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Perković Vukčević N, Mijatović Jovin V, Vuković Ercegović G, Antunović M, Kelečević I, Živanović D, Vučinić S. Carbapenems as Antidotes for the Management of Acute Valproic Acid Poisoning. Pharmaceuticals (Basel) 2024; 17:257. [PMID: 38399472 PMCID: PMC10893297 DOI: 10.3390/ph17020257] [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: 12/04/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Valproic acid (VPA) is a broad-spectrum drug primarily used in the treatment of epilepsy and bipolar disorder. It is not an uncommon occurrence for VPA to cause intoxication. The established treatment of VPA poisoning includes supportive care, multiple doses of activated charcoal, levocarnitine and hemodialysis/hemoperfusion. There is a clinically significant interaction between carbapenem antibiotics and VPA. By affecting enterohepatic recirculation, carbapenems can increase the overall VPA clearance from the blood of intoxicated patients. It is suggested that carbapenems could successfully be used as antidotes in the treatment of acute VPA poisonings. THE AIM To evaluate the effectiveness of carbapenems in the treatment of patients acutely poisoned by VPA. PATIENTS AND METHODS This retrospective study included patients acutely poisoned by VPA and treated with carbapenems at the Department of Clinical Toxicology at the Military Medicinal Academy in Serbia for a two-year period. RESULTS After the admission, blood concentrations of VPA kept increasing, reaching their peak at 114-724 mg/L, while the mental state of the patients continued to decline, prompting a decision to introduce carbapenems. After the introduction of carbapenems, the concentrations of the drug dropped by 46-93.59% (average 72%) followed by rapid recovery of consciousness. Ten out of eleven patients had positive outcomes, while one patient died. The most commonly observed complication in our group of patients was bronchopneumonia. CONCLUSIONS The application of carbapenems for the management of acute VPA poisoning might be a useful and effective treatment option.
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Affiliation(s)
- Nataša Perković Vukčević
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
| | - Vesna Mijatović Jovin
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Gordana Vuković Ercegović
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
| | - Marko Antunović
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
| | - Igor Kelečević
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
| | - Dejan Živanović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia
- Department of Psychology, College of Social Work, 11000 Belgrade, Serbia
| | - Slavica Vučinić
- National Poison Control Centre, Military Medical Academy, 11000 Belgrade, Serbia
- Medical Faculty Military Medical Academy, University of Defense, 11042 Belgrade, Serbia
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Sidlak AM, York SR, Janicki AJ, Pizon AF. Highest reported clearance of valproate by hemodialysis in massive overdose. Am J Emerg Med 2020; 39:255.e5-255.e6. [PMID: 32709418 DOI: 10.1016/j.ajem.2020.06.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/15/2020] [Accepted: 06/25/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alexander M Sidlak
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States of America.
| | - Samuel R York
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States of America
| | - Adam J Janicki
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States of America
| | - Anthony F Pizon
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh School of Medicine, United States of America
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Revisiting clinical practice in therapeutic drug monitoring of first-generation antiepileptic drugs. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-019-00662-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Muñiz AE. Valproic Acid Overdose Review of a Case With Electrocardiographic Changes. J Emerg Med 2017; 53:333-338. [PMID: 28992869 DOI: 10.1016/j.jemermed.2016.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 07/14/2016] [Accepted: 07/19/2016] [Indexed: 10/18/2022]
Abstract
BACKGROUND Valproic acid (VPA) is increasingly used to treat a variety of medical disorders, such as seizures, psychiatric disorders, and headaches. Therefore, accidental and intentional ingestions with valproic acid are increasing. OBJECTIVES A case is presented in an adolescent with ischemic electrocardiographic changes after an acute overdose with VPA. DISCUSSION Major features of a valproic acid overdose include respiratory depression, progressive coma, hepatotoxicity, thrombocytopenia, and hemodynamic instability. Electrocardiographic abnormalities usually consist of tachycardia and nonspecific changes. Supportive care is indicated in most overdoses and involves the monitoring and correction of electrolyte abnormalities, coagulopathies, and acid-base imbalances. Treatment may include activated charcoal, naloxone, l-carnitine, and extracorporeal detoxification. CONCLUSIONS Valproic acid overdose is a relatively rare and electrocardiographic changes usually consist of tachycardia and nonspecific changes, but ischemic changes may occur and usually transient and require only recognition.
