Epilim/Epilim Chrono Adverse Reactions

The following CIOMS frequency rating is used, when applicable: Very common (≥1/10); common (≥1/100 to ≤1/10); uncommon (≥1/1,000 to ≤1/100); rare (≥1/10,000 to ≤1/1,000); very rare (≤1/10,000); not known (cannot be estimated from the available data).
Congenital malformations and developmental disorders: (see Warnings and Use in Pregnancy & Lactation).
Hepatobiliary disorders: Common: liver injury (see Special warnings under Precautions).
Severe liver damage including hepatic failure, sometimes resulting in death, has been reported (see Dosage & Administration, Contraindications and Special warnings under Precautions). Increased liver enzymes are common, particularly early in treatment and may be transient.
Gastrointestinal disorders: Very common: nausea, occurs a few minutes after intravenous injection with spontaneous resolution within a few minutes.
Common: vomiting, gingival disorder (mainly gingival hyperplasia), stomatitis, gastralgia, diarrhoea.
The previously mentioned adverse events frequently occur at the start of treatment, but they usually disappear after a few days without discontinuing treatment. These problems can usually be overcome by taking Epilim with or after food or by using enteric-coated Epilim.
Uncommon: pancreatitis, sometimes lethal (see Special warnings under Precautions).
Nervous system disorders: Very common: tremors.
Common: extrapyramidal disorder, stupor*, somnolence, convulsion*, memory impairment, headache, nystagmus.
Uncommon: coma*, encephalopathy, lethargy* (see as follows), reversible parkinsonism, ataxia, paraesthesia, aggravated convulsions.
Rare: reversible dementia associated with reversible cerebral atrophy, cognitive disorder.
Sedation has been reported occasionally, usually when in combination with other anticonvulsants. In monotherapy, it occurred early in treatment on rare occasions and is usually transient.
*Rare cases of lethargy and confusion occasionally progressing to stupor, sometimes with associated hallucinations or convulsions have been reported. Encephalopathy and coma have very rarely been observed. These cases have often been associated with too high a starting dose or too rapid a dose escalation or concomitant use of other anticonvulsants, notably phenobarbital or topiramate. They have usually been reversible on withdrawal of treatment or reduction of dosage.
An increase in alertness may occur; this is generally beneficial but occasionally aggression, hyperactivity and behavioural deterioration have been reported.
Epilim IV: dizziness may occur within a few minutes and it usually resolves spontaneously within a few minutes. 
Psychiatric disorders: Common: confusional state, hallucinations, aggression, agitation, disturbance in attention.
Rare: abnormal behaviour, psychomotor hyperactivity, learning disorder.
Metabolism and nutrition disorders: Common: hyponatraemia, weight increased*.
*Weight increase should be carefully monitored since it is a factor for polycystic ovary syndrome (see Precautions).
Rare: hyperammonaemia* (see Precautions), obesity.
*Cases of isolated and moderate hyperammonaemia without change in liver function tests may occur, are usually transient and should not cause treatment discontinuation. However, they may present clinically as vomiting, ataxia and increasing clouding of consciousness. Should these symptoms occur, Epilim should be discontinued.
Hyperammonaemia associated with neurological symptoms has also been reported (see Precautions). In such cases, further investigations should be considered.
Endocrine disorders: Uncommon: Syndrome of Inappropriate Secretion of ADH (SIADH), hyperandrogenism (hirsutism, virilism, acne, male pattern alopecia, and/or androgen increase).
Rare: hypothyroidism (see Use in Pregnancy & Lactation).
Blood and lymphatic system disorders: Common: anaemia, thrombocytopenia (see Precautions).
Uncommon: pancytopenia, leucopenia.
The blood picture returned to normal when the drug was discontinued.
Rare: bone marrow failure, including pure red cell aplasia, agranulocytosis, anaemia macrocytic, macrocytosis.
Isolated findings of a reduction in blood fibrinogen and/or an increase in prothrombin time have been reported, usually without associated clinical signs and particularly with high doses (Epilim has an inhibitory effect on the second phase of platelet aggregation). Spontaneous bruising or bleeding is an indication for withdrawal of medication pending investigations (see Use in Pregnancy & Lactation).
Skin and subcutaneous tissue disorders: Common: hypersensitivity, transient and/or dose-related alopecia (hair loss), nail and nail bed disorders.
Regrowth normally begins within six months, although the hair may become more curly than previously.
Uncommon: angioedema, rash, hair disorder (such as abnormal hair texture, hair colour changes, abnormal hair growth).
Rare: toxic epidermal necrolysis, Stevens-Johnson syndrome, erythema multiforme, Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome.
Epilim EC tab: Hirsutism and acne have been very rarely reported.
Reproductive system and breast disorders: Common: dysmenorrhea.
Uncommon: amenorrhea.
Rare: polycystic ovaries, male infertility (see Use in Pregnancy & Lactation).
Very rarely gynaecomastia has occurred.
Vascular disorders: Common: haemorrhage (see Precautions; Use in Pregnancy & Lactation).
Uncommon: vasculitis.
Eye disorders: Rare: diplopia.
Ear and labyrinth disorders: Common: deafness, a cause and effect relationship has not been established.
Renal and urinary disorders: Common: urinary incontinence.
Uncommon: renal failure.
Rare: enuresis, tubulointerstitial nephritis, reversible Fanconi syndrome (a defect in proximal renal tubular function giving rise to glycosuria, amino aciduria, phosphaturia, and uricosuria) associated with valproate therapy, but the mode of action is as yet unclear.
General disorders and administration site conditions: Uncommon: hypothermia, non-severe peripheral oedema.
Musculoskeletal and connective tissue disorders: Uncommon: bone mineral density decreased, osteopenia, osteoporosis and fractures in patients on long-term therapy with valproate. The mechanism by which valproate affects bone metabolism has not been identified.
Rare: systemic lupus erythematosus, rhabdomyolysis (see Precautions).
Respiratory, thoracic and mediastinal disorder: Uncommon: pleural effusion.
Investigations: Rare: coagulation factors decreased (at least one), abnormal coagulation tests (such as prothrombin time prolonged, activated partial thromboplastin time prolonged, thrombin time prolonged, INR prolonged) (see Special Warnings under Precautions and Use in Pregnancy & Lactation).
Neoplasms benign, malignant and unspecified (including cysts and polyps): Rare: myelodysplastic syndrome.
Paediatric population: The safety profile of valproate in the paediatric population is comparable to adults, but some ADRs are more severe or principally observed in the paediatric population. There is a particular risk of severe liver damage in infants and young children especially under the age of 3 years. Young children are also at particular risk of pancreatitis. These risks decrease with increasing age (see Special warnings under Precautions). Psychiatric disorders such as aggression, agitation, disturbance in attention, abnormal behaviour, psychomotor hyperactivity and learning disorder are principally observed in the paediatric population. Based on a limited number of post-marketing cases, Fanconi Syndrome, enuresis and gingival hyperplasia have been reported more frequently in paediatric patients than in adult patients.