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Gziut T, Thanacoody R. L-carnitine for valproic acid-induced toxicity. Br J Clin Pharmacol 2024. [PMID: 39261302 DOI: 10.1111/bcp.16233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 08/05/2024] [Accepted: 08/07/2024] [Indexed: 09/13/2024] Open
Abstract
AIMS Review the effectiveness and dosing of L-carnitine for valproic-acid induced toxicity. METHODS A literature review of the pharmacokinetics and clinical use of L-carnitine was performed. RESULTS Valproic acid is a fatty acid used for numerous therapeutic indications ranging from epilepsy to bipolar disorder. The metabolism of valproic acid produces both therapeutic and toxic metabolites. Whilst it has a good safety profile, adverse effects of valproic acid in chronic use include hepatotoxicity ranging from transient elevation of liver enzymes to fulminant liver failure and hyperammonaemia with resultant encephalopathy. L-carnitine is an essential cofactor for mitochondrial fatty acid metabolism, which is an important source of energy in cardiac and skeletal muscle. Physiological concentrations of L-carnitine are maintained in man by exogenous dietary intake and endogenous synthesis. Following exogenous oral administration of L-carnitine, the bioavailability ranges from 14% to 18%. After bolus intravenous administration of L-carnitine in doses ranging from 20 to 100 mg/kg, the volume of distribution is 0.2-0.3 L/kg, and the fraction excreted unchanged in urine is 0.73-0.95, suggesting that renal clearance of L-carnitine is dose dependent due to saturable renal reabsorption at supraphysiological concentrations. CONCLUSIONS There is evidence supporting the use of L-carnitine in treating hyperammonaemia and hepatotoxicity following chronic therapeutic use and after acute overdose of valproic acid, but the optimal dose and route of administration is unknown. Based on the pharmacokinetics of L-carnitine, we advocate the administration of L-carnitine for valproic-acid induced hyperammonaemia or hepatotoxicity as an intravenous loading dose of 5 mg/kg followed by a continuous intravenous infusion instead of the oral or intravenous boluses that are currently advocated.
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Affiliation(s)
- Tomasz Gziut
- National Poisons Information Service (Newcastle unit), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
| | - Ruben Thanacoody
- National Poisons Information Service (Newcastle unit), Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
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Pan C, Zhao Z, Liu Z, Luo T, Zhu M, Xu Z, Yu C, Huang H. Valproate encephalopathy: Case series and literature review. SAGE Open Med Case Rep 2024; 12:2050313X241260152. [PMID: 38911175 PMCID: PMC11191625 DOI: 10.1177/2050313x241260152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/07/2024] [Indexed: 06/25/2024] Open
Abstract
Valproate encephalopathy is one of the unusual and severe but treatable side effect. This research focuses on four female patients who had valproate medication for epilepsy and developed an increased frequency of seizures, exacerbated disruption of consciousness, gastrointestinal problems, cognitive dysfunction, ataxia, and psychobehavioral abnormalities. The patient's symptoms improved over time once sodium valproate was stopped. As a result, when using sodium valproate, one should be aware of the risk of sodium valproate encephalopathy and cease using the medication right once if any of the above symptoms of unknown etiology manifest clinically. We also go over the potential pathogenesis that lead to valproate encephalopathy and the heightened risk of encephalopathy from taking antiepileptic medications together. It was stressed how crucial it is to identify, diagnose, and treat sodium valproate encephalopathy as soon as possible.
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Affiliation(s)
- Chunhua Pan
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Ziyi Zhao
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Zheng Liu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Ting Luo
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Manmin Zhu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Zucai Xu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Changyin Yu
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Hao Huang
- Department of Neurology, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
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Schiavo A, Maldonado C, Vázquez M, Fagiolino P, Trocóniz IF, Ibarra M. Quantitative systems pharmacology Model to characterize valproic acid-induced hyperammonemia and the effect of L-carnitine supplementation. Eur J Pharm Sci 2023; 183:106399. [PMID: 36740101 DOI: 10.1016/j.ejps.2023.106399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023]
Abstract
Valproic acid (VPA) is a short-chain fatty acid widely prescribed in the treatment of seizure disorders and epilepsy syndromes, although its therapeutic value may be undermined by its toxicity. VPA serious adverse effects are reported to have a significant and dose-dependent incidence, many associated with VPA-induced hyperammonemia. This effect has been linked with reduced levels of carnitine; an endogenous compound involved in fatty acid's mitochondrial β-oxidation by facilitation of its entrance via the carnitine shuttle. High exposure to VPA can lead to carnitine depletion causing a misbalance between the intra-mitochondrial β-oxidation and the microsomal ω-oxidation, a pathway that produces toxic metabolites such as 4-en-VPA which inhibits ammonia elimination. Moreover, a reduction in carnitine levels might be also related to VPA-induced obesity and lipids disorder. In turn, L-carnitine supplementation (CS) has been recommended and empirically used to reduce VPA's hepatotoxicity. The aim of this work was to develop a Quantitative Systems Pharmacology (QSP) model to characterize VPA-induced hyperammonemia and evaluate the benefits of CS in preventing hyperammonemia under both chronic treatment and after VPA overdosing. The QSP model included a VPA population pharmacokinetics model that allowed the prediction of total and unbound concentrations after single and multiple oral doses considering its saturable binding to plasma proteins. Predictions of time courses for 2-en-VPA, 4-en-DPA, VPA-glucuronide, carnitine, ammonia and urea levels, and for the relative change in fatty acids, Acetyl-CoA, and glutamate reflected the VPA induced changes and the efficacy of the treatment with L-carnitine. The QSP model was implemented to give a rational basis for the L-carnitine dose selection to optimize CS depending on VPA dosage regime and to assess the currently recommended L-carnitine rescue therapy after VPA overdosing. Results show that a L-carnitine dose equal to the double of the VPA dose using the same interdose interval would maintain the ammonia levels at baseline. The QSP model may be expanded in the future to describe other adverse events linked to VPA-induced changes in endogenous compounds.