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Ge Y, Xu B, Zhu S, Li C, He Q, Zhu T, Fan R, Gong D. Severe Acute Valproic Acid Intoxication Successfully Treated with Liver Support Therapy. Basic Clin Pharmacol Toxicol 2017; 121:368-370. [PMID: 28481454 DOI: 10.1111/bcpt.12807] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 04/26/2017] [Indexed: 11/30/2022]
Abstract
Valproic acid (VPA) is widely used for the treatment of epilepsy. However, its overdose can cause intoxication and could be life-threatening. Due to the lack of specific antidote and poorness of endogenous clearance, extracorporeal treatment for severe intoxication cases is indicated. Here, we report a case of severe intoxication of VPA which was successfully treated with liver support therapy. A previously healthy woman was admitted due to coma and hypotension after intentional ingestion of 20 g of sodium valproate. Her serum concentration of VPA measured on admission was 420.84 mg/L. In addition to standard therapy, she received two sessions of extracorporeal blood purification using a system based on fractionated plasma separation and adsorption mode integrated with continuous veno-venous haemofiltration (FPSA-CVVH), which is usually used for liver support therapy at our hospital. Her serum concentration of VPA decreased dramatically to 40.18 mg/L and her consciousness recovered completely within 24 hr after admission. Therefore, although haemodialysis has been reported to be effective in the treatment for VPA poisoning, FPSA-CVVH may provide an option for patients who require bedside therapy but have an unstable haemodynamic status or other conditions that result in inability to endure haemodialysis.
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Affiliation(s)
- Yongchun Ge
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Bin Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Shuhua Zhu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Chuan Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Qunpeng He
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Tingting Zhu
- Department of Pharmacology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Rong Fan
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dehua Gong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Schrettl V, Felgenhauer N, Rabe C, Fernando M, Eyer F. L-Arginine in the treatment of valproate overdose - five clinical cases. Clin Toxicol (Phila) 2017; 55:260-266. [PMID: 28152637 DOI: 10.1080/15563650.2017.1284333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Valproic acid and its metabolites - particularly valproyl-CoA - are inhibitors of the enzyme N-acetylglutamate synthetase. The amino acid l-arginine can stimulate N-acetylglutamate synthetase activity and could be potentially used therapeutically to correct hyperammonemia caused by valproate therapy or overdose. Severely valproic-acid-poisoned patients are usually treated with l-carnitine or hemodialysis in order to decrease hyperammonemia. We herein report of five cases, in which l-arginine was administered. METHODS Observational study on five cases. Patients with hyperammonemia (i.e., ammonia 80 > μg/dL) and symptoms consistent with valproate overdose (i.e., drowsiness, coma) were selected for treatment with l-arginine. Data was collected retrospectively. RESULTS l-Arginine decreased ammonia levels in a close temporal relation (case I ammonia in EDTA-plasma [μg/dL] decreased from 381 to 39; case II from 281 to 50; case III from 669 to 74; case IV from 447 to 56; case V from 202 to 60). In cases I and II, hemodialysis was performed and l-carnitine was given before the administration of l-arginine. In case III, hemodialysis was performed after the administration of l-arginine was already started. In cases IV and V, treatment with l-arginine was the sole measure to decrease ammonia levels in plasma. CONCLUSION The results suggest that l-arginine may be beneficial in selected cases of valproate overdose complicated by hyperammonemia. l-Arginine could extend our conventional treatment options for valproic acid overdose.
