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Giuliano L, Durante V, Battaglia G, Gasparini S, Zambrelli E, Ermio C, La Neve A, Mostacci B. Sex Differences in Adverse Effects of Antiseizure Medications in Adults with Epilepsy: A Systematic Review. CNS Drugs 2024; 38:409-423. [PMID: 38691320 DOI: 10.1007/s40263-024-01088-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Sex differences in epilepsy have been described in prevalence, seizure propensity and response to treatment. Therefore, taking into account sex-based differences in epilepsy is important for both diagnostic purposes and therapeutic considerations. However, little is known about sex differences in adverse effects of antiseizure medications (ASMs). OBJECTIVES We performed a systematic review searching for sex differences in adverse effects of ASMs in adult persons with epilepsy (PWE) as part of a wider project aimed to assess sex-based differences in efficacy and adverse effects of ASMs in PWE. METHODS We conducted a comprehensive literature search in the PubMed database. The search was conducted with no restriction on publication date, and all results up to April 2020 were included. We included articles written in English, Italian, Spanish, or French that evaluated adverse effects of one or more ASMs in PWE, with specific mention of the two sexes. When appropriate, Newcastle-Ottawa or Jadad scales were used to assess study quality. RESULTS Of 5164 identified studies, only 167 considered sex in the analysis and were therefore included. Significant sex-related differences were found in 58 of those studies. We found a consistently higher frequency of cutaneous adverse effects in females; higher risk of developing general adverse effects on different ASMs in females; stronger risk of adverse effects on bone metabolism in females, mainly on treatment with enzyme-inducing ASMs; a concordant higher risk of visual field loss was noted in males on vigabatrin; an overall worse lipid profile in males; as well as higher leptin levels and higher body mass index in females treated with various ASMs. CONCLUSIONS Our analysis has identified some important sex differences in the adverse effects of ASMs. Clinicians should be aware of these differences when informing patients about the risks associated with ASM treatment in PWE.
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Affiliation(s)
- Loretta Giuliano
- Department of Medical, Surgical Sciences and Advanced Technologies G.F. Ingrassia, Section of Neurosciences, University of Catania, Catania, Italy.
| | - Vania Durante
- Neurology Unit, "A. Perrino" Hospital, Brindisi, Italy
| | - Giulia Battaglia
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
- Regional Epilepsy Center, "Great Metropolitan Hospital", Reggio Calabria, Italy
| | - Elena Zambrelli
- Epilepsy Center, Sleep Medicine Center, Childhood and Adolescence Neuropsychiatry Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Milan, Italy
| | - Caterina Ermio
- Department of Neuroscience, "S. Giovanni Paolo II" Hospital, Lamezia Terme, Catanzaro, Italy
| | - Angela La Neve
- Department DiBrain, University of Bari "Aldo Moro", Bari, Italy
| | - Barbara Mostacci
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Full Member of the ERN EpiCARE, Bologna, Italy
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Petrović S, Kovačević M, Kovačević SV, Miljković B. Hepatotoxicity of newer antiseizure medications in children: an overview and disproportionality analysis of VigiBase. Expert Opin Drug Metab Toxicol 2024; 20:165-173. [PMID: 38380611 DOI: 10.1080/17425255.2024.2322114] [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: 01/04/2024] [Accepted: 02/16/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND We aimed to characterize newer antiseizure medications (ASMs)-induced hepatotoxicity in children and identify signals of disproportionate reporting of hepatotoxicity-related adverse drug events (ADEs). RESEARCH DESIGN AND METHODS Case reports reported to VigiBase were accessed using Empirica™ Signal software. To summarize characteristics of the retrieved cases, descriptive statistics were used. A disproportionality analysis was conducted using the Multi-item Gamma Poisson Shrinker algorithm, which calculates Empirical Bayesian Geometric Mean value and its lower and upper 95% confidence limits (EB05 and EB95, respectively). EB05 > 2, N > 0 was considered a signal. RESULTS Based on 870 analyzed cases, a higher proportion of cases was reported in girls than in boys and in patients aged 2-11 years than in other age groups. Most cases were serious. In 25 cases, hepatotoxicity resulted in death. A high proportion of patients (n = 275, 31.61%) experienced hypersensitivity reactions, mostly due to lamotrigine. The disproportionality analysis yielded 17 signals concerning felbamate, lamotrigine, levetiracetam, oxcarbazepine, stiripentol, and topiramate. Four signals were for severe liver injury and concerned felbamate, lamotrigine, levetiracetam, and topiramate. Gender-biased reporting frequency was detected for four ASM-ADE combinations. CONCLUSION Our results should serve to raise clinicians' awareness about the potential association between several newer ASMs and drug-induced liver injury in children.
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Affiliation(s)
| | - Milena Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
| | - Sandra Vezmar Kovačević
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
| | - Branislava Miljković
- Department of Pharmacokinetics and Clinical Pharmacy, University of Belgrade - Pharmacy, Belgrade, Serbia
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Zhu QM, Singh AK, Chang HER, Konka SA. Hyperammonemic encephalopathy induced by valproic acid. BMJ Case Rep 2024; 17:e257144. [PMID: 38350699 PMCID: PMC10868277 DOI: 10.1136/bcr-2023-257144] [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] [Indexed: 02/15/2024] Open
Abstract
Valproate (VPA) is broad-spectrum antiepileptic drug. Several adverse reactions including hepatotoxicity, fetal risk and pancreatitis are well known and labelled as boxed warnings in the USA. One adverse reaction that is less well known but clinically significant for its severe morbidity is hyperammonemic encephalopathy. We present a case of woman with hyperammonemic encephalopathy following the initiation of VPA therapy; she had a favourable outcome with discontinuation of the drug and prompt treatment with lactulose and L-carnitine.
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Affiliation(s)
- Qiuyu M Zhu
- Internal Medicine, Kaiser Permanente Mid-Atlantic States, Gaithersburg, Maryland, USA
| | - Amitosh K Singh
- Internal Medicine, Kaiser Permanente Mid-Atlantic States, Gaithersburg, Maryland, USA
| | - Huai-En Rachel Chang
- Internal Medicine, Kaiser Permanente Mid-Atlantic States, Gaithersburg, Maryland, USA
| | - Sandeep A Konka
- Hospital Medicine, Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
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Wesselman K, Cavaliere V, Goyal R, Anderson E. Valproate, risperidone, and paliperidone: A case of valproate-induced hyperammonemic encephalopathy. Ment Health Clin 2024; 14:28-32. [PMID: 38312439 PMCID: PMC10836567 DOI: 10.9740/mhc.2024.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/25/2023] [Indexed: 02/06/2024] Open
Abstract
Hyperammonemia is a well-known adverse effect of valproate that can progress to a potentially fatal condition known as valproate-induced hyperammonemic encephalopathy (VHE). VHE is more common when valproate is used in combination therapy with other antiepileptic medications. A growing number of case reports have pointed to a possible interaction with the antipsychotic risperidone leading to an increased risk of VHE. We present a case of VHE in which a 20-year-old male patient with bipolar affective disorder developed VHE when on concomitant valproate, risperidone, and paliperidone palmitate. On the seventh day of treatment with oral risperidone, oral divalproex sodium was added. Intramuscular paliperidone palmitate was initiated on day 13, and oral risperidone was discontinued after the second loading dose on day 16. The following day, the patient displayed worsening psychomotor retardation, swaying gait, drowsiness, and vomiting. The patient was found to have hyperammonemia and transferred to the emergency department for treatment of suspected VHE.
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Affiliation(s)
- Kyle Wesselman
- Pharmacy Student, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Vincent Cavaliere
- Pharmacy Student, University of Maryland School of Pharmacy, Baltimore, Maryland
- Attending Psychiatrist, Luminis Health, Annapolis, Maryland
- Medical Director, McNew Medical Center, Chief of Psychiatry, Behavioral Health, Luminis Health, Annapolis, Maryland
| | - Rakesh Goyal
- Attending Psychiatrist, Luminis Health, Annapolis, Maryland
| | - Eric Anderson
- Medical Director, McNew Medical Center, Chief of Psychiatry, Behavioral Health, Luminis Health, Annapolis, Maryland
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Kwack DW, Kim DW. Risk factors of hyperammonemia in epilepsy patients with valproic acid therapy. Clin Neurol Neurosurg 2023; 233:107962. [PMID: 37717359 DOI: 10.1016/j.clineuro.2023.107962] [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: 06/22/2023] [Revised: 08/04/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Hyperammonemia can occur after acute overdose or chronic use of valproic acid (VPA). Although VPA-related hyperammonemic encephalopathy (VHE) is a rare complication of VPA therapy, early recognition of VHE and identifying its risk factors are important because VHE can lead to loss of consciousness and increased seizure frequency. PURPOSE The purpose of our study is to evaluate the risk factors of hyperammonemia in epilepsy patients during treatment with VPA therapy. METHODS We reviewed the medical records of 1084 adult patients with epilepsy and enrolled 116 patients with VPA therapy who had results of blood levels of ammonia over a 3-year period. Hyperammonemia was defined as a blood ammonia level exceeding 80 µg/dL. Correlations of blood levels of ammonia with dosages and blood levels of VPA were evaluated. We further performed univariate and multivariate linear regression analyses to identify risk factors for hyperammonemia in epilepsy patients treated with VPA therapy. RESULTS Blood levels of ammonia were well correlated with dosages of VPA (p = 0.036), but not with blood levels of VPA (p = 0.463). Hyperammonemia was more common in patients with higher VPA dosage and higher total drug loads of concurrent antiseizure medications (ASMs). Hyperammonemia was also associated with the use of topiramate and phenobarbital. In multivariate analysis, we identified total drug load of ASMs (p = 0.003) and use of topiramate (p = 0.007) as independent predictors of hyperammonemia. Four patients (4/116, 3.4 %) had clinical symptoms of VHE. Three of them had hyperammonemia while the other patient had normal blood level of ammonia with a high blood level of VPA. CONCLUSION Our study shows that higher total drug loads of concurrent ASMs and use of topiramate were independent risk factors of hyperammonemia in epilepsy patients with VPA therapy. Although the incidence of VHE was not high in our study, clinicians should be aware of this potential adverse effect of VPA therapy, especially in patients with polytherapy of ASMs including topiramate.
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Affiliation(s)
- Dong Won Kwack
- Department of Neurology, Konkuk University School of Medicine, Seoul, the Republic of Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, the Republic of Korea.
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Chang CWJ, Provencio JJ, Pascual J, Heavner MS, Olson D, Livesay SL, Kaplan LJ. State-of-the-Art Evaluation of Acute Adult Disorders of Consciousness for the General Intensivist. Crit Care Med 2023; 51:948-963. [PMID: 37070819 DOI: 10.1097/ccm.0000000000005893] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES To provide a concise review of knowledge and practice pertaining to the diagnosis and initial management of unanticipated adult patient disorders of consciousness (DoC) by the general intensivist. DATA SOURCES Detailed search strategy using PubMed and OVID Medline for English language articles describing adult patient acute DoC diagnostic evaluation and initial management strategies including indications for transfer. STUDY SELECTION Descriptive and interventional studies that address acute adult DoC, their evaluation and initial management, indications for transfer, as well as outcome prognostication. DATA EXTRACTION Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for adult critical care practice. DATA SYNTHESIS Acute adult DoC may be categorized by etiology including structural, functional, infectious, inflammatory, and pharmacologic, the understanding of which drives diagnostic investigation, monitoring, acute therapy, and subsequent specialist care decisions including team-based local care as well as intra- and inter-facility transfer. CONCLUSIONS Acute adult DoC may be initially comprehensively addressed by the general intensivist using an etiology-driven and team-based approach. Certain clinical conditions, procedural expertise needs, or resource limitations inform transfer decision-making within a complex care facility or to one with greater complexity. Emerging collaborative science helps improve our current knowledge of acute DoC to better align therapies with underpinning etiologies.
