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Alsukhni RA, Johnson J, Nashef L. Valproate-induced reversible cognitive decline presenting as dementia and associated clinical features: A literature review. Seizure 2023; 111:45-50. [PMID: 37515866 DOI: 10.1016/j.seizure.2023.07.018] [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: 04/02/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND/AIM Valproate (VPA) is an effective broad-spectrum anti-seizure medication. Both VPA induced encephalopathy and reversible cognitive decline (VIRCD) have been reported as rare side effects. While the former is well-described in terms of risk factors, mechanism and management, the latter is less recognised and can be easily mistaken for neurodegenerative dementia. In this paper, we present a literature review of VIRCD, describe its clinical features and compare our findings to those in VPA-induced encephalopathy. METHODS We used PubMed search for valproate induced (dementia OR cognitive impairment OR cognitive decline OR cognitive dysfunction). Patients included were those with normal or well-defined cognitive baseline who presented with dementia after valproate therapy, in whom cognitive decline reversed after VPA dose reduction or discontinuation. Clinical features were compared to published descriptions of VPA-induced encephalopathy. RESULTS A total of 33 cases in 11 publications were included. Mean age was 51.2 years. Most were being treated for epilepsy on VPA with good seizure control and no encephalopathic features. VPA levels were within the usual quoted range. Mean latency after VPA initiation and symptoms was 6.87 years. Most had parkinsonian features. The most commonly reported cognitive deficits were in short-term memory and processing speed. All recovered fully on VPA discontinuation. CONCLUSION VIRCD mimics neurodegenerative dementia but is reversible on VPA discontinuation. The absence of encephalopathic features and good seizure control in addition to the prolonged latency make it easy to miss. VIRCD should be considered in relevant patient groups, especially in the presence of extrapyramidal signs.
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Affiliation(s)
| | - Jeremy Johnson
- The neurology department, King's College Hospital, London, UK, SE5 9RS
| | - Lina Nashef
- The neurology department, King's College Hospital, London, UK, SE5 9RS
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Rissardo JP, Caprara ALF, Durante Í. Valproate-associated Movement Disorder: A Literature Review. Prague Med Rep 2021; 122:140-180. [PMID: 34606429 DOI: 10.14712/23362936.2021.14] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Valproate (VPA) was first synthesized in 1882, but it was only in the early 1960s that its anticonvulsant properties were discovered. The aim of this literature review is to evaluate the clinical epidemiological profile, pathological mechanisms, and management of VPA-associated movement disorder (MD). Relevant reports in six databases were identified and assessed by two reviewers without language restriction. A total of 138 reports containing 362 cases of subjects who developed a MD secondary to VPA were reported. The MD identified were parkinsonism (PKN) (252), myoclonus (MCL) (54), dystonia (DTN) (17), dyskinesia (DKN) (16), stutters (4), tics (3), akathisia (AKT) (1). In the not clearly defined group, 15 extrapyramidal symptoms, 3 AKT, 2 DTN, 1 rigidity, 1 unstable gait were assessed. The mean and median age was 55.8 (SD: 16.58) and 61 years (range: 4-87 years). The most common VPA-indication was epilepsy, and 51.36% were males. The mean and median time from the VPA start to the MD onset was 32.75 (SD: 30.05) and 21.15 months (range: 1 day - 20 years). The mean and median time from the VPA withdrawal until the MD recovery was 2.89 (SD: 2.79) and 3 months (1 day - 12 months). The most common management was drug withdrawal. A complete recovery was obtained in 80.61%. VPA-associated MD was extensively reported in the literature. PKN was the most well-described. Future studies need to clearly report the clinical history of the patient, considering the full investigation of other adverse events during their entire life.