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Affiliation(s)
- Verena Schrettl
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Norbert Felgenhauer
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Christian Rabe
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Malkanthi Fernando
- b Laboratory of Clinical Biochemistry and Metabolism , Center for Pediatrics and Adolescent Medicine Freiburg, University Freiburg , Freiburg , Germany
| | - Florian Eyer
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
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Smetana KS, Cook AM, Bastin MLT, Oyler DR. Antiepileptic dosing for critically ill adult patients receiving renal replacement therapy. J Crit Care 2016; 36:116-124. [PMID: 27546759 DOI: 10.1016/j.jcrc.2016.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/06/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this review was to evaluate current literature for dosing recommendations for the use of antiepileptic medications in patients receiving renal replacement therapy (RRT). DATA SOURCES With the assistance of an experienced medical librarian specialized in pharmacy and toxicology, we searched MEDLINE, EMBASE, CINAHL, Web of Science, WorldCat, and Scopus through May 2016. STUDY SELECTION AND DATA EXTRACTION Four hundred three articles were screened for inclusion, of which 130 were identified as potentially relevant. Micromedex® DRUGDEX as well as package inserts were used to obtain known pharmacokinetic properties and dosage adjustment recommendations in RRT if known. DATA SYNTHESIS Data regarding antiepileptic drug use in RRT are limited and mostly consist of case reports limiting our proposed dosing recommendations. Known pharmacokinetic parameters should guide dosing, and recommendations are provided where possible. CONCLUSION Additional studies are necessary before specific dosing recommendations can be made for most antiepileptic drugs in critically ill patients receiving RRT, specifically with newer agents.
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Affiliation(s)
- Keaton S Smetana
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY.
| | - Aaron M Cook
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Douglas R Oyler
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
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Ghannoum M, Laliberté M, Nolin TD, MacTier R, Lavergne V, Hoffman RS, Gosselin S. Extracorporeal treatment for valproic acid poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2015; 53:454-65. [PMID: 25950372 DOI: 10.3109/15563650.2015.1035441] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup presents its systematic review and clinical recommendations on the use of extracorporeal treatment (ECTR) in valproic acid (VPA) poisoning. METHODS The lead authors reviewed all of the articles from a systematic literature search, extracted the data, summarized the key findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote was conducted to determine the final workgroup recommendations. RESULTS The latest literature search conducted in November 2014 retrieved a total of 79 articles for final qualitative analysis, including one observational study, one uncontrolled cohort study with aggregate analysis, 70 case reports and case series, and 7 pharmacokinetic studies, yielding a very low quality of evidence for all recommendations. Clinical data were reported for 82 overdose patients while pharmaco/toxicokinetic grading was performed in 55 patients. The workgroup concluded that VPA is moderately dialyzable (level of evidence = B) and made the following recommendations: ECTR is recommended in severe VPA poisoning (1D); recommendations for ECTR include a VPA concentration > 1300 mg/L (9000 μmol/L)(1D), the presence of cerebral edema (1D) or shock (1D); suggestions for ECTR include a VPA concentration > 900 mg/L (6250 μmol/L)(2D), coma or respiratory depression requiring mechanical ventilation (2D), acute hyperammonemia (2D), or pH ≤ 7.10 (2D). Cessation of ECTR is indicated when clinical improvement is apparent (1D) or the serum VPA concentration is between 50 and 100 mg/L (350-700 μmol/L)(2D). Intermittent hemodialysis is the preferred ECTR in VPA poisoning (1D). If hemodialysis is not available, then intermittent hemoperfusion (1D) or continuous renal replacement therapy (2D) is an acceptable alternative. CONCLUSIONS VPA is moderately dialyzable in the setting of overdose. ECTR is indicated for VPA poisoning if at least one of the above criteria is present. Intermittent hemodialysis is the preferred ECTR modality in VPA poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal , Verdun, QC , Canada
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9
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Abstract
The topic of central nervous system intoxicants encompasses a multitude of agents. This article focuses on three classes of therapeutic drugs, with specific examples in which overdoses require admission to the intensive care unit. Included are some of the newer antidepressants, the atypical neuroleptic agents, and selected anticonvulsant drugs. The importance of understanding pertinent physiology and applicable supportive care is emphasized.
