Does Valproic Acid Warrant Therapeutic Drug Monitoring in Bipolar Affective Disorder?

Management of psychiatric treatments of patients diagnosed with bipolar disorder in the COVID-19 pandemic: A one-year evaluation in the pandemic

OBJECTIVE

The course of bipolar disorder (BD) is sensitive to factors that may disrupt biological and social rhythms. It is important for patients diagnosed with BD to continue their follow-up and treatment during the pandemic due to personal and social effects. This study aimed to evaluate the disease course and treatment compliance of individuals diagnosed with BD during the pandemic.

METHODS

A total of 267 patients with BD were included in the study. The scales were applied by phone calls. A sociodemographic data form was filled out during the phone interviews. Diagnostic criteria for hypomanic, manic, and depressive episodes in DSM-5 were questioned and recorded through the created form.

RESULTS

During the first of the pandemic, a total of 72 (27.0%) patients had a mood episode, of which 56 (21.0%) were manic/hypomanic episodes and 16 (6.0%) depressive episodes. Also, 54.7% of the patients were able to obtain their medications thanks to the extended medication reports. Being unable to use their medications regularly, having a seasonal pattern of disease, and using an increased number of psychotropics were significant predictors of a new episode. While 74.5% of the patients wanted to talk to their psychiatrists online, only 1.1% could reach the psychiatrist online.

DISCUSSION

The effects of the COVID-19 pandemic are particularly evident in patients with a seasonal pattern. Telepsychiatry practices should be actively included in clinical practice, and government policies developed for treatment compliance seem important.

Rescue strategies for valproic acid overdose poisoning: Case series and literature review

Valproic acid (VPA) is a wide-ranging anti-epileptic medication that primarily affects bipolar disorder, mania, and migraine. The leading causes of mortality associated with acute poisoning from VPA are nervous system toxicity, drug-induced shock due to encephalopathy from hyperammonemia, as well as acute liver and kidney failure, and respiratory depression that contribute to hemodynamic instability. Treatment of acute VPA poisoning primarily involves in vitro elimination methods, including hemoperfusion (HP), hemodialysis, and hemofiltration, as well as drug remedies such as L-carnitine and meropenem. Nonetheless, there are conflicting opinions regarding drug usage. This article details the three cases of acute poisoning from VPA. The fundamental approach to treatment employs HP assisted by blood concentration monitoring to alleviate shock and stabilize hemodynamics. This investigation presents guidance for the treatment and management of acute poisoning with VPA in clinical settings.

Impact of CYP2C9*2 and *3 polymorphisms on valproate-associated adverse drug reactions in individuals living with epilepsy: a case-control study

Epilepsy is characterized by repeated seizure activity. Valproate, a commonly used antiepileptic drug, shows large inter-individual variation in plasma valproic levels and causes many adverse drug reactions. Aim: To find the influence of CYP2C9*2 and *3 polymorphisms on valproate-associated adverse drug reactions and plasma valproic acid levels in people with epilepsy. Methods: We recruited 158 people with epilepsy (79 cases and 79 controls) from an epilepsy clinic. Steady-state plasma valproic acid levels were measured using liquid chromatography-mass spectrometry and genotyping of CYP2C9 variants was carried out with helps of RT-PCR. Results: The presence of a mutant heterozygous genotype showed an odds ratio (OR) of 2.82 (95% CI: 1.10-7.24) and the adjusted OR was 5.39 (95% CI: 1.69-17.16). There was no significant difference in steady-state plasma valproate concentration between genotypes. Conclusion: The presence of a mutant heterozygous CYP2C9 genotype possesses five-times the risk of developing adverse drug reactions to valproate in people with epilepsy.