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Affiliation(s)
| | | | - Jose Pascual
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mojdeh S Heavner
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - DaiWai Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern, Dallas, TX
| | - Sarah L Livesay
- Department of Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, IL
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Shakerdi L, Ryan A. Drug-induced hyperammonaemia. J Clin Pathol 2023:jcp-2022-208644. [PMID: 37164630 DOI: 10.1136/jcp-2022-208644] [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: 11/23/2022] [Accepted: 04/28/2023] [Indexed: 05/12/2023]
Abstract
Hyperammonaemia (HA) as a consequence of numerous primary or secondary causes, gives rise to clinical manifestations due to its toxic effects on the brain. The neurological consequences broadly reflect the ammonia level, duration and age, with paediatric patients being more susceptible. Drug-induced HA may arise due to either decreased ammonia elimination or increased production. This is associated most frequently with use of valproate and presents a dilemma between ongoing therapeutic need, toxicity and the possibility of an alternative cause. As there is no specific test for drug-induced HA, prompt discussion with a metabolic physician is recommended, as the neurotoxic effects are time-dependent. Specific guidelines for managing drug-induced HA have yet to be published and hence the treatment approach outlined in this review reflects that outlined in relevant urea cycle disorder guidelines.
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Affiliation(s)
- Loai Shakerdi
- National Centre for Inherited Metabolic Disorders, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aidan Ryan
- Chemical Pathology, Cork University Hospital Biochemistry Laboratory, Cork, Ireland
- Pathology, University College Cork College of Medicine and Health, Cork, Ireland
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Valproic acid-induced hyperammonemia in neuropsychiatric disorders: a 2-year clinical survey. Psychopharmacology (Berl) 2023; 240:149-156. [PMID: 36459199 DOI: 10.1007/s00213-022-06289-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Valproic acid (VPA)-induced hyperammonemia (HA) is a rare adverse effect reported even at therapeutic VPA levels. The present study aimed to investigate the characteristics of VPA-induced HA and its association with the total dose, duration, and level of VPA. This study also investigated whether the use of VPA in combination with other medications has any effect on elevating serum ammonia levels. METHODS A total of 316 patients with a history of VPA prescribed for underlying neuropsychiatric disorders were found eligible for the study. Data including demographic information, medical history and diagnosis, VPA dosage, VPA treatment duration, VPA level, and ammonia serum level were extracted and reviewed from our hospital records. The history of other neuropsychiatric medications was also included. RESULTS Among 316 patients receiving VPA, HA was observed in 54 (17%) patients, and 15 patients were symptomatic among them. There was no significant difference in demographics between symptomatic and asymptomatic HA groups except for the number of co-administrated medications (p = 0.044). Besides, VPA duration and dose did not show a significant difference between the two groups. Additionally, the VPA level was significantly higher in patients who used risperidone in addition to VPA (p = 0.019). Eventually, VPA level showed a significant association with ammonia level (p = 0.025) and symptomatic HA (p = 0.033) after adjusting for possible confounders. CONCLUSION VPA level showed a significant association with ammonia level and symptomatic HA. Moreover, co-administrated medications such as risperidone might have an impact on the serum level of VPA. Further studies are recommended to confirm these findings.
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Risk factors and outcome of hyperammonaemia in people with epilepsy. J Neurol 2022; 269:6395-6405. [PMID: 35907043 PMCID: PMC9618503 DOI: 10.1007/s00415-022-11304-7] [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: 04/11/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Hyperammonaemia is a recognised complication of antiseizure treatment but risk factors leading to individual patient susceptibility and outcome remain unclear. OBJECTIVE To identify risk factors for hyperammonaemia and investigate the impact of its management on clinical outcomes. METHODS We carried out a retrospective observational study of adults with epilepsy who had ammonia tested over a 3-year period. Hyperammonaemia was defined as ammonia level > 35 μmol/L. Patients were classified into two groups: hyperammonaemic and non-hyperammonaemic. Association analyses and linear regression analysis were used to identify risk factors for hyperammonaemia. RESULTS We reviewed 1002 ammonia requests in total and identified 76 people with epilepsy who had ammonia concentration measured, including 26 with repeated measurements. 59/76 (78%) were found to have hyperammonaemia. There was borderline statistical significance of hyperammonaemia being less common in patients with an established monogenic/metabolic condition than in those with structural or cryptogenic epilepsy (P = 0.05). Drug resistance, exposure to stiripentol and oxcarbazepine were identified as risk factors for hyperammonaemia. We found a dose-dependent association between valproate and hyperammonaemia (P = 0.033). Clinical symptoms were reported in 22/59 (37%) of the hyperammonaemic group. Improved clinical outcomes with concurrent decrease in ammonia concentration were seen in 60% of patients following treatment adjustment. CONCLUSIONS Drug resistance and exposure to stiripentol, oxcarbazepine or high-dose valproate are associated with an increased risk of hyperammonaemia. Clinicians should consider symptoms related to hyperammonaemia in patients on high-dose valproate or multiple antiseizure treatments. Prompt identification of hyperammonaemia and subsequent treatment adjustments can lead to improved clinical outcomes.
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Leporini C, De Sarro C, Palleria C, Caccavo I, Piro B, Citraro R, De Sarro G. Pediatric Drug Safety Surveillance: A 10-Year Analysis of Adverse Drug Reaction Reporting Data in Calabria, Southern Italy. Drug Saf 2022; 45:1381-1402. [PMID: 36112324 PMCID: PMC9483327 DOI: 10.1007/s40264-022-01232-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 01/09/2023]
Abstract
Introduction The paucity of pediatric clinical trials has led to many medicines frequently prescribed to children without a license for use in pediatrics, resulting in an increased risk of adverse drug reactions. Pharmacovigilance databases remain, among others, a valuable tool for evaluating pediatric drug safety in the real-life setting. Objective We aimed to characterize pediatric adverse drug reactions reported in the Italian Pharmacovigilance database coming from the Calabria region (Southern Italy) over 10 years. Methods All Individual Case Safety Reports (ICSRs) concerning individuals aged under 18 years were extracted from 2010 to 2019. Duplicate and vaccine ICSRs were excluded. The remaining ICSRs were analyzed with respect to patients’ demographic data, suspected drugs, and category of adverse drug reactions across different age groups. Results Among 6529 selected ICSRs, 395 pediatric ICSRs corresponding to 556 adverse drug reactions were analyzed. From 2010 to 2015, an increasing number of ICSRs were observed, but the reporting rate decreased after 2015. The highest proportion of ICSRs concerned children and adolescents. Around 52% of ICSRs involved boys: a trend observed in all age groups excluding newborns. Sixty ICSRs were serious and among them, 75% required hospitalization mainly in children and adolescents. Most of the ICSRs were issued by physicians (64.1%), followed by other healthcare professionals (22.5%) and pharmacists (9.9%). Anti-infective agents for systemic use and skin disorders were, respectively, the most frequently reported drug group and adverse drug reaction category. Conclusions This study provides an overview of adverse drug reactions reported in the pediatric population of the Calabria region and emphasizes the need for strengthening the surveillance in specific age subgroups and on given drugs in relation to their pattern of use. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-022-01232-w.
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Yokoyama S, Sugawara N, Maruo K, Yasui-Furukori N, Shimoda K. Blood Levels of Ammonia and Carnitine in Patients Treated with Valproic Acid: A Meta-analysis. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2022; 20:536-547. [PMID: 35879038 PMCID: PMC9329117 DOI: 10.9758/cpn.2022.20.3.536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Objective Long-term valproic acid (VPA) administration is associated with adverse metabolic effects, including hyperammonemia and hypocarnitinemia. However, the pathogeneses of these adverse events remain unclear, and not enough reviews have been performed. The aim of this study was to conduct a meta-analysis of studies examining blood levels of ammonia and carnitine in patients treated with VPA. Methods We conducted database searches (PubMed, Web of Science) to identify studies examining blood levels of ammonia and carnitine in patients treated with VPA. A meta-analysis was performed to conduct pre- and post-VPA treatment comparisons, cross-sectional comparisons between groups with and without VPA use, and estimations of the standardized correlations between blood levels of ammonia, carnitine, and VPA. Results According to the cross-sectional comparisons, the blood ammonia level in the VPA group was significantly higher than that in the non-VPA group. Compared to that in the non-VPA group, the blood carnitine level in the VPA group was significantly lower. In the meta-analysis of correlation coefficients, the blood VPA level was moderately correlated with blood ammonia and blood free carnitine levels in the random effects model. Furthermore, the blood ammonia level was moderately correlated with the blood free carnitine level. Conclusion Although the correlation between ammonia and free carnitine levels in blood was significant, the moderate strength of the correlation does not allow clinicians to infer free carnitine levels from the results of ammonia levels. Clinicians should measure both blood ammonia and free carnitine levels, especially in patients receiving high dosages of VPA.
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Affiliation(s)
- Saaya Yokoyama
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Norio Sugawara
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Kazushi Maruo
- Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Kazutaka Shimoda
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Mibu, Japan
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Chen Y, Chen J, Zhuang X, Chen X, Zeng J, Wang R, Miao J. Risk factors of elevated blood ammonia level in epilepsy patients treated with lamotrigine. Medicine (Baltimore) 2022; 101:e29780. [PMID: 35776999 PMCID: PMC9239605 DOI: 10.1097/md.0000000000029780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AbstractThe aim of this study was to explore the effect of lamotrigine (LTG) on blood ammonia level in patients with epilepsy and identify risk factors affecting blood ammonia level. This study included 91 epilepsy patients who were treated with LTG at Department of Neurology, Zhongshan Hospital, Xiamen University from January 2011 to April 2016, and were followed up for 3 years. Blood samples were taken during the interictal state and analyzed for blood LTG and ammonia levels. Total of 46.1% of the samples exceeded the median blood ammonia level, and 2.1% of patients had hyperammonemia. Blood ammonia level was positively correlated with LTG blood concentration. LTG combined with valproic acid therapy, seizure within 1 year, and elevated neutrophils affected blood ammonia level. Blood ammonia level was significantly correlated with plasma concentration of LTG. LTG combined with valproic acid therapy, seizure within 1 year, and elevated neutrophils may be risk factors for elevated blood ammonia level in epilepsy patients treated with LTG.
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Affiliation(s)
- Yiqian Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jingzhen Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xiaorong Zhuang
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jianqi Zeng
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Ru Wang
- Department of Neurology, Weinan Central Hospital, Weinan, China
| | - Jiayin Miao
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
- *Correspondence: Jiayin Miao, Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen 361004, China (e-mail )
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13
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Young MR, Bisaccia EK, Romantseva L, Hovey SW. Valproic Acid Serum Concentration and Incidence of Toxicity in Pediatric Patients. J Child Neurol 2022; 37:461-470. [PMID: 35253521 DOI: 10.1177/08830738221083480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In certain pediatric patients on valproic acid, therapeutic range (50-100 μg/mL) is maximized or exceeded to achieve better seizure control. This study compared incidence of common valproic acid adverse effects (thrombocytopenia, hepatotoxicity, and hyperammonemia) across maintenance concentration and age group. One hundred twenty-four children on maintenance valproic acid between January 2013 and January 2021 were eligible for inclusion. Fifty-six patients were maintained in concentration range 50 to 80 μg/mL, an additional 44 between 80 and 100 μg/mL and 24 between 100 and 120 μg/mL. Forty-one patients were prepubescent, 57 pubescent, and 26 postpubescent. There were no statistically significant differences observed in the primary endpoint of thrombocytopenia across serum concentration range (P = .093) or age group (P = .628). No significant differences in hepatic dysfunction (P = .099) or hyperammonemia (P = .548) were observed in serum concentration groups. Similarly, age group analysis observed no difference in hepatic dysfunction (P = .615) or hyperammonemia (P = .369). Serum valproic acid levels >100 μg/mL can be considered in select pediatric patients based on this study.