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Affiliation(s)
- Matthew W Hedge
- Department of Emergency Medicine, Detroit Receiving Hospital, Children's Hospital of Michigan Regional Poison Control Center, Wayne State University, Hutzel Building, 4707 Street Antoine, Suite 302, Detroit, MI 48201, USA.
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10
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Garlich FM, Goldfarb DS. Have advances in extracorporeal removal techniques changed the indications for their use in poisonings? Adv Chronic Kidney Dis 2011; 18:172-9. [PMID: 21531323 DOI: 10.1053/j.ackd.2011.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 01/13/2011] [Accepted: 01/20/2011] [Indexed: 11/11/2022]
Abstract
During the past 25 years, numerous changes have taken place in the use of hemodialysis as a therapeutic modality. Advances in technologies and a progression in our collective understanding of the pharmacokinetics of certain xenobiotics have resulted in alterations in the indications, effectiveness, and safety of hemodialysis. However, these changes have not necessarily been reflected in the current published data regarding treatment of intoxications. Reported clearance rates often reflect what was achievable in the 1970s and 1980s, and more recent reports are frequently lacking. Our goal in this review is to summarize the changes in hemodialysis and in other extracorporeal removal technologies and highlight the effects of these changes on the current indications for hemodialysis of the poisoned patient. Changes in dialysis performance that are reviewed in this article include the use of high-efficiency and high-flux dialysis membranes, improved hemodynamic stability because of ultrafiltration control, and the use of bicarbonate as a source of base. We review the indications for hemodialysis for removal of specific toxins, including vancomycin, methotrexate, carbamazepine, and valproic acid.
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11
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Fertel BS, Nelson LS, Goldfarb DS. Extracorporeal Removal Techniques for the Poisoned Patient: A Review for the Intensivist. J Intensive Care Med 2010; 25:139-48. [DOI: 10.1177/0885066609359592] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The kidney is able to rapidly eliminate many water-soluble xenobiotics (exogenous chemicals). However, in the face of extraordinary serum concentrations of these xenobiotics or renal dysfunction, alternative elimination techniques often become necessary. Extracorporeal removal (ECR) techniques are used to increase the clearance of xenobiotics. These techniques include hemodialysis (HD), charcoal hemoperfusion (HP), and modalities grouped under the heading of continuous renal replacement therapy (CRRT): continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodiafiltration (CVVHDF). Extracorporeal removal is limited to patients with significant or potentially significant clinical poisoning because the resources required to perform ECR are great. Therefore, most patients who are treated with these techniques are being cared for in intensive care units (ICUs). Our goal in this review is to discuss the properties that make xenobiotics amenable to removal by ECR and the advantages and disadvantages of the individual techniques. We discuss xenobiotics that constitute clear indications for ECR, including the toxic alcohols, salicylates, and lithium. We review the use of CRRT, a modality for which clear indications for treatment of poisonings are currently lacking.
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Affiliation(s)
- Baruch S. Fertel
- Department of Emergency Medicine, University of Cincinnati, Ohio, USA
| | - Lewis S. Nelson
- Department of Emergency Medicine, New York University School of Medicine and New York City Poison Control Center, NY, USA
| | - David S. Goldfarb
- Nephrology Section, NY Harbor VA Medical Center and Nephrology Division, NYU School of Medicine, NY, USA,
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Abstract
The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life support--airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). These may include syrup of ipecac, orogastric lavage, activated single- or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). Pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. In the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, N-acetylcysteine, physostigmine, L-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. In summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. Data supporting antidotes effectiveness vary considerably. Clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases.
