the College of Pharmacy and Allied Health Professions, St. John’s University, St. Albert Hall, Room 114, 8000 Utopia Parkway, Queens, NY 11439 (ezzod{at}stjohns.edu).

Purpose. A case of flushing associated with duloxetine use is presented. Summary. A 43-year-old nonmenopausal woman was prescribed duloxetine 20 mg daily for migraine prophylaxis after the usual medications for treatment and prevention of migraines were used with little or no success. Magnetic resonance imaging and computed tomography ruled out structural causes of migraines. The patient took 20 mg daily for five days and then decided, on her own, to decrease the dosage after experiencing insomnia, a common adverse effect of duloxetine. She opened the 20-mg capsules and took half of the contents to "create" the 10-mg dose, placing the contents of the opened capsule directly onto her tongue. She did this for two weeks and found the migraines to be significantly reduced in number and intensity. At that time, she began to experience what she described as a hot flash and facial flushing. The flushing was not accompanied by itching and did not spread beyond the face. The flushing occurred one to two hours after administering the 10-mg dose and typically resolved the following day. One week later, the patient noticed that the vessels in her face were more prominent. Concomitant therapies included pindolol for hypertension and duloxetine and botulinum toxin type A injections for migraines. The patient weaned herself off duloxetine. Facial flushing continued for one week after discontinuation of the drug. At a one-month follow-up visit, she stated that the flushing had resolved and not occurred since the original episodes. Conclusion. A patient treated with duloxetine developed facial flushing, possibly caused by inappropriate administration of the drug. Index terms: Antidepressants; Botulinum toxin A; Dosage; Duloxetine hydrochloride; Flushing; Migraine; Pindolol; Rational therapy; Toxicity