An individualized medication model of sodium valproate for patients with bipolar disorder based on machine learning and deep learning techniques

Valproic acid/sodium valproate (VPA) is a widely used anticonvulsant drug for maintenance treatment of bipolar disorders. In order to balance the efficacy and adverse events of VPA treatment, an individualized dose regimen is necessary. This study aimed to establish an individualized medication model of VPA for patients with bipolar disorder based on machine learning and deep learning techniques. The sequential forward selection (SFS) algorithm was applied for selecting a feature subset, and random forest was used for interpolating missing values. Then, we compared nine models using XGBoost, LightGBM, CatBoost, random forest, GBDT, SVM, logistic regression, ANN, and TabNet, and CatBoost was chosen to establish the individualized medication model with the best performance (accuracy = 0.85, AUC = 0.91, sensitivity = 0.85, and specificity = 0.83). Three important variables that correlated with VPA daily dose included VPA TDM value, antipsychotics, and indirect bilirubin. SHapley Additive exPlanations was applied to visually interpret their impacts on VPA daily dose. Last, the confusion matrix presented that predicting a daily dose of 0.5 g VPA had a precision of 55.56% and recall rate of 83.33%, and predicting a daily dose of 1 g VPA had a precision of 95.83% and a recall rate of 85.19%. In conclusion, the individualized medication model of VPA for patients with bipolar disorder based on CatBoost had a good prediction ability, which provides guidance for clinicians to propose the optimal medication regimen.

Therapeutic drug monitoring of valproic acid using a dried plasma spot sampling device

Valproic acid (VPA) dosing needs to be individualized for epilepsy patients through therapeutic drug monitoring (TDM). The patients must show up in the clinic at the therapeutic window time to venipuncture sample. Dried plasma spot (DPS) sampling is an alternative way to replace conventional venipuncture sampling. The aim of this study was to develop and validate a DPS-based liquid chromatography-tandem mass spectrometry (LC-MS/MS) method to monitor VPA in a routine clinical laboratory setting. We compare the DPS with the wet plasma method of clinical samples by LC-MS/MS. The method was linear over the dynamic range of 10-200 μg/ml (covering entire therapeutic range) with a correlation coefficient r² ≥ 0.995. Both the DPS and wet plasma methods were fully validated for the accuracy, precision, recovery, and matrix effect. The analyte stability was examined under conditions mimicking the sample storage, transport, and analysis procedures. A clinical study with epilepsy patients receiving VPA (n = 35) showed that, after correction for hematocrit (HCT), plasma concentrations can be successfully calculated from the DPS quantification results. Passing-Bablok regression coefficients showed no proportional bias between estimated and measured plasma concentrations. Similar agreement was found by Bland-Altman plots. The dried sample could be mailed to the clinical lab to test by regular mail service. So DPS can be used for drug monitoring with self-sampling strategy at the patient's convenient time and place specially for ambulatory patients not attending a clinic.

Simple determination of valproic acid serum concentrations using BioSPME followed by gas chromatography-mass spectrometric analysis

Valproic acid (VA) is a drug widely used on the treatment of epilepsy and bipolar affective disorders, with stablished therapeutic concentration ranges in serum. The measurement of VA serum concentrations using chromatographic methods requires a sample preparation step. In this context, this study aims to describe the development and validation of an assay for VA measurement in serum using a new microextraction strategy, known as BioSPME, followed by GC-MS analysis. The extraction procedure was very simple based on direct immersion of the BioSPME tips on acidified serum, followed by agitation and desorption in methanol. The methanolic extracts were directly injected into the chromatograph. Extraction yield was 95.6 to 101.3%. The assay was linear from 10 to 150 mg L^-1. Precision, accuracy and stability assays were acceptable according to bioanalytical validation guidelines. The method was applied to 41 clinical serum samples also tested with a previously GC-MS validated assay, which used liquid-liquid extraction as sample preparation. Measurements obtained with both methods were comparable. This study is the first description of the use of BioSPME tips for a therapeutic drug. BioSPME is a promising alternative for the preparation of biological specimens prior to the determination of therapeutic drugs by GC-MS.

Valproate Protein Binding Is Highly Variable in ICU Patients and Not Predicted by Total Serum Concentrations: A Case Series and Literature Review

STUDY OBJECTIVE

The free fraction of valproate (the pharmacologically active moiety, normally 5-10%) may vary significantly in critically ill patients, but this topic is understudied, with only four prior intensive care unit (ICU) case reports. The objective of this study was to evaluate the range of valproate plasma protein binding in ICU patients.