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Affiliation(s)
- Silas W Smith
- New York City Poison Control Center, New York University School of Medicine, New York, USA.
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Thanacoody RH. Extracorporeal elimination in acute valproic acid poisoning. Clin Toxicol (Phila) 2009; 47:609-16. [DOI: 10.1080/15563650903167772] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Manoguerra AS, Erdman AR, Woolf AD, Chyka PA, Martin Caravati E, Scharman EJ, Booze LL, Christianson G, Nelson LS, Cobaugh DJ, Troutman WG. Valproic acid poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2009; 46:661-76. [DOI: 10.1080/15563650802178136] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Jacobs FM, Pinot G, Prat D, Pilorge C, Brivet FG. Valproic acid overdose and continuous venovenous haemodiafiltration. NDT Plus 2008; 1:60-61. [PMID: 30792792 PMCID: PMC6375240 DOI: 10.1093/ndtplus/sfm026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Frédéric M Jacobs
- Medical Intensive Care Unit, Antoine Béclère Hospital AP-HP, 157 rue de la Porte de Trivaux, 92140 Clamart, France
| | - Gabrielle Pinot
- Medical Intensive Care Unit, Antoine Béclère Hospital AP-HP, 157 rue de la Porte de Trivaux, 92140 Clamart, France
| | - Dominique Prat
- Medical Intensive Care Unit, Antoine Béclère Hospital AP-HP, 157 rue de la Porte de Trivaux, 92140 Clamart, France
| | - Catherine Pilorge
- Medical Intensive Care Unit, Antoine Béclère Hospital AP-HP, 157 rue de la Porte de Trivaux, 92140 Clamart, France
| | - François G Brivet
- Medical Intensive Care Unit, Antoine Béclère Hospital AP-HP, 157 rue de la Porte de Trivaux, 92140 Clamart, France
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Abstract
Extracorporeal elimination of drugs and toxins is a critical component in the management of poisonings, though specific techniques and indications remain a matter of debate. Conventional hemodialysis is frequently the treatment of choice because of its widespread availability and proven effectiveness for certain drugs and toxins. With the increased availability of continuous renal replacement therapy (CRRT) modalities, there is yet another therapeutic option, but one that has yet to find a definitive role in this field. The continuous nature of these therapies is attractive for the management of acute renal failure, but the relatively slower clearance rates as compared to conventional hemodialysis is a distinct drawback in patients with acute xenobiotic-induced toxicity. There are abundant case reports as well as a few small case series in the medical literature documenting the use of CRRT, but specific techniques and the clinical outcomes vary considerably. Therefore one cannot draw definitive conclusions regarding benefit. Some patients, particularly those who are hemodynamically unstable and are not candidates for conventional hemodialysis, may warrant a trial of CRRT. However, at the present time, routine use for the treatment of poisoning is not supported. Controlled trials to better clarify its role would be beneficial, though such studies would be extremely difficult to conduct in this field. We believe that the intelligent application of extracorporeal modalities requires a thorough knowledge of drug pharmacokinetics, of the techniques utilized, and a skeptical analysis of the available literature.
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Affiliation(s)
- Jeffrey W Goodman
- Nephrology Section, New York Harbor VA Medical Center, New York, New York 10010, USA
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Wilimowska J, Florek E, Piekoszewski W. Disposition of valproic acid in self-poisoned adults. Basic Clin Pharmacol Toxicol 2006; 99:22-6. [PMID: 16867166 DOI: 10.1111/j.1742-7843.2006.pto_417.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Acute intoxication with valproic acid is increasingly being observed in clinical practice. In Poland, such intoxication frequently occurs as a result of mixing different drugs or alcohol. We studied the pharmacokinetics of valproic acid in five intoxicated patients. Apart from valproic acid, barbiturates, chlorprotixene, tricyclic antidepressants, tetrahydrocannabinols and alcohol were detected and measured. The absorption of the drug was rapid and the maximum concentration was observed after the period of 3.5-5.6 hr. The lowering of the valproic acid level in plasma was biphasic, with terminal half-life ranging between 8.8-30.9 hr. The calculated apparent volume of distribution was 0.17-0.72 l/kg and could be affected by varied levels of doses as well as time of drug intake (data from interviews of patients) used for calculation and reduction in plasma protein binding at higher concentration of valproic acid. Frequent multiple drug poisonings oblige toxicological laboratories not only to monitor valproic acid concentration in serum, but also to perform the toxicological screenings.