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Affiliation(s)
- McKenzie R Young
- Department of Pharmacy, 2468Rush University Medical Center, Chicago, IL, USA
| | - Elizabeth K Bisaccia
- Department of Pharmacy, 21886Advocate Lutheran General Hospital, Park Ridge, IL, USA
| | - Lubov Romantseva
- Section of Pediatric Neurology, Department of Pediatrics, 2468Rush University Medical Center, Chicago, IL, USA
| | - Sara W Hovey
- Department of Pharmacy, 2468Rush University Medical Center, Chicago, IL, USA
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Calvo-López A, Rebollo-Calderon B, Ormazábal A, Artuch R, Rosell-Ferrer J, Alonso-Chamarro J, Puyol M. Biomedical point-of-care microanalyzer for potentiometric determination of ammonium ion in plasma and whole blood. Anal Chim Acta 2022; 1205:339782. [DOI: 10.1016/j.aca.2022.339782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/24/2022] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
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15
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Tsai CM, Chang SF, Chang H. Transcranial photobiomodulation add-on therapy to valproic acid for pentylenetetrazole-induced seizures in peripubertal rats. BMC Complement Med Ther 2022; 22:81. [PMID: 35313886 PMCID: PMC8935768 DOI: 10.1186/s12906-022-03562-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 03/09/2022] [Indexed: 12/15/2022] Open
Abstract
Background Convulsive status epilepticus (CSE) prevention is critical for pediatric patients with epilepsy. Immediate intervention before CSE reduce severity. Despite its wide usage as an anticonvulsant, valproic acid (VPA) results in harmful side effects such as dose-dependent hepatotoxicity. Hence, reducing VPA dosage to minimize side effects while maintaining its efficacy is necessary, and transcranial photobiomodulation (tPBM) add-on therapy could facilitate this. We recently demonstrated for the first time that tPBM at a wavelength of 808 nm attenuated CSE in peripubertal rats. However, the effects of VPA with the add-on therapy of tPBM prior to seizures have not yet been explored. This study investigated whether adding tPBM to VPA exerts synergistic effect for CSE prevention in peripubertal rats. Methods A gallium-aluminum-arsenide laser (wavelength of 808 nm with an exposure duration of 100 s and irradiance of 1.333 W/cm2 at the target) was applied transcranially 30 min after VPA injection in Sprague Dawley rats. All the rats received 90 mg/kg of pentylenetetrazole (PTZ). Except for the saline (n = 3), tPBM + saline (n = 3), and PTZ group (n = 6), all the rats received a PTZ injection 30 min after VPA injection. The rats received add-on tPBM with PTZ immediately after tPBM. In the VPA + PTZ group, the rats received low-dose (100 mg/kg, n = 6), medium-dose (200 mg/kg, n = 6), and high-dose (400 mg/kg, n = 7) VPA. In the VPA + tPBM + PTZ group, the rats received low (100 mg/kg, n = 5), medium (200 mg/kg, n = 6), and high (400 mg/kg, n = 3) doses of VPA. Seizures were evaluated according to the revised Racine’s scale in a non-blinded manner. Results Adding tPBM to low-dose VPA reduced the incidence of severe status epilepticus and significantly delayed the latency to stage 2 seizures. However, adding tPBM to high-dose VPA increased the maximum seizure stage, prolonged the duration of stage 4–7 seizures, and shortened the latency to stage 6 seizures. Conclusions Adding tPBM to low-dose VPA exerted a synergistic prevention effect on PTZ-induced seizures, whereas adding tPBM to high-dose VPA offset the attenuation effect.
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Affiliation(s)
- Chung-Min Tsai
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Shwu-Fen Chang
- Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsi Chang
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Department of Pediatrics, Taipei Medical University Hospital, 250 Wuxing St., Taipei, 11031, Taiwan.
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Szczygieł-Pilut EE, Zajączkowska-Dutkiewicz A, Pilut D, Dutkiewicz J. HYPERAMMONAEMIA AND COGNITIVE IMPAIRMENT IN EPILEPSY PATIENTS TREATED WITH VALPROIC ACID - PRELIMINARY STUDY. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1459-1465. [PMID: 35907216 DOI: 10.36740/wlek202206106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aim: To determine whether VPA pharmacotherapy, mainly in the group of patients using subtherapeutic doses of VPA, could contribute to the occurrence of cognitive impairment. PATIENTS AND METHODS Materials and methods: The study involved 14 patients: six women and eight men, aged 24 - 77 years (mean SD ± - 52.36±13.71) diagnosed with epilepsy in accordance with the ILAE criteria (International League Against Epilepsy), in whom the main clinical complaint, in addition to poor control of epileptic seizures, were impaired concentration, attention and memory impairment. RESULTS Results: Mild cognitive impairment - MCI was diagnosed in 4 patients (28.57%) (3 with elevated ammonia levels, 1 without), in 1 patient (7.14%) there was a mild level of dementia. In only one MCI case, elevated serum concentrations of valproic acid were also recorded. It is very important to highlight that cognitive impairment has never been diagnosed before (prior to VPA therapy) in this group. Of these 5 patients, in four cases, after discontinuation of the drug, an improvement in the clinical condition was achieved. In a patient with mild level dementia, the termination of therapy did not give a similar effect. This proves the possibility of other mechanisms responsible for generating these sometimes irreversible disorders. CONCLUSION Conclusions: Regardless of the dose and concentration of ammonia in blood serum of patients diagnosed with epilepsy, VPA therapy may cause various, significant dysfunctions that significantly impair quality of life.
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Affiliation(s)
- Elżbieta Ewa Szczygieł-Pilut
- DEPARTMENT OF NEUROLOGY WITH STROKE AND NEUROLOGICAL REHABILITATION SUB-UNIT, JOHN PAUL II SPECIALIST HOSPITAL, CRACOW, POLAND
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17
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De Fazio C, Goffin M, Franchi F, Ferlini L, Orinckx C, Spadaro S, Brasseur A, Gaspard N, Antonucci E, Khattar L, Peluso L, Romeo I, Creteur J, Legros B, Taccone FS. Hyperammonemia during treatment with valproate in critically ill patients. Clin Neurol Neurosurg 2021; 212:107092. [PMID: 34923197 DOI: 10.1016/j.clineuro.2021.107092] [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: 11/01/2021] [Revised: 12/08/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Hyperammonemia (HA) is a potential side-effect of valproate (VPA) treatment, which has been described during long-term administration. The aim of this study was to evaluate the incidence, the impact and the risk factors of HA in critically ill patients. METHODS We reviewed the data of all adult patients treated in our mixed 35-bed Department of Intensive Care over a 12-year period (2004-2015) who: a) were treated with VPA for more than 72 h and b) had at least one measurement of ammonium and VPA levels during the ICU stay; patients with Child-Pugh C liver cirrhosis were excluded. HA was defined as ammonium levels above 60 μg/dl. RESULTS Of a total of 2640 patients treated with VPA, 319 patients met the inclusion criteria (median age 64 years; male gender 55%); 78% of them were admitted for neurological reasons and ICU mortality was 30%. Median ammonium levels were 88 [63-118] µg/dl. HA was found in 245 (77%) patients. For those patients with HA, median time from start of VPA therapy to HA was 3 [2-5] days. In a multivariable analysis, high VPA serum levels, mechanical ventilation and sepsis were independently associated with HA during VPA therapy. In 98/243 (40%) of HA patients, VPA was interrupted; VPA interruption was more frequent in patients with ammonium levels > 100 μg/dl than others (p = 0.001). HA was not an independent predictor of ICU mortality or poor neurological outcome. CONCLUSIONS In this study, HA was a common finding during treatment with VPA in acutely ill patients. VPA levels, sepsis and mechanical ventilation were risk factors for HA. Hyperammonemia did not influence patients' outcome.
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Affiliation(s)
- Chiara De Fazio
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium; Department of Morphological Surgery and Experimental Medicine, Arcispedale Sant'Anna, Università di Ferrara, Via Aldo Moro, 8, Ferrara, Italy
| | - Manon Goffin
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Federico Franchi
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Lorenzo Ferlini
- Departmentt of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Cindy Orinckx
- Departmentt of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Savino Spadaro
- Department of Morphological Surgery and Experimental Medicine, Arcispedale Sant'Anna, Università di Ferrara, Via Aldo Moro, 8, Ferrara, Italy
| | - Alexandre Brasseur
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Nicolas Gaspard
- Departmentt of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Elio Antonucci
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Lina Khattar
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium.
| | - Immacolata Romeo
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Benjamin Legros
- Departmentt of Neurology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
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18
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Guo J, Ma J, Wang S, Li X, Ji H, Li Y, Peng F, Sun Y. Valproic Acid After Neurosurgery Induces Elevated Risk of Liver Injury: A Prospective Nested Case-Control Study. Ann Pharmacother 2021; 56:888-897. [PMID: 34749535 DOI: 10.1177/10600280211055508] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Valproic acid (VPA) has been widely used to prevent epileptic seizures after neurosurgery in China. We have found that the incidence of liver injury (LI) in patients using VPA after neurosurgery is higher than that in other patients. OBJECTIVE The objective of this study was to investigate the risk factors of LI in patients using VPA after neurosurgery. METHODS A nested case-control study was conducted in patients using VPA after neurosurgery between September 2019 and March 2021. Cases of LI were matched to controls by age and body mass index (BMI). Conditional logistic regression was used to estimate matched odds ratios representing the odds of LI. A receiver operating characteristic curve was used to analyze the optimal cutoff condition. RESULTS A total of 248 people (62 LI and 186 control) were enrolled. Among patients with vs without LI, the matched odds ratio for trough concentration of VPA was significant (matched odds ratio [OR], 1.09; 95% confidence interval [CI]: 1.01-1.19). The course of treatment (OR: 1.17, 95% CI: 1.02-1.33), Glasgow score (OR: 0.26, 95% CI: 0.10-0.67), gene polymorphisms of CYP2C19 (OR: 2.09, 95% CI: 1.03-146.93), and UGT1A6 (OR: 34.61, 95% CI: 1.19-1003.23) were all related to the outcome. The optimal cutoff of the course of treatment was 10 days, while the trough concentration of VPA was determined to be 66.16 mg/L. CONCLUSION Length of treatment, VPA trough concentration, and Glasgow score were associated with LI in patients after neurosurgery. A gene test may be necessary for people who are prescribed VPA for a long time.
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Affiliation(s)
- Jinlin Guo
- Department of Pharmacy, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Jiuhong Ma
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Shan Wang
- Department of Pharmacy, NYU Langone Hospital-Long Island, Mineola, USA
| | - Xingang Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hongming Ji
- Department of Neurosurgery, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Yuanping Li
- Department of Pharmacy, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Fangchen Peng
- Department of Pharmacy, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Yiqi Sun
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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19
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McMorris T, Chu A, Vu L, Bernardini A. Hyperammonemia in patients receiving valproic acid in the hospital setting: A retrospective review. Ment Health Clin 2021; 11:243-247. [PMID: 34316420 PMCID: PMC8287865 DOI: 10.9740/mhc.2021.07.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/07/2021] [Indexed: 01/09/2023] Open
Abstract
Introduction Valproic acid (VPA) is widely used for the treatment of epilepsy, migraine, and a variety of psychiatric conditions. The reported incidences of hyperammonemia induced by VPA use is variable. The purpose of this study is to evaluate the incidence of VPA-induced hyperammonemia in the general adult inpatient population. Methods Adult patients who received at least 1 dose of VPA and derivatives between June 1, 2017 to December 31, 2017 were included. Patients were excluded if they did not have VPA administered during their inpatient stay or if they had elevated ammonia levels (>33 μmol/L) prior to initiation of VPA. Patients with a confirmed diagnosis of liver cirrhosis were also excluded. The primary endpoint was the incidence of hyperammonemia. Secondary outcomes included symptoms of hyperammonemia, diagnosis of VPA-induced hyperammonemia, and treatment of VPA-induced hyperammonemia. Results A total of 162 patients were included in this study. A total of 33 (20.4%) patients were identified as having the primary outcome of hyperammonemia; 26 (16.0%) patients had symptoms of hyperammonemia, and 13 (8.0%) patients were diagnosed with VPA-induced hyperammonemia. Treatment modalities included administration of lactulose, levocarnitine, discontinuing VPA, or decreasing the VPA dose. Discussion The administration of VPA in the general adult inpatient population resulted in a 20.4% incidence of hyperammonemia, with a lower rate of diagnosed VPA-induced hyperammonemia. Clinicians should be encouraged to obtain ammonia levels in patients receiving VPA if symptoms of altered mental status or encephalopathy develop.