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Affiliation(s)
| | | | - Ícaro Durante
- Department of Medicine, Federal University of Fronteira Sul, Passo Fundo, Brazil
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Dinçer M, Akgün A, Bodur Ş, Gül H, Taş Torun Y, Bolu A, Çelik C, Çetinkaya M, Kara H, Cöngöloğlu MA. Hyperammonemic encephalopathy without hepatic dysfunction due to treatment with valproate: four cases and a mini review. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1448133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Mustafa Dinçer
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Abdullah Akgün
- Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Şahin Bodur
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Hesna Gül
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Yasemin Taş Torun
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Abdullah Bolu
- Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Cemil Çelik
- Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Miray Çetinkaya
- Child and Adolescent Psychiatry Department, Sami Ulus Child Hospital, Ankara, Turkey
| | - Halil Kara
- Child and Adolescent Psychiatry Department, Aksaray State Hospital, Aksaray, Turkey
| | - M. Ayhan Cöngöloğlu
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
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Hamed SA, Abdellah MM. The relationship between valproate induced tremors and circulating neurotransmitters: a preliminary study. Int J Neurosci 2016; 127:236-242. [PMID: 27161592 DOI: 10.1080/00207454.2016.1181631] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Beauvais K, Disson-Dautriche A, Jacquin A, Antoniol C, Martin ML. Gabapentin-induced encephalopathy. Clin Neurophysiol 2015; 126:845-6. [DOI: 10.1016/j.clinph.2014.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 07/04/2014] [Accepted: 07/08/2014] [Indexed: 11/28/2022]
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Abstract
INTRODUCTION Drug-induced parkinsonism (DIP) is the second most common cause of parkinsonism after idiopathic Parkinson's disease (iPD). Initially reported as a complication of antipsychotics, it was later recognized as a common complication of antidepressants, calcium channel antagonists, gastrointestinal prokinetics, antiepileptic drugs and many other compounds. Despite being a major health problem in certain populations, it seems to be frequently overlooked by the medical community. AREAS COVERED This paper approaches the concept of DIP, reviews its epidemiology, clinical features and ancillary tests recommended for a correct diagnosis. The authors discuss the different drugs and its pathogenic mechanisms. The relevance of an early recognition and recommendations for a correct management are commented. EXPERT OPINION Prescribers need to remain vigilant for DIP, particularly in the elderly, patients taking multiple drugs and those with genetic risk factors involved in iPD. Cessation of the causing agent is the main treatment and there is no evidence of benefit for the use of anticholinergics or levodopa. If the medication cannot be withdrawn, it should be switched to agents with a lower risk of DIP.
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Affiliation(s)
- José López-Sendón
- Hospital Ramón y Cajal, Servicio de Neurología, CIBERNED, Ctra de Colmenar Km 9,100, Madrid, 28034, Spain
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Chopra A, Kolla BP, Mansukhani MP, Netzel P, Frye MA. Valproate-induced hyperammonemic encephalopathy: an update on risk factors, clinical correlates and management. Gen Hosp Psychiatry 2012; 34:290-8. [PMID: 22305367 DOI: 10.1016/j.genhosppsych.2011.12.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 12/14/2011] [Accepted: 12/16/2011] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Valproate (VPA)-induced hyperammonemic encephalopathy (VHE) is a serious drug-related adverse effect characterized by lethargy, vomiting, cognitive slowing, focal neurological deficits and decreased levels of consciousness ranging from drowsiness to coma. METHODS We present a case series (n=5) and also review previous cases of VHE (n=30) in psychiatric patients to provide an update on risk factors, clinical correlates and management of VHE. RESULTS To our knowledge, there are 30 (16 female, 14 male) previously reported VHE cases in psychiatric patients. Risk factors for VHE include VPA-drug interactions, mental retardation, carnitine deficiency and presence of urea cycle disorders. Length of VPA treatment, VPA dosage, serum VPA levels and serum ammonia levels do not appear to correlate with onset or severity of VHE.VPA discontinuation is the primary treatment of VHE, although, l-carnitine, lactulose and neomycin have been used adjunctively in some patients. CONCLUSION Clinicians should consider VHE in patients taking VPA who present with lethargy, gastrointestinal symptoms, confusion and decreased levels of drowsiness. VPA discontinuation is currently the mainstay of treatment for VHE, although more research is warranted to delineate the underlying risk factors for VHE and consolidate treatment modalities for this potentially life-threatening drug adverse effect.