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Affiliation(s)
- Jolanta Wilimowska
- Department of Analytical Toxicology and Therapeutic Drug Monitoring, Collegium Medicum, Jagiellonian University, Krakow, Poland
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Al Aly Z, Yalamanchili P, Gonzalez E. Extracorporeal management of valproic acid toxicity: a case report and review of the literature. Semin Dial 2006; 18:62-6. [PMID: 15663767 DOI: 10.1111/j.1525-139x.2005.18106.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The incidence of intentional or accidental valproic acid (VPA) overdose is increasing. Severe VPA toxicity may lead to coma and death. Traditionally the treatment of patients with VPA toxicity has been limited to supportive measures. VPA is highly protein bound and therefore it is considered not to be removable by extracorporeal means. However, studies of VPA toxicokinetics indicate that at blood levels that exceed therapeutic concentrations, VPA protein binding sites become saturated, leading to increased concentration of the free unbound drug. The free unbound drug has a small molecular weight and therefore it is theoretically amenable to removal by extracorporeal means. We present a patient with VPA toxicity who was successfully treated with "in-series" hemodialysis and hemoperfusion followed by continuous venovenous hemodiafiltration (CVVHDF) and review the literature on the management of VPA toxicity using extracorporeal therapies.
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Affiliation(s)
- Ziyad Al Aly
- Division of Nephrology, Saint Louis University, St. Louis, Missouri 63110, USA.
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Minville V, Roche Tissot C, Samii K. Épuration extrarénale, supplémentation en L-carnitine et intoxication à l’acide valproïque. ACTA ACUST UNITED AC 2004; 23:357-60. [PMID: 15120780 DOI: 10.1016/j.annfar.2003.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2003] [Revised: 11/28/2003] [Accepted: 11/28/2003] [Indexed: 10/26/2022]
Abstract
We report the case of a severe valproic acid poisoning in a 36-year-old man. In front of a high serum concentration of valproic acid at the admission, haemodialysis was initiated to decrease serum valproic acid concentration. A L-carnitine therapy (50 mg/kg per day) was also started. A cerebral oedema appeared at the third day, but the patient recovered without any sequela.
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Affiliation(s)
- V Minville
- Département d'anesthésie réanimation, hôpital de Rangueil, CHU de Toulouse, 31403 Toulouse cedex 04, France.