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Affiliation(s)
- Tressa McMorris
- Assistant Professor of Pharmacy Practice, College of Pharmacy, Roseman University of Health Sciences, South Jordan, Utah.,Pharmacist, CVS Pharmacy, Tuscon, Arizona; previously: Roseman University of Health Sciences College of Pharmacy.,Pharmacist, Raley's Pharmacy, Reno, Nevada; previously: Roseman University of Health Sciences College of Pharmacy
| | - Angela Chu
- Assistant Professor of Pharmacy Practice, College of Pharmacy, Roseman University of Health Sciences, South Jordan, Utah
| | - Lynn Vu
- Pharmacist, CVS Pharmacy, Tuscon, Arizona; previously: Roseman University of Health Sciences College of Pharmacy
| | - Amanda Bernardini
- Pharmacist, Raley's Pharmacy, Reno, Nevada; previously: Roseman University of Health Sciences College of Pharmacy
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20
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Loikas D, Linnér L, Sundström A, Wettermark B, von Euler M. Post-stroke epilepsy and antiepileptic drug use in men and women. Basic Clin Pharmacol Toxicol 2021; 129:148-157. [PMID: 34021701 DOI: 10.1111/bcpt.13617] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 12/14/2022]
Abstract
Evidence-based recommendations for choice of antiepileptic drug (AED) in post-stroke epilepsy (PSE) are lacking. The aim of this study was to describe the use and persistence of AEDs when initiating treatment in men and women with PSE. An observational study based on individual-level patient data from a regional healthcare register in Stockholm, Sweden, was conducted. Adults (≥18 years) with a stroke diagnosis 2012-2016, a dispensed prescription of any AED within two years after the stroke, and with an epilepsy-related diagnosis were identified. Multinomial logistic regression and logistic regression were used to identify factors associated with choice of AED and discontinuation within 90 days, respectively. Of 9652 men and 9844 women with a stroke diagnosis, 287 men and 273 women had PSE and were dispensed AED. More than 60% of both men and women with PSE were treated with levetiracetam. Carbamazepine was the second most common drug followed by lamotrigine and valproic acid. There were significant differences in AED choice depending on for instance sex, age and renal impairment. Levetiracetam had the highest persistence in both men and women. Choice of AED, oral anticoagulant use and percutaneous endoscopic gastrostomy (PEG) showed an association with the persistence to therapy. We conclude that in both men and women with PSE, levetiracetam was the most used AED for initiation of treatment and also had the highest persistence.
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Affiliation(s)
- Desirée Loikas
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.,Region Stockholm, Health and Medical Care Administration, Stockholm, Sweden
| | - Love Linnér
- Region Stockholm, Health and Medical Care Administration, Stockholm, Sweden
| | - Anders Sundström
- Department of Pharmacy, Faculty of Pharmacy, Disciplinary Domain of Medicine and Pharmacy, Uppsala university, Uppsala, Sweden
| | - Björn Wettermark
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Stockholm, Sweden.,Department of Pharmacy, Faculty of Pharmacy, Disciplinary Domain of Medicine and Pharmacy, Uppsala university, Uppsala, Sweden
| | - Mia von Euler
- School of Medicine, Örebro University, Örebro, Sweden.,Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden
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Abstract
BACKGROUND Hyperammonemia is a common side effect of valproic acid (VPA) and can occur after generalized seizures, but the clinical significance is unclear. The aim of this study was to better understand the clinical practice and utility of ammonia testing in status epilepticus (SE) treated with or without VPA. METHODS Charts of adult patients with SE from St. Mary's Hospital Intensive Care Units (ICUs) (Mayo Clinic, Rochester, MN) from 2011 to 2016 were reviewed. Clinical factors were compared between patients who had ammonia checked versus those who did not, and those with normal ammonia versus hyperammonemia (>50 µg/dL). Charts were reviewed to determine if hyperammonemia changed clinical management and if it was felt to be symptomatic. RESULTS There were 304 patients identified: 94 received VPA, 142 had ammonia checked and receiving VPA was associated with ammonia testing (P<0.001). Hyperammonemia was identified in 32 and associated with younger age, being in a non-neurological intensive care unit, and liver disease, but was not statistically associated with VPA. Only one patient had valproate-induced hyperammonemic encephalopathy; however, many patients received treatment for hyperammonemia such as lactulose, levocarnitine, or VPA dose reductions. CONCLUSIONS This study demonstrated variability in ammonia testing and management changes in SE but does not support the routine monitoring of ammonia levels and showed that hyperammonemic encephalopathy was rare in this clinical setting.
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22
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Meijer R, Vivekananda U, Balestrini S, Walker M, Lachmann R, Haeberle J, Murphy E. Ammonia: what adult neurologists need to know. Pract Neurol 2020:practneurol-2020-002654. [PMID: 33310884 DOI: 10.1136/practneurol-2020-002654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2020] [Indexed: 12/31/2022]
Abstract
Hyperammonaemia is often encountered in acute neurology and can be the cause of acute or chronic neurological symptoms. Patients with hyperammonaemia may present with seizures or encephalopathy, or may be entirely asymptomatic. The underlying causes are diverse but often straightforward to diagnose, although sometimes require specialist investigations. Haemodialysis or haemo(dia)filtration is the first-line treatment for acute severe hyperammonaemia (of any cause) in an adult. Here we discuss our approach to adult patients with hyperammonaemia identified by a neurologist.
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Affiliation(s)
- Rick Meijer
- Department of Internal Medicine, Amsterdam University Medical Centers, Location VU University Medical Center, Amsterdam, The Netherlands
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Umesh Vivekananda
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Simona Balestrini
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
- Chalfont Centre for Epilepsy, Buckinghamshire, UK
| | - Matthew Walker
- Department of Clinical and Experimental Epilepsy, UCL Queen Square Institute of Neurology, London, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Johannes Haeberle
- Department of Pediatrics, University Children's Hospital Zurich and Children's Research Centre, Zurich, Switzerland
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
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23
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Yao ZP, Li Y, Liu Y, Wang HL. Relationship between the incidence of non-hepatic hyperammonemia and the prognosis of patients in the intensive care unit. World J Gastroenterol 2020; 26:7222-7231. [PMID: 33362378 PMCID: PMC7723668 DOI: 10.3748/wjg.v26.i45.7222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/14/2020] [Accepted: 10/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ammonia is a normal constituent of body fluids and is found mainly through the formation of urea in the liver. Blood levels of ammonia must remain low as even slightly elevated concentrations (hyperammonemia) are toxic to the central nervous system.
AIM To examine the relationship between the incidence of non-hepatic hype-rammonemia (NHH) and the prognosis of patients who were admitted to the intensive care unit (ICU).
METHODS This is a prospective, observational and single-center study. A total of 364 patients who were admitted to the ICU from November 2019 to February 2020 were initially enrolled. Changes in the levels of blood ammonia at the time of ICU admission and after ICU admission were continuously monitored. In addition, factors influencing the prognosis of NHH patients were analyzed.
RESULTS A total of 204 patients who met the inclusion criteria were enrolled in this study, including 155 NHH patients and 44 severe-NHH patients. The incidence of NHH and severe-NHH was 75.98% and 21.57%, respectively. Patients with severe-NHH exhibited longer length of ICU stay and higher Acute Physiologic Assessment and Chronic Health Evaluation and Sequential Organ Failure Assessment scores compared to those with mild-NHH and non-NHH. Glasgow Coma Scale scores of patients with severe-NHH were than those of non-NHH patients. In addition, the mean and initial levels of ammonia in the blood might be helpful in predicting the prognosis of NHH.
CONCLUSION High blood ammonia level is frequent among NHH patients admitted to the ICU, which is related to the clinical characteristics of patients. Furthermore, the level of blood ammonia may be helpful for prognosis prediction.
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Affiliation(s)
- Zhi-Peng Yao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Yue Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Yang Liu
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Hong-Liang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
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Chen CL, Liang TM, Chen HH, Lee YY, Chuang YC, Chen NC. Constipation and Its Associated Factors among Patients with Dementia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17239006. [PMID: 33287267 PMCID: PMC7730313 DOI: 10.3390/ijerph17239006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/26/2020] [Accepted: 11/30/2020] [Indexed: 12/12/2022]
Abstract
Constipation is one of the most frequent non-motor problems in older adults. As constipation is commonly ignored by dementia patients, it is not usually reported on time. Constipation has a serious impact on the activity of daily living and quality of life in dementia patients. The relationships between constipation, demographic variables, and the nutritional status of patients with dementia remain unknown. This study aimed to assess the possible factors associated with constipation. This cross-sectional study was conducted at the Kaohsiung Chang Gung Memorial Hospital from January to November 2019. This hospital is a medical center and the main referral hospital of southern Taiwan, serving 3 million inhabitants. In total, 119 patients with dementia were evaluated using the Rome III diagnostic criteria for functional constipation. There were 30 patients with dementia included in the constipation group and 89 patients with dementia included in the no constipation group. Mini-Nutritional Assessment and 3-day diet diary records were employed. The clinical dementia rating score was used to evaluate the severity of dementia in patients of the outpatient clinic. Approximately 25.2% of dementia patients had constipation. Patients in the dementia with constipation group were older, had severer dementia, and displayed a lower water intake. After multivariable adjustment, low liquid consumption was the predictor of constipation among patients with dementia. The findings support the clinical recommendations to treat constipation with an increased liquid intake, but not exercise, in dementia patients.
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Affiliation(s)
- Chien-Liang Chen
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan;
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei 112, Taiwan
| | - Tzu-Ming Liang
- Nutrition Therapy Department, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 813, Taiwan;
| | - Hsiu-Hui Chen
- Physical Education, National Kaohsiung University of Science and Technology, Kaohsiung 807, Taiwan;
| | - Yan-Yuh Lee
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan;
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
- Department of Neurology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
- Correspondence: ; Tel.: +886-7731-7123 (ext. 3304); Fax: +886-7-7318762
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Incidence, Presentation, and Risk Factors for Sodium Valproate–Associated Hyperammonemia in Neurosurgical Patients: A Prospective, Observational Study. World Neurosurg 2020; 144:e597-e604. [DOI: 10.1016/j.wneu.2020.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/18/2022]
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Badawy AA, Elghaba R, Soliman M, Hussein AM, AlSadrah SA, Awadalla A, Abulseoud OA. Chronic Valproic Acid Administration Increases Plasma, Liver, and Brain Ammonia Concentration and Suppresses Glutamine Synthetase Activity. Brain Sci 2020; 10:brainsci10100759. [PMID: 33096612 PMCID: PMC7589689 DOI: 10.3390/brainsci10100759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/07/2020] [Accepted: 10/15/2020] [Indexed: 01/09/2023] Open
Abstract
Asymptomatic valproic acid (VPA)-induced hyperammonemia in the absence of liver impairment is fairly common. However, the underlying mechanisms through which VPA causes elevation in plasma ammonia (NH4) remains under investigation. Male Sprague Dawley rats (n = 72) were randomly allocated to receive VPA 400 mg/kg, 200 mg/kg, or vehicle IP daily for either 8, 14, or 28 consecutive days. The behavioral effects of VPA were assessed. Plasma, liver, and prefrontal cortex (PFC), striatum (Str), and cerebellum (Cere) were collected 1 h post last injection and assayed for NH4 concentration and glutamine synthetase (GS) enzyme activity. Chronic VPA treatment caused attenuation of measured behavioral reflexes (p < 0.0001) and increase in plasma NH4 concentration (p < 0.0001). The liver and brain also showed significant increase in tissue NH4 concentrations (p < 0.0001 each) associated with significant reduction in GS activity (p < 0.0001 and p = 0.0003, respectively). Higher tissue NH4 concentrations correlated with reduced GS activity in the liver (r = −0.447, p = 0.0007) but not in the brain (r = −0.058, p = 0.4). Within the brain, even though NH4 concentrations increased in the PFC (p = 0.001), Str (p < 0.0001), and Cere (p = 0.01), GS activity was reduced only in the PFC (p < 0.001) and not in Str (p = 0.2) or Cere (p = 0.1). These results suggest that VPA-induced elevation in plasma NH4 concentration could be related, at least in part, to the suppression of GS activity in liver and brain tissues. However, even though GS is the primary mechanism in brain NH4 clearance, the suppression of brain GS does not seem to be the main factor in explaining the elevation in brain NH4 concentration. Further research is urgently needed to investigate brain NH4 dynamics under chronic VPA treatment and whether VPA clinical efficacy in treating seizure disorders and bipolar mania is impacted by its effect on GS activity or other NH4 metabolizing enzymes.