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Affiliation(s)
- Amit Chopra
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA
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Granel B, Gavaret M, Le Baut X, Sautereau N, Rodriguez D, Rossi P, Bagnères D, Demoux AL, Francès Y. Encéphalopathie hyperammoniémique au valproate de sodium. Rev Med Interne 2011; 32:e72-5. [DOI: 10.1016/j.revmed.2010.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 05/10/2010] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
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Ghozzi H, Hakim A, Sahnoun Z, Ben Mahmoud L, Atheymen R, Hammami S, Zeghal K. [Relationship between plasma concentrations of valproic acid and hepatotoxicity in patients receiving high doses]. Rev Neurol (Paris) 2011; 167:600-6. [PMID: 21492891 DOI: 10.1016/j.neurol.2011.02.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 10/12/2010] [Accepted: 02/02/2011] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Valproic acid (VPA) is an anticonvulsivant drug widely prescribed in the treatment of many forms of generalized epilepsy. In literature, the incidence of liver damage induced by AVP is 0.01%. It is potentialized by the combination therapy (phenobarbital, carbamazepine). Severe hepatotoxicity is rare and appears to be independent of dose and to cause a high mortality. METHODS The aim of our study was to evaluate the relationship between plasma concentrations of AVP and the occurrence of side effects especially hepatotoxicity in patients receiving high doses of AVP. RESULTS In this period, 425 plasmatic AVP monitoring were carried out in our laboratory. From 128 patients treated by high doses of AVP, only 73 were included in this study. Our work showed that adverse effects in epileptics under high doses of AVP was related to the association of the AVP with other antiepileptic in particular carbamazépine, phenobarbital and benzodiazepines rather than supra-therapeutic plasmatic concentrations of AVP. The association of AVP to major antiepileptics (carbamazépine and or phenobarbital) does not seem to generate an increase in the plasmatic concentration of AVP, which was not associated with a greater risque of adverse effects. CONCLUSION Consequently, clinical signs of liver toxicity may be present in AVP concentrations generally considered in the therapeutic range especially when used in high doses and or combined with antiepileptic drugs like phenobarbital or carbamazepine.
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Affiliation(s)
- H Ghozzi
- Laboratoire de pharmacologie, faculté de médecine de Sfax, avenue Majida-Boulila, 3029 Sfax, Tunisie
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De Dios C, Fudio S, Lorenzo A. Reversible parkinsonism and cognitive decline due to a possible interaction of valproic acid and quetiapine. J Clin Pharm Ther 2010; 36:430-2. [DOI: 10.1111/j.1365-2710.2010.01197.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gerstner T, Bell N, Koenig SA. Valproate-associated reversible encephalopathy in a 3-year-old girl with Pallister-Killian syndrome. Ther Clin Risk Manag 2008; 4:645-7. [PMID: 18827862 PMCID: PMC2500259 DOI: 10.2147/tcrm.s2570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Valproic acid (VPA) is considered to be a drug of first choice for the therapy of generalized and focal epilepsies, including special epileptic syndromes. The drug is usually well tolerated, rare serious complications may occur in some patients, including hemorrhagic pancreatitis, coagulapathies, bone marrow suppression, VPA-induced hepatotoxicity and encephalopathy. We report a case of VPA-associated encephalopathy without hyperammonemia in a 3-year-old girl with Pallister-Killian-Syndrom, combined with a mild hepatopathy and thrombopathy. After withdrawal of VPA, the clinical symptoms and the electroencephalography-alterations vanished rapidly.
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Gerstner T, Bell N, König S. Oral valproic acid for epilepsy--long-term experience in therapy and side effects. Expert Opin Pharmacother 2008; 9:285-92. [PMID: 18201150 DOI: 10.1517/14656566.9.2.285] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Valproic acid (VPA) is considered to be a drug of first choice and one of the most frequently-prescribed antiepileptic drugs worldwide for the therapy of generalized and focal epilepsies, including special epileptic. It is a broad-spectrum antiepileptic drug and is usually well tolerated. Rarely, serious complications may occur in some patients, including hemorrhagic pancreatitis, coagulopathies, bone marrow suppression, VPA-induced hepatotoxicity and encephalopathy, but there is still a lack of knowledge about the incidence and occurrence of these special side effects. Additionally, the consequences for VPA therapy and indication are more or less unclear. By literature review and own data this review addresses some of the challenges of VPA therapy and its side effects, which are not unique to epilepsy in childhood.