DESIGN

Observational study of consecutive ICU patients.

SETTING

Neurocritical and medical critical care services in a nonuniversity academic medical center.

PATIENTS

Consecutive ICU patients treated with valproate with serum albumin less than 4 g/dl.

MEASUREMENTS AND MAIN RESULTS

Simultaneous total and free trough serum valproate concentrations were measured as were serum creatinine, blood urea nitrogen, albumin, platelets, and transaminase values. The reference concentration range was 50-125 mg/L (total) and 5-17 mg/L (free). Valproate concentrations were categorized as within reference range, low, or high, and as concordant if both concentrations were in the same category. Data are reported as median (interquartile range). Fifteen patients (nine men) were evaluated. The median age was 63 (34-70) years. The valproate dose was 3 g/day (35 mg/kg/day). No patient had a valproate free fraction of 5-10%; the median was 48%, and the range was 15-89%. Total and free concentrations showed poor correlation (0.43) and were concordant in only two patients (both in the reference range). Free valproate concentration was poorly predicted by an equation correcting for albumin (r = 0.45). Suspected adverse drug events occurred in 10 patients: hyperammonemia in 7 of 12 tested (58%), elevated transaminases in 2 of 15 (13%), and thrombocytopenia in 5 of 15 (33%).

CONCLUSIONS

Protein binding of valproate was highly inconsistent in this cohort of ICU patients, and total valproate concentrations did not predict free concentrations, even when correcting for albumin. Additional research to define best practice for dosing and monitoring valproate and the relationship between free valproate concentrations and clinical or adverse effects in ICU patients is needed.

Space-Time Cluster Analysis to Detect Innovative Clinical Practices: A Case Study of Aripiprazole in the Department of Veterans Affairs

OBJECTIVE

To identify space-time clusters of changes in prescribing aripiprazole for bipolar disorder among providers in the VA.

DATA SOURCES

VA administrative data from 2002 to 2010 were used to identify prescriptions of aripiprazole for bipolar disorder. Prescriber characteristics were obtained using the Personnel and Accounting Integrated Database.

STUDY DESIGN

We conducted a retrospective space-time cluster analysis using the space-time permutation statistic.

DATA EXTRACTION METHODS

All VA service users with a diagnosis of bipolar disorder were included in the patient population. Individuals with any schizophrenia spectrum diagnoses were excluded. We also identified all clinicians who wrote a prescription for any bipolar disorder medication.

PRINCIPAL FINDINGS

The study population included 32,630 prescribers. Of these, 8,643 wrote qualifying prescriptions. We identified three clusters of aripiprazole prescribing centered in Massachusetts, Ohio, and the Pacific Northwest. Clusters were associated with prescribing by VA-employed (vs. contracted) prescribers. Nurses with prescribing privileges were more likely to make a prescription for aripiprazole in cluster locations compared with psychiatrists. Primary care physicians were less likely.

CONCLUSIONS

Early prescribing of aripiprazole for bipolar disorder clustered geographically and was associated with prescriber subgroups. These methods support prospective surveillance of practice changes and identification of associated health system characteristics.

Non-24-hour sleep-wake syndrome improved by low-dose valproic acid: a case report

A woman was diagnosed with non-24-hour sleep-wake syndrome and depressive symptoms. Her depressive symptoms did not respond to standard doses of several antidepressants or mood stabilizers. Furthermore, her sleep-wake cycle remained non-entrained despite treatment with a melatonin-related drug, vitamin B12, and phototherapy. Ultimately, her sleep-wake rhythm was restored to a 24-hour pattern with a low dose of valproic acid, and her depressive symptoms tended to improve as a result of synchronization without antidepressants. Low-dose valproic acid appears to be one of the effective means of entraining circadian rhythms in patients with non-24-hour sleep-wake syndrome, which in turn likely improves associated depressive symptoms.

Diagnosis and management of bipolar disorder in primary care: a DSM-5 update

This review discusses the diagnosis and detection of bipolar disorder in the primary care population with recent changes introduced by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the pharmacotherapy and psychosocial management of this psychiatric condition.