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Affiliation(s)
- Abdelnaser A. Badawy
- Department of Biochemistry, Faculty of Medicine, Northern Border University, Arar 73213, Saudi Arabia;
- Department of Biochemistry, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Rasha Elghaba
- Department of Medical Physiology, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt;
| | - Mohamed Soliman
- Department of Microbiology, Faculty of Medicine, Northern Border University, Arar 73213, Saudi Arabia;
| | - Abdelaziz M. Hussein
- Department of Medical Physiology, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt;
- Correspondence: (A.M.H.); (O.A.A.)
| | - Sana A. AlSadrah
- Department of Preventive Medicine, Governmental Hospital Khobar, Health Centers in Khobar, Ministry of Health, Khobar 34446, Saudi Arabia;
| | - Amira Awadalla
- Center of Excellence and Cancer Genome, Mansoura Urology and Nephrology Center, Mansoura 35516, Egypt;
| | - Osama A. Abulseoud
- Neuroimaging Research Branch, IRP, National Institute on Drug Abuse, National Institutes of Health, Biomedical Research Center, Baltimore, MD 21224, USA
- Correspondence: (A.M.H.); (O.A.A.)
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Association Between the Serum Carnitine Level and Ammonia and Valproic Acid Levels in Patients with Bipolar Disorder. Ther Drug Monit 2020; 42:766-770. [DOI: 10.1097/ftd.0000000000000778] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Safety range of free valproic acid serum concentration in adult patients. PLoS One 2020; 15:e0238201. [PMID: 32877431 PMCID: PMC7467252 DOI: 10.1371/journal.pone.0238201] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
Background Therapeutic drug monitoring (TDM) is recommended during valproic acid (VPA) use, and total serum concentration has been widely adopted. However, the free form of VPA is responsible for its pharmacologic and toxic effects, and the total and free concentrations are highly discordant because of VPA’s highly protein bound and saturable binding characteristics. Therefore, free VPA monitoring is increasingly advocated. Nevertheless, the correlation between free VPA concentration and associated adverse effects remains unknown. Objective To determine the optimal safety range of free VPA concentration in adult patients. Materials and methods This prospective cohort study enrolled adult patients undergoing VPA therapy with TDM. Patient characteristics, VPA use, and adverse effects (thrombocytopenia, hyperammonemia, and hepatotoxicity) were recorded. A multivariate logistic regression model was applied to identify the predictors of adverse effects, and the receiver operating characteristic curve was applied to locate the cutoff point of free VPA concentration. Results A total of 98 free serum concentrations from 51 patients were included for final analysis. In total, 31 (31.6%), 27 (27.6%), and 4 (4.1%) episodes of hyperammonemia, thrombocytopenia, and hepatotoxicity were observed, respectively. Free VPA concentration was a predicting factor for thrombocytopenia but not for hyperammonemia. A free VPA concentration of >14.67 mcg/mL had the greatest discriminating power (area under the curve = 0.77) for the occurrence of thrombocytopenia. Conclusions A free VPA serum concentration of 14.67 mcg/mL had the optimal discriminating power for the occurrence of thrombocytopenia. Ammonemia should be monitored even if free VPA concentration is within the safety range.
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Palomino Pérez LM, Martín‐Rivada Á, Cañedo Villaroya E, García‐Peñas JJ, Cuervas‐Mons Vendrell M, Pedrón‐Giner C. Use of carglumic acid in valproate-induced hyperammonemia: 25 pediatric cases. JIMD Rep 2020; 55:3-11. [PMID: 32905024 PMCID: PMC7463051 DOI: 10.1002/jmd2.12131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 04/08/2020] [Accepted: 05/04/2020] [Indexed: 01/09/2023] Open
Abstract
Hyperammonemic encephalopathy is a rare but potentially dangerous complication of the antiepileptic drug (AED) sodium valproate (VPA). We report a retrospective study of 25 pediatric patients, (15 females [60%]; age: 7.6 ± 4.9 years), with different underlying disorders, who suffered from hyperammonemia due to VPA and who were treated with carglumic acid (CA). The duration of treatment with VPA was 15 ± 1 month, with a dose of 40 ± 16.6 mg/kg/d. VPA blood levels were 75.5 ± 60 mg/L with seven patients being overdosed (>100 mg/L). Twenty-three patients received concomitant treatment with other AEDs. The initial dose of CA was 100 mg/kg. Subsequently, CA doses of 25 mg/kg were given to 22 patients every 6 hours (average treatment length 2.17 ± 1.1 days) until ammonemia was normalized. In nine patients, CA was used in combination with other drugs to treat hyperammonemia. In all cases, blood ammonia levels were brought under control and symptoms of hyperammonemia resolved. Two hours after CA administration, the average reduction in ammonium levels was 53 ± 29 and 88.6 ± 47.5 μmol/L at 24 hours, resulting in a statistically significant decrease when compared to pretreatment levels. There were no statistically significant differences between sexes, in the presence or not of cognitive impairment or previous carnitine treatment. There were no statistically significant differences when comparing treatment with CA plus ammonia scavengers vs CA alone. In 17 patients (68%) VPA was discontinued and 62% of the patients who maintained treatment had recurrent episodes of hyperammonemia.
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Affiliation(s)
| | | | - Elvira Cañedo Villaroya
- Section of Gastroenterology and NutritionHospital Infantil Universitario Niño JesúsMadridSpain
| | | | | | - Consuelo Pedrón‐Giner
- Section of Gastroenterology and NutritionHospital Infantil Universitario Niño JesúsMadridSpain
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Levocarnitine for the Treatment of Valproic Acid-Induced Hyperammonemic Encephalopathy in Children: The Experience of a Large, Tertiary Care Pediatric Hospital and a Poison Center. Am J Ther 2019; 26:e344-e349. [PMID: 29232283 DOI: 10.1097/mjt.0000000000000706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although rare, symptomatic hyperammonemia is sometimes associated with valproic acid (VPA), especially in children. L-carnitine (levocarnitine), sometimes classified as an essential amino acid, is vital to mitochondrial utilization of fatty acids and can be helpful in treating this condition. The data supporting this, however, are limited. STUDY QUESTION The aim of the study was to illustrate the role of L-carnitine in the treatment of patients with VPA-induced hyperammonemic encephalopathy (VPE) at 2 different institutions. METHODS Medical records of affected patients were reviewed; data collected included exposure history, clinical manifestations, physical examination, and laboratory values. RESULTS There were 13 cases of VPE; 12 were associated with therapeutic dosing and 1 with an overdose. The maximum ammonia concentration was 557 μmol/L, and blood concentrations of VPA ranged from 68 to 600 μg/mL (therapeutic range 50-100 μg/mL). In all cases, liver function tests were normal or only mildly increased. In this study, 12 patients received a daily dose of L-carnitine 100 mg/kg, and 1 received 200 mg/kg (intravenous infusion over 30 minutes) divided every 8 hours until clinical improvement. All patients made a full recovery. None developed adverse effects or reactions, and no cases of toxicity were reported. CONCLUSION Our series suggests that intravenous L-carnitine, at a dose of 100 mg·kg·d in 3 divided doses each over 30 minutes until clinical improvement occurs, is a safe and effective treatment in the management of VPE in children.
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Abstract
RATIONALE Adult hyperammonemia is most often the result of hepatic dysfunction. Hyperammonemia in the setting of normal hepatic function is a much less common phenomenon and has usually been associated with medications and certain disease states. Here, we present an unusual case of severe hyperammonemia caused physiologically by intense muscle activity in a patient lacking any evidence of liver disease. PATIENT CONCERNS A 36-year-old woman was brought to the emergency department for a suicide attempt after being found covered in Lysol and Clorox germicidal bleach. She was noted to be in a state of violent psychosis with extreme agitation and had to be sedated and intubated for airway protection. DIAGNOSIS AND INTERVENTIONS Initial labs revealed hyperammonemia, lactic acidosis, and anion gap metabolic acidosis. Aminotransferases, bilirubin, and creatine kinase (CK) were normal. Renal function, prothrombin time, activated partial thromboplastin time, and international normalized ratio were also unremarkable and remained so at 24 hours. Ethyl alcohol, acetaminophen, salicylate, and valproic acid were all undetectable in blood. She received 2 doses of lactulose overnight, with a subsequent bowel movement. Next day, her mentation, serum ammonia level, and lactic acid level were back to normal, and she was extubated. Aminotransferases and CK levels were elevated but improved with supportive care. A detailed history and relevant biochemical investigations were unremarkable for any other etiology of hyperammonemia including the common inborn errors of metabolism (IEM). The combination of clinical findings of extreme skeletal muscle activity along with hyperammonemia and lactic acidosis, and subsequently rhabdomyolysis in the setting of unremarkable history and otherwise normal hepatic function strongly suggest the myokinetic origin of hyperammonemia in the patient. OUTCOME The patient recovered well with supportive care and was discharged on day 5. LESSONS This unique case illustrates the important role of skeletal muscle in the human metabolism of ammonia. In our discussion, we also elucidate the underlying pathophysiology, with the objective of improving clinician understanding of various differential diagnoses.
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Affiliation(s)
| | - Haneesh Jasuja
- Materials and Nanotechnology Program, North Dakota State University, Fargo, ND
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Baumgartner J, Hoeflich A, Hinterbuchinger B, Fellinger M, Graf I, Friedrich F, Frey R, Mossaheb N. Fulminant Onset of Valproate-Associated Hyperammonemic Encephalopathy. Am J Psychiatry 2019; 176:900-903. [PMID: 31672038 DOI: 10.1176/appi.ajp.2019.18040363] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Josef Baumgartner
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Anna Hoeflich
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Barbara Hinterbuchinger
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Matthaeus Fellinger
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Irene Graf
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Fabian Friedrich
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Richard Frey
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
| | - Nilufar Mossaheb
- The Department of Psychiatry and Psychotherapy, Clinical Division of Social Psychiatry (Baumgartner, Hoeflich, Hinterbuchinger, Fellinger, Friedrich, Mossaheb), and the Department of Psychiatry and Psychotherapy, Clinical Division of General Psychiatry (Graf, Frey), Medical University of Vienna
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Yamada H, Shishido T, Mukai T, Araki M, Naka H, Tokinobu H. [Valproic acid-induced hyperammonemic encephalopathy in a patient receiving valproic acid monotherapy]. Rinsho Shinkeigaku 2019; 59:258-263. [PMID: 31061301 DOI: 10.5692/clinicalneurol.cn-001254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A 79-year-old female was diagnosed with epilepsy because she experienced loss of consciousness twice in January and February and then had a seizure in June 2016. She was treated with 800 mg sodium valproate (sustained release). After 3 days, she experienced loss of appetite, and more than 3 days later, disturbance of consciousness. Serum valproic acid (VPA) concentration was 128.3 μg/ml and serum ammonia was 404 μmol/l. Cerebral edema and status epilepticus occurred. Severe neurological dysfunction remained, even after treatment with continuous hemodiafiltration and levocarnitine. VPA is widely used for the treatment of generalized epilepsy. VPA-induced hyperammonemic encephalopathy is a rare but serious adverse event of VPA. Thus, we must pay attention to serum ammonia levels when using VPA, even VPA monotherapy.