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Affiliation(s)
- Thorsten Gerstner
- University Children's Hospital, Neuropediatric Unit, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Valproate-induced hyperammonaemic encephalopathy: review of 14 cases in the psychiatric setting. Int Clin Psychopharmacol 2007; 22:330-7. [PMID: 17917551 DOI: 10.1097/yic.0b013e3281c61b28] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To review signs and symptoms of valproate-induced hyperammonaemic encephalopathy without hepatotoxicity in the psychiatric setting, explore its mechanisms, and give recommendations for prevention and treatment. METHODS Medline search with keywords valproate, ammonia, hyperammonaemia, encephalopathy, and then cross-references to articles obtained through this search. Only cases with indication of valproate for psychiatric condition were included. RESULTS Fourteen cases published in the psychiatric setting are reviewed. Valproate-induced hyperammonaemic encephalopathy is a rare adverse event, occurring almost equally in men and women, with a large age range, and reported in two patients with mental retardation. Symptoms appeared either a few days after initiation of valproate therapy, or after several months or years. The main symptoms were fluctuations in consciousness and disorientation. Clinical severity was not related to blood ammonia levels. All patients recovered after valproate-induced hyperammonaemic encephalopathy diagnosis and treatment, usually involving discontinuation of valproate. CONCLUSIONS Valproate-induced hyperammonaemic encephalopathy is rare and usually reversible in patients without urea cycle disorders when valproate is discontinued. Therapy with carnitine is recommended. Special caution should be used in patients with mental retardation. Psychiatrists should suspect valproate-induced hyperammonaemic encephalopathy when consciousness deteriorates.
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Imipramine, methylphenidate and valproic acid-related EPS in a child: a case report. Int J Neuropsychopharmacol 2007; 10:705-7. [PMID: 17982753 DOI: 10.1017/s1461145707007791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Abstract
Drug-induced parkinsonism (DIP) is the second cause of akinetic rigid syndrome in the Western world and its prevalence is increasing and approaching that of idiopathic Parkinson's disease due to the ageing of the population and to the rising of polypharmacotherapy. DIP was initially reported as a complication of neuroleptics in psychiatric patients, but it has also been described with a great diversity of compounds such as antiemetics, drugs used for the treatment of vertigo, antidepressants, calcium channel antagonists, antiarrythmics, antiepileptics, cholinomimetics and other drugs. Although traditionally considered reversible, DIP may persist after drug withdrawal. At least 10% of patients with DIP develop persistent and progressive parkinsonism in spite of the discontinuation of the causative drug. Irreversible or progressive DIP has been considered as an indication of presymptomatic parkinsonian deficit, unmasked but not caused by the offending drug, but it could be explained by persistent toxicity of the responsible pharmacological agents on the nigrostriatal dopamine pathway. The best treatment of DIP is prevention, including the avoidance of prescription of causative drugs whenever it is not strictly necessary. In patients who require potentially risky medication, it is necessary to perform adequate monitoring for early parkinsonian deficits and early discontinuation if these deficits appear. Atypical neuroleptics are associated with lower risk than first generation antipsychotic drugs. Special precautions are needed in elderly subjects, in patients treated with multiple drugs for prolonged periods of time and in those with familial risk factors including familial parkinsonism or tremor, or in those with genetic variants of genes involved in idiopathic Parkinson's disease.
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Affiliation(s)
- Maria A Mena
- Head of Neuropharmacology Unit, Hospital Ramón y Cajal, Servicio de Neurobiología, Ctra de Colmenar, Madrid 28034, Spain
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Gerstner T, Buesing D, Longin E, Bendl C, Wenzel D, Scheid B, Goetze G, Macke A, Lippert G, Klostermann W, Mayer G, Augspach-Hofmann R, Fitzek S, Haensch CA, Reuland M, Koenig SA. Valproic acid induced encephalopathy – 19 new cases in Germany from 1994 to 2003 – A side effect associated to VPA-therapy not only in young children. Seizure 2006; 15:443-8. [PMID: 16787750 DOI: 10.1016/j.seizure.2006.05.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Revised: 05/10/2006] [Accepted: 05/23/2006] [Indexed: 01/26/2023] Open
Abstract
Valproic acid (VPA) is a broad-spectrum antiepileptic drug and is usually well-tolerated. Rare serious complications may occur in some patients, including haemorrhagic pancreatitis, bone marrow suppression, VPA-induced hepatotoxicity and VPA-induced encephalopathy. The typical signs of VPA-induced encephalopathy are impaired consciousness, sometimes marked EEG background slowing, increased seizure frequency, with or without hyperammonemia. There is still no proof of causative effect of VPA in patients with encephalopathy, but only of an association with an assumed causal relation. We report 19 patients with VPA-associated encephalopathy in Germany from the years 1994 to 2003, none of whom had been published previously.
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Affiliation(s)
- Thorsten Gerstner
- University Children's Hospital Mannheim, Neuropediatric Unit, Theodor-Kutzer-Ufer 1-3, 69167 Mannheim, Germany
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