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Meier C, Burns K, Manolikos C, Fatovich D, Bell DA. Hyperammonaemia: review of the pathophysiology, aetiology and investigation. Pathology 2024; 56:763-772. [PMID: 39127541 DOI: 10.1016/j.pathol.2024.06.002] [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: 12/07/2023] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 08/12/2024]
Abstract
Acute hyperammonaemia is a medical emergency as it can progress to cerebral oedema, seizures, coma and death. Hepatic encephalopathy secondary to cirrhotic disease or portosystemic shunting are relatively well-known causes, but non-cirrhotic aetiologies of acute hyperammonaemia are less well-known, especially in the emergency department. However, an elevated ammonia is not required to make the diagnosis of hepatic encephalopathy. Although measurement of plasma ammonia is recommended for patients with acute, unexplained, altered mental status, as early identification allows early effective management which may prevent irreversible brain damage, there is currently reduced awareness among physicians of the non-cirrhotic aetiologies of acute hyperammonaemia. Furthermore, measurement of ammonia in patients with cirrhosis has been shown to have low sensitivity and specificity, and not to have altered management in the majority of cases; thus, measurement of ammonia is currently not recommended in guidelines for management of hepatic encephalopathy. We sought to describe the pathophysiology of hyperammonaemia and review the non-cirrhotic causes. This was achieved by review of MEDLINE, PubMed and Web of Science databases to include published English literature within the last 20 years. We also present a framework for investigating the acute non-cirrhotic causes of hyperammonaemia to assist both chemical pathologists and clinicians managing these often challenging cases.
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Affiliation(s)
- Ciselle Meier
- The University of Western Australia, Perth, WA, Australia
| | - Kharis Burns
- The University of Western Australia, Perth, WA, Australia; Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia
| | - Catherine Manolikos
- Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia
| | - Daniel Fatovich
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia; Emergency Department, Royal Perth Hospital, The University of Western Australia, Perth, WA, Australia
| | - Damon A Bell
- The University of Western Australia, Perth, WA, Australia; Inborn Errors of Metabolism Service, Department of Endocrinology, Royal Perth Hospital, Perth, WA, Australia; PathWest Laboratory Medicine, Department of Biochemistry, Fiona Stanley Hospital Network, Perth, WA, Australia.
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Balcerac A, Bihan K, Lebrun-Vignes B, Thabut D, Salem JE, Weiss N. Drug-associated hyperammonaemia: a Bayesian analysis of the WHO Pharmacovigilance Database. Ann Intensive Care 2022; 12:55. [PMID: 35716335 PMCID: PMC9206694 DOI: 10.1186/s13613-022-01026-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background Hyperammonaemia is frequent in Intensive Care Unit patients. Some drugs have been described as associated with this condition, but there are no large-scale studies investigating this topic and most descriptions only consist of case-reports. Methods We performed a disproportionality analysis using VigiBase, the World Health Organization Pharmacovigilance Database, using the information component (IC). The IC compares observed and expected values to find associations between drugs and hyperammonaemia using disproportionate Bayesian reporting. An IC0.25 (lower end of the IC 95% credibility interval) > 0 is considered statistically significant. The main demographic and clinical features, confounding factors, and severity of cases have been recorded. Results We identified 71 drugs with a disproportionate reporting in 2924 cases of hyperammonaemia. Most of the suspected drugs could be categorised into 4 main therapeutic classes: oncologic drugs, anti-epileptic drugs, immunosuppressants and psychiatric drugs. The drugs most frequently involved were valproic acid, fluorouracil, topiramate, oxaliplatin and asparaginase. In addition to these molecules known to be responsible for hyperammonaemia, our study reported 60 drugs not previously identified as responsible for hyperammonaemia. These include recently marketed molecules including anti-epileptics such as cannabidiol, immunosuppressants such as basiliximab, and anti-angiogenics agents such as tyrosine kinase inhibitors (sunitinib, sorafenib, regorafenib, lenvatinib) and monoclonal antibodies (bevacizumab, ramucirumab). The severity of cases varies depending on the drug class involved and high mortality rates are present when hyperammonaemia occurs in patients receiving immunosuppressant and oncologic drugs. Conclusions This study constitutes the first large-scale study on drug-associated hyperammonaemia. This description may prove useful for clinicians in patients’ care as well as for trial design. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01026-4.