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Affiliation(s)
| | | | - Tomoya Mukai
- Department of Neurology, Hiroshima Prefectural Hospital
| | - Mutsuko Araki
- Department of Neurology, Hiroshima Prefectural Hospital
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Monostory K, Nagy A, Tóth K, Bűdi T, Kiss Á, Déri M, Csukly G. Relevance of CYP2C9 Function in Valproate Therapy. Curr Neuropharmacol 2019; 17:99-106. [PMID: 29119932 PMCID: PMC6341495 DOI: 10.2174/1570159x15666171109143654] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 10/09/2017] [Accepted: 11/07/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Genetic polymorphisms of drug metabolizing enzymes can substantially modify the pharmacokinetics of a drug and eventually its efficacy or toxicity; however, inferring a patient's drug metabolizing capacity merely from his or her genotype can lead to false prediction. Non-genetic host factors (age, sex, disease states) and environmental factors (nutrition, comedication) can transiently alter the enzyme expression and activities resulting in genotypephenotype mismatch. Although valproic acid is a well-tolerated anticonvulsant, pediatric patients are particularly vulnerable to valproate injury that can be partly attributed to the age-related differences in metabolic pathways. METHODS CYP2C9 mediated oxidation of valproate, which is the minor metabolic pathway in adults, appears to become the principal route in children. Genetic and non-genetic variations in CYP2C9 activity can result in significant inter- and intra-individual differences in valproate pharmacokinetics and valproate induced adverse reactions. RESULTS The loss-of-function alleles, CYP2C9*2 or CYP2C9*3, display significant reduction in valproate metabolism in children; furthermore, low CYP2C9 expression in patients with CYP2C9*1/*1 genotype also leads to a decrease in valproate metabolizing capacity. Due to phenoconversion, the homozygous wild genotype, expected to be translated to CYP2C9 enzyme with normal activity, is transiently switched into poor (or extensive) metabolizer phenotype. CONCLUSION Novel strategy for valproate therapy adjusted to CYP2C9-status (CYP2C9 genotype and CYP2C9 expression) is strongly recommended in childhood. The early knowledge of pediatric patients' CYP2C9-status facilitates the optimization of valproate dosing which contributes to the avoidance of misdosing induced adverse reactions, such as abnormal blood levels of ammonia and alkaline phosphatase, and improves the safety of children's anticonvulsant therapy.
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Affiliation(s)
- Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Andrea Nagy
- Heim Pal Children's Hospital, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Tamás Bűdi
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Ádám Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Gábor Csukly
- Department of Psychiatry and Psychotherapy, Semmelweis University, Budapest, Hungary
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Haznedar P, Doğan Ö, Albayrak P, Öz Tunçer G, Teber S, Deda G, Eminoglu FT. Effects of levetiracetam and valproic acid treatment on liver function tests, plasma free carnitine and lipid peroxidation in childhood epilepsies. Epilepsy Res 2019; 153:7-13. [PMID: 30925397 DOI: 10.1016/j.eplepsyres.2019.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/06/2019] [Accepted: 03/14/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The relationship between anti-epileptic usage and oxidative damage has not yet been clearly understood. In our study, we investigated oxidative stress parameters, carnitine levels, liver function tests (LFT) and their relationship in epileptic children treated with valproic acid or levetiracetam. METHOD LFTs, serum free carnitine and oxidative damage markers and their relations with each other were determined in patients who are on valproic acid or levetiracetam treatment at least for 6 months. 25 patients on therapeutic doses of valproic acid, 26 patients on therapeutic doses of levetiracetam and 26 healthy volunteers as controls were included. LFTs, ammonia, carnitine, lipid peroxidation biomarker malondialdehyde (MDA) and a sensitive marker of DNA damage, 8-hydroxy-2-deoxyguanosine (8-OHdG) levels were measured. Results of patients are compared to healthy controls. The data is evaluated with IBM SPSS Statistics 22.0. RESULTS Ammonia and MDA levels were elevated in patients using levetiracetam; 8-OHdG levels were elevated in both patient groups. Carnitine levels were significantly low in patients under valproic acid therapy, however they were not found to be correlated with MDA, 8-OHdG or LFTs. MDA showed positive correlation with ammonia and 8-OHdG in the levetiracetam group. CONCLUSION We did not observe hepatotoxicity in patients under therapeutic doses of valproic acid. However, epileptic children under therapeutic doses of levetiracetam showed significantly elevated levels of MDA and 8-OHdG, which is supportive for oxidative damage under levetiracetam therapy. This result was observed for the first time in childhood epilepsies and further studies are needed to understand its mechanism.
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Affiliation(s)
- Pınar Haznedar
- Ankara University Faculty of Medicine, Department of Pediatrics Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
| | - Özlem Doğan
- Ankara University Faculty of Medicine, Biochemistry Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
| | - Pelin Albayrak
- Ankara University Faculty of Medicine, Department of Pediatric Neurology Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
| | - Gökçen Öz Tunçer
- Ankara University Faculty of Medicine, Department of Pediatric Neurology Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
| | - Serap Teber
- Ankara University Faculty of Medicine, Department of Pediatric Neurology Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
| | - Gülhis Deda
- Ankara University Faculty of Medicine, Department of Pediatric Neurology Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
| | - F Tuba Eminoglu
- Ankara University Faculty of Medicine, Department of Pediatric Metabolism Cebeci Mahallesi, Cebeci Yerleşkesi, 06590 Çankaya, Mamak, Ankara, Turkey.
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Gayam V, Mandal AK, Khalid M, Shrestha B, Garlapati P, Khalid M. Valproic acid induced acute liver injury resulting in hepatic encephalopathy- a case report and literature review. J Community Hosp Intern Med Perspect 2018; 8:311-314. [PMID: 30356994 PMCID: PMC6197012 DOI: 10.1080/20009666.2018.1514933] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/14/2018] [Indexed: 01/09/2023] Open
Abstract
Valproic acid (VPA) is a commonly used agent in the management of seizures and psychiatric disorders. Hyperammonemia is a common complication of VPA with 27.8% of patients having elevated levels – that is unrelated to hepatotoxicity and normal transaminases. Common side effects include obesity, insulin resistance, metabolic disorder and severe forms of hepatotoxicity. Other rare and idiosyncratic reactions have been reported, one of which is presented in our case. A 27-year old patient presented with hyperammonemia and encephalopathy as a consequence of idiosyncratic VPA reaction causing drug-induced liver injury (DILI) with severely elevated transaminases. DILI is commonly overlooked when investigating encephalopathy in the setting of VPA. Physicians should consider DILI in the context of hyperammonemia and transaminitis.
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Affiliation(s)
- Vijay Gayam
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | | | - Mazin Khalid
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Binav Shrestha
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Pavani Garlapati
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY, USA
| | - Mowyad Khalid
- Department of Medicine, Wayne State University/Detroit Medical center, Detroit, MI, USA
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Zhu X, Li X, Zhang T, Zhao L. Risk Factors for Valproic Acid-induced Hyperammonaemia in Chinese Paediatric Patients with Epilepsy. Basic Clin Pharmacol Toxicol 2018; 123:628-634. [PMID: 29791065 DOI: 10.1111/bcpt.13049] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/15/2018] [Indexed: 11/28/2022]
Abstract
This study was aimed at identifying genetic and non-genetic risk factors for valproic acid (VPA)-induced hyperammonaemia in Chinese paediatric patients with epilepsy. A total of 210 epileptic patients, treated with VPA as monotherapy, were enrolled and classified into hyperammonaemia and control groups according to their blood ammonia level (cut-off value 50 μmol/L). Serum concentrations of VPA and its major metabolites were simultaneously determined by ultrahigh-performance liquid chromatography-tandem mass spectrometry. Six single nucleotide polymorphisms in the candidate genes, CYP2C9, CYP2A6, CYP2B6 and CPS1, were analysed by a matrix-assisted laser desorption ionization-time of flight mass spectrometry method or nested PCR. Significant differences in age, aspartate transaminase level and the incidence of liver injury were observed between patients of hyperammonaemia and control groups. Genotype distributions of CYP2C9*3, CYP2A6*4 and CPS1 4217C>A allelic variants were also significantly different between the two groups. According to multiple regression analysis, a significant negative correlation was detected between age and the blood ammonia level, while liver injury, the concentration-dose ratio (CDR) of VPA and 2-propyl-4-pentenoic acid (4-ene VPA), and the presence of CYP2A6*4 or CPS1 4217C>A showed positive correlations with the blood ammonia level. In addition, the risk factors for hyperammonaemia identified by logistic regression analysis were as follows: a younger age (odds ratio [OR] = 0.85; 95% confidence interval [CI] = 0.76-0.96; p = 0.007), occurrence of liver injury (OR = 4.60; 95% CI = 1.27-16.74; p = 0.021), higher CDR of 4-ene VPA (OR = 1.08; 95% CI = 1.03-1.14; p = 0.001), and carrying mutant alleles of CYP2C9*3 (OR = 3.42; 95% CI = 1.15-10.19; p = 0.028), CYP2A6*4 (OR = 3.23; 95% CI = 1.40-7.48; p = 0.006) and CPS1 4217C>A (OR = 3.25; 95% CI = 1.52-6.94; p = 0.002). Our findings indicated that multiple genetic and non-genetic risk factors that were identified can be used to predict the development of VPA-induced hyperammonaemia in Chinese paediatric patients with epilepsy.
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Affiliation(s)
- Xu Zhu
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xinlin Li
- Department of Pharmacy, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ti Zhang
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
| | - Limei Zhao
- Department of Pharmacy, Shengjing Hospital of China Medical University, Shenyang, China
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Raru Y, Zeid F. Hypoxic respiratory failure due to hyperammonemic encephalopathy induced by concurrent use of valproic acid and topiramate, a case report and review of the literature. Respir Med Case Rep 2018; 25:1-3. [PMID: 29872630 PMCID: PMC5986170 DOI: 10.1016/j.rmcr.2018.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 05/26/2018] [Accepted: 05/26/2018] [Indexed: 01/09/2023] Open
Abstract
Valproic acid (VPA) is widely used for the treatment of epilepsy, migraine, and a variety of psychiatric symptoms, including bipolar disorder, borderline personality disorder, and alcohol withdrawal. Valproate is associated with severe idiosyncratic adverse effects, the most notable being valproate-induced hyperammonemic encephalopathy (VHE). Topiramate is also a broad-spectrum anticonvulsant that is also extensively used for migraine prophylaxis, as a mood stabilizer, and for alcohol dependency. There is increased occurrence of VHE when valproate is used with other medications like phenytoin, phenobarbital, and topiramate. Our case report is on a young patient who was on valproic acid and topiramate and developed metabolic encephalopathy with hypoxic respiratory failure. We reviewed the causes and management of the hyperammonemic encephalopathy. We believe that clinicians should be aware of possible hyperammonemic encephalopathy in any patient who is taking valproic acid and presenting with impaired consciousness and cognitive decline. We also underline the importance of early recognition and high index of suspicion of encephalopathy related to hyperammonemia.