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Isbister GK, Balit CR, Whyte IM, Dawson A. Valproate overdose: a comparative cohort study of self poisonings. Br J Clin Pharmacol 2003; 55:398-404. [PMID: 12680889 PMCID: PMC1884232 DOI: 10.1046/j.1365-2125.2003.01772.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS Based on individual case reports of massive overdoses, valproate is often regarded as having significant toxicity. This study aimed to describe the epidemiology of valproate poisoning and the spectrum of its clinical effects. METHODS Consecutive valproate poisonings were identified and compared with other anticonvulsant overdoses and all other poisonings, from a prospective database of poisoning admissions presenting to a regional toxicology service. National prescription data for the same period were obtained. RESULTS There were 79 patients with valproate poisoning from January 1991 to November 2001, 15 cases with valproate alone. Of the 15 cases, drowsiness occurred in two patients (both taking> 200 mg kg-1), vomiting occurred in four and tachycardia in five. In patients co-ingesting other medications, moderate to severe effects were consistent with the co-ingestants. There was one death not directly related to valproate. One patient had metabolic acidosis and thrombocytopaenia consistent with severe valproate toxicity. Comparison of valproate, carbamazepine, phenytoin and control groups showed that length of stay for both phenytoin and carbamazepine was significantly longer than for valproate (P < 0.0001), and there was a significantly increased risk of intensive care unit admission for carbamazepine vs valproate (OR 2.73; 95% CI 1.22, 6.28; P = 0.015). Although valproate prescriptions increased over the 10 years, there was relatively greater increase in the incidence of valproate poisoning. The odds of a valproate overdose in 1992 compared with carbamazepine were 0.29 (95% CI 0.07, 1.28; P = 0.141), but in 2001 were 2.73 (95% CI 1.38, 5.39; P = 0.004). CONCLUSIONS Valproate causes mild toxicity in the majority of cases. Massive overdoses of greater than 400 mg kg-1 can cause severe toxicity, but these are uncommon. The older anticonvulsants phenytoin and carbamazepine remain a greater problem than valproate in overdose.
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Affiliation(s)
- Geoffrey K Isbister
- Discipline of Clinical Pharmacology, University Of Newcastle, Level 5, Clinical Sciences Building, Newcastle Mater Misericordiae Hospital, Waratah, NSW 2298, Newcastle, Australia.
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Sztajnkrycer MD. Valproic acid toxicity: overview and management. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2002; 40:789-801. [PMID: 12475192 DOI: 10.1081/clt-120014645] [Citation(s) in RCA: 152] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Acute valproic acid intoxication is an increasing problem, accounting for more than 5000 calls to the American Association of Poison Control Centers in 2000. The purpose of this paper is to review the pharmacology and toxicology of valproic acid toxicity. Unlike earlier antiepileptic agents, valproic acid appears to function neither through sodium channel inhibition nor through direct gamma-aminobutyric acid agonism, but through an indirect increase in regional brain gamma-aminobutyric acid levels. Manifestations of acute valproic acid toxicity are myriad, and reflect both exaggerated therapeutic effect and impaired intermediary metabolism. Central nervous system depression is the most common finding noted in overdose, and may progress to coma and respiratory depression. Cerebral edema has also been observed. Although hepatotoxicity is rare in the acute overdose setting, pancreatitis and hyperammonemia have been reported. Metabolic and hematologic derangements have also been described. Management of acute valproic acid ingestion requires supportive care and close attention to the airway. The use of controversial adjunctive therapies, including extracorporeal drug elimination and L-carnitine supplementation, will be discussed.
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Abstract
Intoxications frequently perturb acid-base and electrolyte status, intravascular volume, and renal function. In selected cases, extracorporeal techniques effectively restore homeostasis and augment intoxicant removal. The use of 4-methylpyrazole, an inhibitor of alcohol dehydrogenase, is a new and effective treatment for patients exposed to toxic alcohols. In this section, practical approaches to commonly encountered intoxicants and the use of extracorporeal techniques are critically reviewed.
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Affiliation(s)
- Steven C Borkan
- Department of Medicine, Boston University, Boston Medical Center, Renal Section, Boston, MA, USA.