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Affiliation(s)
- Alejandra Schiavo
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República. Montevideo, Uruguay; Graduate Program in Chemistry, Faculty of Chemistry, Universidad de la República. Montevideo, Uruguay
| | - Cecilia Maldonado
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República. Montevideo, Uruguay
| | - Marta Vázquez
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República. Montevideo, Uruguay
| | - Pietro Fagiolino
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República. Montevideo, Uruguay
| | - Iñaki F Trocóniz
- Pharmacometrics and Systems Pharmacology Research Unit, Department of Pharmaceutical Technology and Chemistry, School of Pharmacy and Nutrition, University of Navarra. Pamplona, Spain; IdiSNA; Navarra Institute for Health Research, Pamplona, Spain
| | - Manuel Ibarra
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República. Montevideo, Uruguay.
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Shnayder NA, Grechkina VV, Khasanova AK, Bochanova EN, Dontceva EA, Petrova MM, Asadullin AR, Shipulin GA, Altynbekov KS, Al-Zamil M, Nasyrova RF. Therapeutic and Toxic Effects of Valproic Acid Metabolites. Metabolites 2023; 13:metabo13010134. [PMID: 36677060 PMCID: PMC9862929 DOI: 10.3390/metabo13010134] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
Valproic acid (VPA) and its salts are psychotropic drugs that are widely used in neurological diseases (epilepsy, neuropathic pain, migraine, etc.) and psychiatric disorders (schizophrenia, bipolar affective disorder, addiction diseases, etc.). In addition, the indications for the appointment of valproate have been expanding in recent years in connection with the study of new mechanisms of action of therapeutic and toxic metabolites of VPA in the human body. Thus, VPA is considered a component of disease-modifying therapy for multiple tumors, neurodegenerative diseases (Huntington's disease, Parkinson's disease, Duchenne progressive dystrophy, etc.), and human immunodeficiency syndrome. The metabolism of VPA is complex and continues to be studied. Known pathways of VPA metabolism include: β-oxidation in the tricarboxylic acid cycle (acetylation); oxidation with the participation of cytochrome P-450 isoenzymes (P-oxidation); and glucuronidation. The complex metabolism of VPA explains the diversity of its active and inactive metabolites, which have therapeutic, neutral, or toxic effects. It is known that some active metabolites of VPA may have a stronger clinical effect than VPA itself. These reasons explain the relevance of this narrative review, which summarizes the results of studies of blood (serum, plasma) and urinary metabolites of VPA from the standpoint of the pharmacogenomics and pharmacometabolomics. In addition, a new personalized approach to assessing the cumulative risk of developing VPA-induced adverse reactions is presented and ways for their correction are proposed depending on the patient's pharmacogenetic profile and the level of therapeutic and toxic VPA metabolites in the human body fluids (blood, urine).
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Affiliation(s)
- Natalia A. Shnayder
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
- Shared Core Facilities “Molecular and Cell Technologies”, V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-620-0222 (N.A.S. & R.F.N.)
| | - Violetta V. Grechkina
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
| | - Aiperi K. Khasanova
- Department of Psychiatry, Russian Medical Academy for Continual Professional Education, 125993 Moscow, Russia
| | - Elena N. Bochanova
- Shared Core Facilities “Molecular and Cell Technologies”, V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Evgenia A. Dontceva
- Shared Core Facilities “Molecular and Cell Technologies”, V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Marina M. Petrova
- Shared Core Facilities “Molecular and Cell Technologies”, V.F. Voino-Yasenetsky Krasnoyarsk State Medical University, 660022 Krasnoyarsk, Russia
| | - Azat R. Asadullin
- Department of Psychiatry and Addiction, Bashkir State Medical University, 45000 Ufa, Russia
| | - German A. Shipulin
- Centre for Strategic Planning and Management of Biomedical Health Risks, 119121 Moscow, Russia
| | - Kuanysh S. Altynbekov
- Republican Scientific and Practical Center of Mental Health, Almaty 050022, Kazakhstan
- Department of Psychiatry and Narcology, S.D. Asfendiarov Kazakh National Medical University, Almaty 050022, Kazakhstan
| | - Mustafa Al-Zamil
- Department of Physiotherapy, Faculty of Continuing Medical Education, Peoples’ Friendship University of Russia, 11798 Moscow, Russia
| | - Regina F. Nasyrova
- Institute of Personalized Psychiatry and Neurology, Shared Core Facilities, V.M. Bekhterev National Medical Research Centre for Psychiatry and Neurology, 192019 Saint Petersburg, Russia
- Correspondence: (N.A.S.); (R.F.N.); Tel.: +7-(812)-620-0222 (N.A.S. & R.F.N.)