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Affiliation(s)
- Yonas Raru
- Department of Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, WV, USA
| | - Fuad Zeid
- Pulmonary and Critical Care Medicine, Department of Internal Medicine Marshall University Joan C. Edwards School of Medicine, Huntington, WV, USA
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Chen NC, Chen CH, Lin TK, Chen SD, Tsai MH, Chang CC, Tsai WC, Chuang YC. Risk of Microangiopathy in Patients with Epilepsy under Long-term Antiepileptic Drug Therapy. Front Neurol 2018; 9:113. [PMID: 29593629 PMCID: PMC5857530 DOI: 10.3389/fneur.2018.00113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 02/14/2018] [Indexed: 01/04/2023] Open
Abstract
Background Long-term antiepileptic drug (AED) therapy is considered a risk factor of atherosclerosis. Furthermore, the duration of therapy contributes to acceleration of large-vessel atherosclerosis. Therefore, in this study, we tested the hypothesis that long-term AED therapy plays a crucial role in the pathogenesis of microangiopathy in patients with epilepsy. Methods We recruited 120 patients with epilepsy (age, 18–60 years) and 40 healthy controls. Optical coherence tomography (OCT) was used to measure the central macular thickness and diameters of the retinal artery and vein to evaluate atherosclerotic retinopathy; microalbumin and creatinine levels in urine were assessed to evaluate atherosclerotic nephropathy. In addition, high-sensitivity C-reactive protein (hs-CRP), lipid profiles, homocysteine, folate, uric acid, and body mass index were determined. Results The ratio of urine albumin to creatine and OCT findings showed that patients with epilepsy had higher abnormal microalbuminuria and narrowing retinal vein diameters, respectively. Multiple linear regression analysis showed that increased triglyceride and hs-CRP levels might contribute to microalbuminuria. In addition, serum creatinine, duration of AED therapy, enzyme-inducing AED therapy, and duration of enzyme-inducing AED therapy were candidate risk factors for retinal vein narrowing. Conclusion Patients with epilepsy are at a higher risk for microangiopathy presented as retinopathy and nephropathy. Long-term AED therapy, particularly with enzyme-inducing AEDs; high triglyceride levels, and inflammatory processes play an important role in the development of microangiopathy in patients with epilepsy.
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Affiliation(s)
- Nai-Ching Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hsin Chen
- Department of Ophthalmology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tsu-Kung Lin
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shang-Der Chen
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Han Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiung-Chih Chang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wan-Chen Tsai
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Chung Chuang
- Department of Neurology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Department of Neurology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biological Science, National Sun Yat-sen University, Kaohsiung, Taiwan
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Monostory K, Bűdi T, Tóth K, Nagy A, Szever Z, Kiss Á, Temesvári M, Háfra E, Tapodi A, Garami M. In response: Commentary on clinical significance of CYP2C9-status-guided valproic acid therapy in children. Epilepsia 2018; 57:1339-40. [PMID: 27485380 DOI: 10.1111/epi.13451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Katalin Monostory
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary.
| | - Tamás Bűdi
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Katalin Tóth
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Andrea Nagy
- Heim Pál Children's Hospital, Budapest, Hungary
| | | | - Ádám Kiss
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Manna Temesvári
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | - Edit Háfra
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
| | | | - Miklós Garami
- 2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
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Kipervasser S, Elger CE, Korczyn AD, Nass RD, Quesada CM, Neufeld MY. Gait instability in valproate-treated patients: Call to measure ammonia levels. Acta Neurol Scand 2017; 136:401-406. [PMID: 28436001 DOI: 10.1111/ane.12765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Hyperammonemia induced by valproate (VPA) treatment may lead to several neurological and systemic symptoms as well as to seizure exacerbation. Gait instability and recurrent falls are rarely mentioned as symptoms, especially not as predominant ones. METHODS We report five adult patients with frontal lobe epilepsy (FLE) who were treated with VPA and in whom a primary adverse effect was unstable gait and falls. RESULTS There were four males and one female patients with FLE, 25-42-year-old, three following epilepsy surgery. All of them were treated with antiepileptic drug polytherapy. Gait instability with falls was one of the principal sequelae of the treatment. Patients also exhibited mild encephalopathy (all patients) and flapping tremor (three patients) that developed following the addition of VPA (three patients) and with chronic VPA treatment (two patients). VPA levels were within the reference range. Serum ammonia levels were significantly elevated (291-407 μmole/L, normal 20-85) with normal or slightly elevated liver enzymes. VPA dose reduction or discontinuation led to the return of ammonia levels to normal and resolution of the clinical symptoms, including seizures, which disappeared in two patients and either decreased in frequency or became shorter in duration in the other three. CONCLUSIONS Gait instability due to hyperammonemia and VPA treatment is probably under-recognized in many patients. It can develop when the VPA levels are within the reference range and with normal or slightly elevated liver enzymes.
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Affiliation(s)
- S. Kipervasser
- EEG and Epilepsy Unit; Department of Neurology; Tel-Aviv Sourasky Medical Center; Tel-Aviv Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - C. E. Elger
- Department of Epileptology; University of Bonn; Bonn Germany
| | - A. D. Korczyn
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - R. D. Nass
- Department of Epileptology; University of Bonn; Bonn Germany
| | - C. M. Quesada
- Department of Epileptology; University of Bonn; Bonn Germany
| | - M. Y. Neufeld
- EEG and Epilepsy Unit; Department of Neurology; Tel-Aviv Sourasky Medical Center; Tel-Aviv Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
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Ando M, Amayasu H, Itai T, Yoshida H. Association between the blood concentrations of ammonia and carnitine/amino acid of schizophrenic patients treated with valproic acid. Biopsychosoc Med 2017; 11:19. [PMID: 28690671 PMCID: PMC5497353 DOI: 10.1186/s13030-017-0101-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 05/29/2017] [Indexed: 01/09/2023] Open
Abstract
Background Administration of valproic acid (VPA) is complicated with approximately 0.9% of patients developing hyperammonemia, but the pathogenesis of this adverse effect remains to be clarified. The aim of the present study was to search for mechanisms associated with VPA-induced hyperammonemia in the light of changes in serum amino acids concentrations associated with the urea cycle of schizophrenic patients. Method Blood samples (10 mL) were obtained from 37 schizophrenic patients receiving VPA for the prevention of violent behaviors in the morning after overnight fast. Blood concentrations of ammonia, VPA, free carnitine, acyl-carnitine, and 40 amino acids including glutamate and citrulline were measured for each patient. Univariate and multivariate regression analyses were performed to identify amino acids or concomitantly administered drugs that were associated with variability in the blood concentrations of ammonia. Result The blood ammonia level was positively correlated with the serum glutamate concentration (r = 0.44, p < 0.01) but negatively correlated with glutamine (r = −0.41, p = 0.01), citrulline (r = −0.42, p = 0.01), and glycine concentrations (r = −0.54, p < 0.01). It was also revealed that the concomitant administration of the mood stabilizers (p = 0.04) risperidone (p = 0.03) and blonanserin (p < 0.01) was positively associated with the elevation of the blood ammonia level. Conclusion We hypothisized that VPA would elevate the blood ammonia level of schizophrenic patients. The observed changes in serum amino acids are compatible with urea cycle dysfunction, possibly due to reduced carbamoyl-phosphate synthase 1 (CPS1) activity. We conclude that VPA should be prudently prescribed to schizophrenic patients, particularly those receiving mood stabilizers or certain antipsychotics.
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Affiliation(s)
- Masazumi Ando
- Department of Drug Metabolism and Disposition, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588 Japan.,Department of Pharmacy, Heartful Kawasaki Hospital, 2-1-3 Shimonoge, Takatsu-ku, Kawasaki, Kanagawa 213-0006 Japan.,Department of Pharmacy, the 2nd Totsuka Kyoritsu Hospital, 579-1 Yoshida-cho, Totsuka-ku, Yokohama, Kanagawa 244-0817 Japan
| | - Hideaki Amayasu
- Division of Psychiatry, Heartful Kawasaki Hospital, 2-1-3 Shimonoge, Takatsu-ku, Kawasaki, Kanagawa 213-0006 Japan
| | - Takahiro Itai
- Division of Psychiatry, Heartful Kawasaki Hospital, 2-1-3 Shimonoge, Takatsu-ku, Kawasaki, Kanagawa 213-0006 Japan
| | - Hisahiro Yoshida
- Department of Drug Metabolism and Disposition, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588 Japan
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Valproic acid-induced hyperammonemic encephalopathy in a full-term neonate: a brief review and case report. Eur J Clin Pharmacol 2017; 73:647-649. [PMID: 28168312 DOI: 10.1007/s00228-017-2208-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/19/2017] [Indexed: 10/20/2022]
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Patel N, Landry KB, Fargason RE, Birur B. Reversible Encephalopathy due to Valproic Acid Induced Hyperammonemia in a Patient with Bipolar I Disorder: A Cautionary Report. PSYCHOPHARMACOLOGY BULLETIN 2017; 47:40-44. [PMID: 28138203 PMCID: PMC5274530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Valproic acid (VPA) is an FDA-approved medication widely prescribed for seizures, migraines, and mixed or manic episodes in bipolar disorder. Hyperammonemia is a rare complication of VPA use, which can result in high morbidity and occasionally fatal encephalopathy. The scant literature on Valproate Induced Hyperammonemic Encephalopathy (VIHE) is characterized by acute onset of decreasing level of consciousness, drowsiness, lethargy which in rare instances can lead to seizures, stupor, coma, and persistent morbidity and cortical damage. Below we describe a case report of a patient with Bipolar I Disorder with no primary evidence of hepatic dysfunction that was initiated on VPA and olanzapine to address manic and psychotic symptoms. This patient subsequently developed elevated ammonia (NH4) levels that led to a reversible encephalopathy. This cautionary case report highlights the potential for a rare but serious complication from VPA, a medication increasingly used in both neurologic and neuropsychiatric settings. It is imperative that clinicians perform a thorough physical, neurological and diagnostic evaluation, routinely check NH4 and VPA levels when prescribing these agents and exercise caution when VPA is concomitantly prescribed with antipsychotics and cytochrome P450 inducing antiepileptic medications.
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Affiliation(s)
- Neel Patel
- Drs. Patel, MD, Landry, DO, Fargason, MD, Birur, MD, PGY2 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Landry, DO, PGY1 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Fargason, MD, Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Birur, MD, Assistant Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA
| | - Katherine B Landry
- Drs. Patel, MD, Landry, DO, Fargason, MD, Birur, MD, PGY2 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Landry, DO, PGY1 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Fargason, MD, Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Birur, MD, Assistant Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA
| | - Rachel E Fargason
- Drs. Patel, MD, Landry, DO, Fargason, MD, Birur, MD, PGY2 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Landry, DO, PGY1 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Fargason, MD, Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Birur, MD, Assistant Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA
| | - Badari Birur
- Drs. Patel, MD, Landry, DO, Fargason, MD, Birur, MD, PGY2 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Landry, DO, PGY1 Psychiatry Resident, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Fargason, MD, Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA. Dr. Birur, MD, Assistant Professor, Department of Psychiatry and Behavioral Neurobiology, University of Alabama, Birmingham, USA
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Hyperammonemia induced by prophylactic administration of antiepileptic drugs during the perioperative period of craniotomy. Clin Chim Acta 2016; 462:33-39. [PMID: 27591106 DOI: 10.1016/j.cca.2016.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 08/29/2016] [Indexed: 01/09/2023]
Abstract
BACKGROUND Antiepileptic drugs (AEDs) are increasingly used prophylactically during the perioperative period to prevent epilepsy in patients undergoing craniotomy. Evidence concerning the use of AEDs and the incidence, extent and risk factors of hyperammonemia induced by different types of AEDs is lacking. METHODS Patients were divided into groups with 3 different AED regimens, levetiracetam, valproate and carbamazepine regimens, and the blood ammonia concentration and liver and coagulation functions were assessed during the perioperative period. RESULTS Sixty-five patients were enrolled consecutively and the postoperative hyperammonemia was found in 46 patients (70.77%), and 45 (97.83%) were asymptomatic. A total of 80.95% of the patients using valproate developed hyperammonemia, and the postoperative blood ammonia concentration continued to rise in 61.90% of these patients. Additionally, valproate had the least impact on liver enzymes. The synthetic function of the liver in patients with higher concentrations of preoperative blood ammonia was more seriously damaged than that in patients with normal postoperative ammonia concentrations. CONCLUSIONS Selection of AED for patients undergoing craniotomy should be based on the individual medical situation. Carbamazepine may be a proper choice for the majority of these patients, while valproate is likely to be more appropriate for patients with abnormal liver aminotransferases.