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Affiliation(s)
- L K Hicks
- Department of Internal Medicine, University of Toronto, Ontario, Canada
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Spiller HA, Krenzelok EP, Klein-Schwartz W, Winter ML, Weber JA, Sollee DR, Bangh SA, Griffith JR. Multicenter case series of valproic acid ingestion: serum concentrations and toxicity. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 38:755-60. [PMID: 11192462 DOI: 10.1081/clt-100102388] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Valproic acid exposures reported to poison centers have increased more than 4-fold over the last 5 years. There are no large case series published on valproic acid ingestion. METHODS A prospective multicenter case series of all patients reporting an ingestion of valproic acid. Data collected included: age, gender, dose ingested, concomitant medications, symptoms and vital signs, laboratory values, length of hospital stay, and medical outcome. Entrance into the study required a serum valproic acid concentration above the therapeutic threshold of 100 microg/mL. Statistical analysis was by Fisher's exact test. RESULTS A total of 335 patients were reported to participating centers of which 186 (55%) had serum valproic acid concentrations greater than 100 microg/mL. Of the 186 cases, 53 were multiple drug exposures leaving 133 cases of sole valproic acid ingestion for evaluation. Age ranged from 2 to 66 years with a mean of 30.1 years +/- 12. Peak serum valproic acid concentrations ranged from 110 microg/mL to 1840 microg/mL with a mean of 378.3 microg/mL +/- 310.2 microg/mL. Time from postingestion to the peak measured valproic acid concentration ranged from 1 to 18 hours, with a mean of 7.4 hours +/- 3.9. Symptoms included lethargy (n = 94), coma (n = 19), tachycardia (n = 24), aspiration (n = 8), metabolic acidosis (n = 8), and hypotension (n = 4). A peak concentration of > 450 microg/mL was more likely to be associated with a moderate or major adverse outcome (p < 0.005). A peak concentration > 850 microg/mL was more likely to be associated with coma (p < 0.005) and acidosis (p < 0.005). Eleven patients experienced transient thrombocytopenia (platelets < 150,000) and all had peak valproic acid concentrations >450 microg/mL. Four patients experienced transient leukopenia (WBC < 3,500). The mean hospital stay for all patients was 42 +/- 33.1 hours. A hospital stay > 48 hours was more likely to be associated with a peak valproic acid concentration > 450 microg/mL (p < 0.05). There were 2 fatalities. CONCLUSIONS In this case series, patients with peak valproic acid concentrations above 450 microg/mL were more likely to develop significant clinical effects and have longer hospital stays. A peak valproic acid concentration above 850 microg/mL was more likely to be associated with coma, respiratory depression, aspiration, or metabolic acidosis.
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Affiliation(s)
- H A Spiller
- Kentucky Regional Poison Center of Kosair Children's Hospital, Louisville 40232-5070, USA.
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Kane SL, Constantiner M, Staubus AE, Meinecke CD, Sedor JR. High-flux hemodialysis without hemoperfusion is effective in acute valproic acid overdose. Ann Pharmacother 2000; 34:1146-51. [PMID: 11054983 DOI: 10.1345/aph.19387] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of valproic acid overdose treated successfully with high-flux hemodialysis without the addition of charcoal hemoperfusion. CASE SUMMARY A 25-year-old white woman with a history of multiple suicide attempts and schizophrenia presented after ingesting an unknown amount of valproic acid. She became comatose and developed hypotension and lactic acidosis as valproic acid concentrations increased to > 1200 micrograms/mL (therapeutic concentration 50-100). High-flux hemodialysis was performed for four hours; the calculated elimination rate constant (kel) during the procedure was 0.2522 h-1 with a half-life (t1/2) of 2.74 hours compared with posthemodialysis kel of 0.0296 h-1 and t1/2 of 23.41 hours, suggesting that high-flux hemodialysis effectively eliminates valproic acid. The patient's hemodynamic status and mental function improved in conjunction with the acute reduction in valproic acid concentrations. Her subsequent hospital course was complicated only by transient thrombocytopenia. DISCUSSION Most literature reports of valproic acid overdose have described the use of charcoal hemoperfusion alone or in combination with hemodialysis to accelerate valproic acid clearance at toxic concentrations. However, the pharmacokinetic properties of valproic acid indicate that hemodialysis alone would be effective therapy for an acute valproic acid overdose. CONCLUSIONS We suggest that toxic concentrations of valproic acid can be effectively reduced with high-flux hemodialysis without the addition of charcoal hemoperfusion and its attendant risks.
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Affiliation(s)
- S L Kane
- College of Pharmacy, Ohio State University, Columbus 43210, USA.
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