Psychopharmacology

Primary care providers (PCPs) are frequently responsible for the pharmacologic management of mood disorders, and the PCP is often an important member of the clinical team in the management of bipolar disorder and schizophrenia. Not only is a good understanding of psychopharmacology important for the effective treatment of psychiatric disease, it is also necessary for patient safety. Clinicians should understand the side effects and the medication interactions associated with psychotropic medications. This article reviews mechanisms of action, indications, dosing, side effects, medication interactions, and general management considerations for common medications used to treat psychiatric conditions encountered in the primary care setting.

Serum brain-derived neurotrophic factor levels in different neurological diseases

Consistent evidence indicates the involvement of the brain-derived neurotrophic factor (BDNF) in neurodegenerative disorders such as Alzheimer's disease (AD) and Parkinson's disease (PD). In the present study, we compared serum BDNF in 624 subjects: 266 patients affected by AD, 28 by frontotemporal dementia (FTD), 40 by Lewy body dementia (LBD), 91 by vascular dementia (VAD), 30 by PD, and 169 controls. Our results evidenced lower BDNF serum levels in AD, FTD, LBD, and VAD patients (P < 0.001) and a higher BDNF concentration in patients affected by PD (P = 0.045). Analyses of effects of pharmacological treatments suggested significantly higher BDNF serum levels in patients taking mood stabilizers/antiepileptics (P = 0.009) and L-DOPA (P < 0.001) and significant reductions in patients taking benzodiazepines (P = 0.020). In conclusion, our results support the role of BDNF alterations in neurodegenerative mechanisms common to different forms of neurological disorders and underline the importance of including drug treatment in the analyses to avoid confounding effects.

Divergent effects of lithium and sodium valproate on brain-derived neurotrophic factor (BDNF) production in human astrocytoma cells at therapeutic concentrations

Mood stabilizers such as lithium (Li) or valproic acid (VPA) are used in the therapy of bipolar disorders, but the mechanisms by which these medicines work is unclear. Recently, neuroprotection has attracted attention as a potential action for VPA and Li. The close spatial relationship of the pre- and post-synapse with an astrocyte process within a 'tripartite synapse' suggests that mood stabilizer actions on astrocytes may be important. Therefore, we examined the effect of Li and VPA, at therapeutic concentrations, on brain-derived neurotrophic factor (BDNF) production in cultured human astrocytoma cells over an extended period of exposure. Released (extracellular) and intracellular BDNF was measured with sandwich-ELISA. Intracellular BDNF mRNA was also quantified using RT-PCR. VPA treatment potentiated the level of extracellular BDNF, whereas Li reduced it. Furthermore, VPA caused increased intracellular levels of BDNF protein and mRNA, while exposure to Li led to no significant differences compared to control cells. We suggest the possibility that VPA and Li have divergent effects on astrocyte BDNF production. Mood stabilizers play an essential role in regulating BDNF not only in neurons, but also in astrocytes. These findings could form the basis of a new astrocyte-targeted approach towards developing effective medications to treat bipolar disorders.

A novel liquefied gas based oral controlled release drug delivery system for liquid drug formulations

A novel liquefied gas based drug delivery system for the oral delivery of liquid and semi-solid drug formulations is presented. The capsule-shaped system is equipped with a capillary as an element controlling the release rate. The delivery mechanism is based on a constant vapor pressure produced by isopentane as a low-boiling liquefied gas. The liquid drug valproic acid (VA) was used as a model compound. The viscosity was increased by the addition of povidone (PVP). The VA-PVP gel exhibited pseudoplastic rheological properties, the shear rate was above 0.1s(-1), similar to a Newtonian liquid. The gels tested in the gas based delivery system provided near-zero-order release kinetics. The longest delivery time was up to ca. 8h. The system is characterized by high flexibility of the delivery rate, which can be achieved by adjusting system parameters such as the diameter and length of the capillary, the vapor pressure of the propellant and the viscosity of the drug formulation.