Valproic Acid Overdose Review of a Case With Electrocardiographic Changes

Design of self-assembling anti-epileptic drug for long-acting drug delivery in vivo

Valproic acid (VPA) has been extensively used for the treatment of seizures in epilepsy. The recommended VPA concentration in the blood is in the range of 50-100 μg mL^-1 and its therapeutic efficiency is well recognized. Since its therapeutic range is relatively narrow, strict scheduling of daily self-medication is required to optimize therapeutic outcomes and avoid adverse effects. To facilitate patient convenience in long-term and chronic therapies, the development of a sustained drug delivery system for VPA is a promising strategy. In this study, an enzyme-metabolizable block copolymer possessing a valproate ester, poly(ethylene glycol)-b-poly(vinyl valproate), was synthesized. The synthesized block copolymers formed stable nanoparticles (denoted Nano^VPA) by self-assembly under physiological conditions and released VPA via enzymatic hydrolysis. Nano^VPA showed improved pharmacokinetics compared to sodium valproate in vivo, and therapeutic efficacy in a pentylenetetrazol (PTZ)-induced kindling mouse model after once-weekly administration.

Management and Associated Toxicokinetics of Massive Valproic Acid Ingestion with High Flow Continuous Venovenous Hemodiafiltration

INTRODUCTION

Valproic acid (VPA) toxicity commonly results in a self-limited state of CNS depression that is managed with supportive care and levocarnitine. In massive overdose, patients can develop toxic encephalopathy, shock, multisystem organ failure, and death. We present a case with relevant toxicokinetics of a patient presenting with a profoundly elevated VPA concentration resulting in survival, treated with supportive care including high-dose continuous venovenous hemodiafiltration (CVVHDF).

CASE REPORT

A 17-year-old female presented to an emergency department after being found unresponsive at home with concern for massive VPA ingestion. She arrived obtunded and hypotensive with initial VPA concentration of 2226 mg/L, estimated 9 h post-ingestion. Her early hospital course was marked by hypotension requiring multiple vasopressors, and her workup was notable for multiple severe metabolic derangements. High-dose CVVHDF was initiated upon transfer to a tertiary children's hospital with the aim to enhance VPA removal and normalize metabolic derangements. At that time, her VPA concentration was 1071 mg/L. Apparent half-life of VPA improved modestly with extracorporeal treatment, but her metabolic derangements and hemodynamic instability corrected rapidly. Her clinical course was complicated by necrotizing pancreatitis, pancytopenia requiring transfusions of multiple cell lines, coma, and seizures. She ultimately recovered with normal neurological function.