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Bayrakli I, Turkmen A, Akman H, Sezer MT, Kutluhan S. Applications of external cavity diode laser-based technique to noninvasive clinical diagnosis using expired breath ammonia analysis: chronic kidney disease, epilepsy. JOURNAL OF BIOMEDICAL OPTICS 2016; 21:87004. [PMID: 27533447 DOI: 10.1117/1.jbo.21.8.087004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 07/25/2016] [Indexed: 06/06/2023]
Abstract
An external cavity laser (ECL)-based off-axis cavity-enhanced absorption spectroscopy was applied to noninvasive clinical diagnosis using expired breath ammonia analysis: (1) the correlation between breath ammonia levels and blood parameters related to chronic kidney disease (CKD) was investigated and (2) the relationship between breath ammonia levels and blood concentrations of valproic acid (VAP) was studied. The concentrations of breath ammonia in 15 healthy volunteers, 10 epilepsy patients (before and after taking VAP), and 27 patients with different stages of CKD were examined. The range of breath ammonia levels was 120 to 530 ppb for healthy subjects and 710 to 10,400 ppb for patients with CKD. There was a statistically significant positive correlation between breath ammonia concentrations and urea, blood urea nitrogen, creatinine, or estimated glomerular filtration rate in 27 patients. It was demonstrated that taking VAP gave rise to increasing breath ammonia levels. A statistically significant difference was found between the levels of exhaled ammonia (NH3) in healthy subjects and in patients with epilepsy before and after taking VAP. The results suggest that our breath ammonia measurement system has great potential as an easy, noninvasive, real-time, and continuous monitor of the clinical parameters related to epilepsy and CKD.
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Affiliation(s)
- Ismail Bayrakli
- Suleyman Demirel University, Biomedical Engineering, Bati kampüsü Isparta, Turkey
| | - Aysenur Turkmen
- Suleyman Demirel University, Biomedical Engineering, Bati kampüsü Isparta, Turkey
| | - Hatice Akman
- Suleyman Demirel University, Biomedical Engineering, Bati kampüsü Isparta, Turkey
| | - M Tugrul Sezer
- Suleyman Demirel University, School of Medicine, Department of Nephrology, Dogu kampüsü Isparta, Turkey
| | - Suleyman Kutluhan
- Suleyman Demirel University, School of Medicine, Department of Neurology, Dogu kampüsü, Isparta, Turkey
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El-Mowafy AM, Katary MM, Pye C, Ibrahim AS, Elmarakby AA. Novel molecular triggers underlie valproate-induced liver injury and its alleviation by the omega-3 fatty acid DHA: role of inflammation and apoptosis. Heliyon 2016; 2:e00130. [PMID: 27441301 PMCID: PMC4946287 DOI: 10.1016/j.heliyon.2016.e00130] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 05/23/2016] [Accepted: 06/24/2016] [Indexed: 12/21/2022] Open
Abstract
Background/Aim Hepatic injury is a hallmark adverse reaction to Valproate (VPA), a common used drug in the management of numerous CNS disorders, including epilepsy. DHA has a myriad of health benefits, including renal- and hepato-protective effects. Unfortunately, however, the underpinnings of such liver-pertinent VPA- and DHA-actions remain largely undefined. Accordingly, this study attempted to unveil the cellular and molecular triggers whereby VPA evokes, while DHA abates, hepatotoxicity. Methods We evaluated activity and/or expression of cellular markers of oxidative stress, inflammation, and apoptosis in rat liver, following treatment with VPA (500 mg/kg/day) with and without concurrent treatment with DHA (250 mg/kg/day) for two weeks. Results and conclusion VPA promoted hepatic oxidative stress as evidenced by enhancing activity/expression of NADPH-oxidase and its subunits, a ROS-generator, and by accumulation of lipid-peroxides. Moreover, VPA enhanced hepatic phosphorylation/activation of mitogen-activated protein kinase (MAPK), and expression of cyclooxygenase-2(COX-2), as proinflammatory signals. Besides, VPA promoted hepatocellular apoptosis, as attested by enhanced expression of cleaved caspase-9 and increased number of TUNEL-positive hepatocytes. Lastly, VPA upregulated levels of hypoxia-inducible factor-1-alpha (HIF-1α), a multifaceted modulator of hepatocytic biology, and activity of its downstream antioxidant enzyme heme-oxygenase-1(HO-1). These changes were significantly blunted by co-administration of DHA. Our findings demonstrate that VPA activated NADPH-oxidase and HIF-1α to induce oxidative-stress and hypoxia as initiators of hepatic injury. These changes were further aggravated by up-regulation of inflammatory (MAPK and COX-2) and apoptotic cascades, but could be partly lessened by HO-1 activation. Concurrent administration of DHA mitigated all VPA-induced anomalies.
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Affiliation(s)
- Abdalla M El-Mowafy
- Department of Pharmacology, Department of Clinical Biochemistry, Faculty of Pharmacy, Mansoura University, Egypt; Department of Pharmacology, Faculty of Pharmaceutical Sciences and Industries, Future University, Egypt
| | - Mohamed M Katary
- Department of Oral Biology and Pharmacology, Augusta University, Augusta, Georgia 30912, USA; Department of Pharmacology, Faculty of Pharmacy, Damanhur University, Egypt
| | - Chelsey Pye
- Department of Oral Biology and Pharmacology, Augusta University, Augusta, Georgia 30912, USA
| | - Ahmed S Ibrahim
- Department of Pharmacology, Department of Clinical Biochemistry, Faculty of Pharmacy, Mansoura University, Egypt; Department of Oral Biology and Pharmacology, Augusta University, Augusta, Georgia 30912, USA
| | - Ahmed A Elmarakby
- Department of Oral Biology and Pharmacology, Augusta University, Augusta, Georgia 30912, USA
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Carnitine and/or Acetylcarnitine Deficiency as a Cause of Higher Levels of Ammonia. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2920108. [PMID: 26998483 PMCID: PMC4779505 DOI: 10.1155/2016/2920108] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/27/2016] [Indexed: 12/24/2022]
Abstract
Blood carnitine and/or acetylcarnitine deficiencies are postulated in the literature as possible causes of higher ammonia levels. The aim of this study was to investigate if the use of valproic acid, the age of the patients, or certain central nervous system pathologies can cause carnitine and/or acetylcarnitine deficiency leading to increased ammonia levels. Three groups of patients were studied: (A) epileptic under phenytoin monotherapy (n = 31); (B) with bipolar disorder under valproic acid treatment (n = 28); (C) elderly (n = 41). Plasma valproic acid and blood carnitine and acyl carnitine profiles were determined using a validated HPLC and LC-MS/MS method, respectively. Blood ammonia concentration was determined using an enzymatic automated assay. Higher ammonia levels were encountered in patients under valproic acid treatment and in the elderly. This may be due to the lower carnitine and/or acetylcarnitine found in these patients. Patients with controlled seizures had normal carnitine and acetylcarnitine levels. Further studies are necessary in order to conclude if the uncontrolled bipolar disorder could be the cause of higher carnitine and/or acetylcarnitine levels.
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Inoue K, Takahashi T, Yamamoto Y, Suzuki E, Takahashi Y, Imai K, Inoue Y, Hirai K, Tsuji D, Itoh K. Influence of glutamine synthetase gene polymorphisms on the development of hyperammonemia during valproic acid-based therapy. Seizure 2015; 33:76-80. [PMID: 26599579 DOI: 10.1016/j.seizure.2015.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/19/2015] [Accepted: 10/30/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Valproic acid (VPA), which is widely used to treat epilepsy, migraine, and bipolar disorder, can causes severe hyperammonemia. However, the mechanism responsible for this adverse effect is not readily apparent. We previously reported that phenytoin coadministration is a strong risk factor for the development of hyperammonemia during VPA-based therapy. In this study, we focused on glutamine synthetase, which catalyzes the synthesis of glutamine from glutamate and ammonia and examined the association with the development of hyperammonemia during VPA-based therapy. METHODS For this study, we recruited 202 Japanese pediatric patients having epilepsy. We selected three polymorphisms (rs10911070, rs10797771, and rs10911021) in the glutamine synthetase (GLUL) gene. Hyperammonemia was defined as a plasma ammonia level exceeding 200 or 170 μg/dL. We evaluated the association between the development of hyperammonemia during VPA-based therapy and the patient characteristics, including three GLUL polymorphisms. RESULTS The number of patients who developed hyperammonemia during VPA-based therapy was 20 (9.9%) using the 200 μg/dL cutoff value and 30 (14.9%) using the 170 μg/dL cutoff value. Using a multivariate logistic regression analysis, the GLUL rs10797771 polymorphism and phenytoin coadministration in the 200 μg/dL cutoff value, and female in addition to two factors in the 170 μg/dL cutoff value, had significant associations with a plasma ammonia level elevation during VPA-based therapy. CONCLUSION Phenytoin coadministration, GLUL rs10797771 polymorphism in the 200μg/dL cutoff value, and female in addition to two factors in the 170μg/dL cutoff value, are independent risk factors for elevated plasma ammonia levels during VPA-based therapy.
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Affiliation(s)
- Kazuyuki Inoue
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Toshiki Takahashi
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Yoshiaki Yamamoto
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Eri Suzuki
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Yukitoshi Takahashi
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Katsumi Imai
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Yushi Inoue
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Keita Hirai
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Daiki Tsuji
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan.
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Yamamoto Y, Takahashi Y, Imai K, Mishima N, Kagawa Y, Inoue Y. Changing incidence of hyperammonemia in Japan from 2006 to 2013: expansion of new antiepileptic drugs reduces the risk of hyperammonemia. Eur J Clin Pharmacol 2015; 71:1517-24. [PMID: 26391520 DOI: 10.1007/s00228-015-1939-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 09/03/2015] [Indexed: 01/09/2023]
Abstract
PURPOSE The purpose of the present study was to examine the relationship between the incidence of hyperammonemia and changes in the prescribing of concomitant antiepileptic drugs (AEDs) in patients receiving valproic acid. METHODS We evaluated 40,363 plasma samples from 6009 epilepsy patients obtained from 2006 to 2013. Hyperammonemia was defined as a plasma ammonia level exceeding 100 μg/dL. RESULTS In 2006, 32.6 % of the plasma samples were from patients with concomitant use of phenytoin but this decreased to 16.0 % in 2013. Lamotrigine and levetiracetam were approved in 2008 and 2010, respectively, and were prescribed for patients who provided 27.8 and 14.9 % of the plasma samples in 2013. The incidence rate of hyperammonemia (per 100 person years) decreased markedly from 40.8 (95 % confidence interval (CI), 37.7-43.9) in 2006 to 14.2 (95 % CI, 12.5-15.9) in 2013. In any year reviewed, concomitant use of phenytoin, phenobarbital, carbamazepine, or carbonic anhydrase inhibitors was a risk factor for hyperammonemia. Among enzyme-inducing AEDs, concomitant use of phenytoin was associated with the highest risk of hyperammonemia. CONCLUSION Drug interactions caused by enzyme-inducing AEDs, especially phenytoin, are closely related to the development of hyperammonemia. This study demonstrated that introduction of new AEDs changed the co-prescribing pattern in patients receiving valproic acid, resulting in a marked decrease of hyperammonemia. Although their higher cost may be problematic, new AEDs are beneficial for reducing the risk of drug interactions.
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Affiliation(s)
- Yoshiaki Yamamoto
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886, Urushiyama, Shizuoka, 420-8688, Japan. .,Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1, Yada, Shizuoka, 422-8526, Japan.
| | - Yukitoshi Takahashi
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886, Urushiyama, Shizuoka, 420-8688, Japan.,Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1, Yada, Shizuoka, 422-8526, Japan
| | - Katsumi Imai
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886, Urushiyama, Shizuoka, 420-8688, Japan
| | - Nobuyuki Mishima
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886, Urushiyama, Shizuoka, 420-8688, Japan
| | - Yoshiyuki Kagawa
- Department of Clinical Pharmaceutics, Graduate School of Pharmaceutical Sciences, University of Shizuoka, 52-1, Yada, Shizuoka, 422-8526, Japan.,Laboratory of Clinical Pharmacokinetics and Drug Safety, Shizuoka General Hospital, 4-27-1 Kita Ando, Shizuoka, 420-8527, Japan
| | - Yushi Inoue
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886, Urushiyama, Shizuoka, 420-8688, Japan
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