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Muacevic A, Adler JR, Sawar K, Trivedi V, Levine DL. Valproate-Induced Encephalopathy Presenting at Therapeutic Blood Concentrations: A Case Report and Literature Review. Cureus 2023; 15:e33559. [PMID: 36779151 PMCID: PMC9908421 DOI: 10.7759/cureus.33559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
Patients presenting with hyperammonemic encephalopathy are likely to have hepatic encephalopathy. However, valproate (an anticonvulsant and mood stabilizer) can also cause hyperammonemic encephalopathy and belongs on the differential for patients taking it, especially if there are recent contributory medication changes. We present a case report of a 61-year-old woman with valproate-induced hyperammonemic encephalopathy but with an initial valproate level within the therapeutic range (50-100 mcg/dL). After withholding valproate and before additional treatment could be initiated, she became fully alert and oriented. We present a literature review exploring valproate toxicity and treatment. Our case shows that clinical suspicion for valproate-induced hyperammonemic encephalopathy is warranted even if the valproate level is within the therapeutic range.
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Duan Y, Zeng S, Lu Z, Dan X, Mo Z, Xing Y, Zhang J, Li Y. Responses of lipid metabolism and lipidomics in the hepatopancreas of Pacific white shrimp Litopenaeus vannamei to microcystin-LR exposure. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 820:153245. [PMID: 35065121 DOI: 10.1016/j.scitotenv.2022.153245] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/25/2021] [Accepted: 01/14/2022] [Indexed: 06/14/2023]
Abstract
Microcystin-LR (MC-LR) is a toxic substance that threatens the health of aquatic animals. Hepatopancreas is the target organ of MC-LR toxicity. In this study, we investigated the effects of MC-LR on hepatopancreas lipid metabolism and lipidomic responses in Litopenaeus vannamei. After MC-LR exposure for 72 h, the hepatopancreas showed obvious tissue damage, and the activities of several lipase isoenzymes were decreased. Furthermore, the relative gene expression levels of lipolysis (CPT1, AMPKα), lipogenesis (SREBP, FAS, ACC, 6PGD), and long-chain fatty acid β-oxidation (ACDL, ACDVL, ACBP) were increased. MC-LR exposure also affected lipidomics homeostasis. Specifically, the levels of glycerophospholipids (phosphatidylcholine, phosphatidic acid, lyso-phosphatidylcholine, lyso-phosphatidylethanolamine, lyso-phosphatidylglycerol), sphingolipids (sphingomyelin and ceramides) and cholesteryl ester were increased, and those of phosphatidylinositol and triglyceride were decreased. The significantly altered lipid molecules were mainly associated with the pathways of lipid and fatty acid metabolism and autophagy. These results reveal that MC-LR exposure influences lipid metabolism and lipidomic homeostasis in the shrimp hepatopancreas.
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Affiliation(s)
- Yafei Duan
- College of Marine Sciences of South China Agricultural University & Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou 510642, PR China; Key Laboratory of South China Sea Fishery Resources Exploitation & Utilization, Ministry of Agriculture and Rural Affairs, Guangdong Provincial Key Laboratory of Fishery Ecology and Environment, South China Sea Fisheries Research Institute, Chinese Academy of Fishery Sciences, Guangzhou 510300, PR China
| | - Shimin Zeng
- College of Marine Sciences of South China Agricultural University & Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou 510642, PR China
| | - Zijun Lu
- College of Marine Sciences of South China Agricultural University & Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou 510642, PR China
| | - Xueming Dan
- College of Marine Sciences of South China Agricultural University & Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou 510642, PR China
| | - Zequan Mo
- College of Marine Sciences of South China Agricultural University & Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou 510642, PR China
| | - Yifu Xing
- Key Laboratory of South China Sea Fishery Resources Exploitation & Utilization, Ministry of Agriculture and Rural Affairs, Guangdong Provincial Key Laboratory of Fishery Ecology and Environment, South China Sea Fisheries Research Institute, Chinese Academy of Fishery Sciences, Guangzhou 510300, PR China
| | - Jiasong Zhang
- Key Laboratory of South China Sea Fishery Resources Exploitation & Utilization, Ministry of Agriculture and Rural Affairs, Guangdong Provincial Key Laboratory of Fishery Ecology and Environment, South China Sea Fisheries Research Institute, Chinese Academy of Fishery Sciences, Guangzhou 510300, PR China.
| | - Yanwei Li
- College of Marine Sciences of South China Agricultural University & Guangdong Laboratory for Lingnan Modern Agriculture, Guangzhou 510642, PR China.
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