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Affiliation(s)
- Alexander Balcerac
- Département de neurologie, Unité de Médecine Intensive Réanimation À Orientation Neurologique, Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de La Pitié-Salpêtrière, 47-83, boulevard de l'hôpital, 75013, Paris, France.,Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.,Groupe de Recherche Clinique en REanimation Et Soins Intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE), Sorbonne Université, Paris, France
| | - Kevin Bihan
- Department of Pharmacology, Regional Pharmacovigilance Center, Sorbonne Université, AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, Sorbonne Université, Paris, France
| | - Bénédicte Lebrun-Vignes
- Department of Pharmacology, Regional Pharmacovigilance Center, Sorbonne Université, AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, Sorbonne Université, Paris, France
| | - Dominique Thabut
- Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.,Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de La Pitié-Salpêtrière, service d'hépatogastroentérologie, Unité de Soins Intensifs d'hépatologie, Paris, France
| | - Joe-Elie Salem
- Department of Pharmacology, Regional Pharmacovigilance Center, Sorbonne Université, AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, Sorbonne Université, Paris, France
| | - Nicolas Weiss
- Département de neurologie, Unité de Médecine Intensive Réanimation À Orientation Neurologique, Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de La Pitié-Salpêtrière, 47-83, boulevard de l'hôpital, 75013, Paris, France. .,Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies métaboliques, biliaires et fibro-inflammatoire du foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France. .,Groupe de Recherche Clinique en REanimation Et Soins Intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE), Sorbonne Université, Paris, France.
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A Case of Carbamazepine-Induced Aggravation of Self-Limited Epilepsy with Centrotemporal Spikes Epilepsy and Valproate-Induced Hyperammonemic Encephalopathy in a Child with Heterozygous Gene Variant of Carbomoyl Phosphatase Synthetase Deficiency. Case Rep Neurol Med 2022; 2021:2362679. [PMID: 35003817 PMCID: PMC8741391 DOI: 10.1155/2021/2362679] [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] [Received: 06/05/2021] [Revised: 12/04/2021] [Accepted: 12/16/2021] [Indexed: 01/08/2023] Open
Abstract
Antiepileptics drugs are the mainstay of the management of epilepsy in children. Sodium valproate (VPA) and carbamazepine (CBZ) are widely used medications in childhood epilepsy. Hyperammonemia has been described as a known side effect of valproate therapy. It is known that VPA-associated HA is common among patients who hold genetic mutations of the carbomoyl phosphatase synthase 1 gene (CPS1). Aggravation of self-limited epilepsy with centrotemporal spikes (SLECTS) is a rare side effect of CBZ. Here, we present a child who had CBZ-induced aggravation of rolandic epilepsy and VPA-induced HA encephalopathy in the background of an unrecognised heterozygous gene variant of CPS1. An 8-year-old boy with SLECTS presented with a history of abnormal behaviours and drowsiness. He was apparently well until six years when he developed seizures in favour of rolandic epilepsy. His electroencephalogram (EEG) showed bilateral predominantly on the right-sided central-temporal spikes and waves. The diagnosis of SLECTS was made, and he was commenced on CBZ. Though he showed some improvement at the beginning, his seizure frequency increased when the dose of CBZ was increased. His repeat EEG showed electrical status in slow-wave sleep, and CBZ was stopped. Subsequently, he was started on VPA, and with that, he developed features of encephalopathy. He had elevated serum ammonia with normal liver functions. VPA was stopped with the suspicion of VPA-induced hyperammonemia. Tandem mass spectrometry did not show significant abnormality in the amino acid profile. Specific genetic analysis revealed a c.2756 C > T.p (Ser919Leu) heterozygote genetic mutation of the CSP 1 gene. This is a classic example where side effects of treatment determine the choice of antiepileptics drugs (AEDs) in childhood epilepsy. It is essential to keep in mind that SLECTS can be aggravated with certain AEDs, and VPA-induced HA in the absence of live failure could be due to underlying inherited metabolic disorders.
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Storch DD. Asymptomatic Hyperammonemia Caused by Valproate: How Often to Check and How to Manage. Psychiatr Ann 2019. [DOI: 10.3928/00485713-20181228-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
A 69-year-old man developed reduced consciousness of sudden onset. Examination and parameters were normal, except for a Glasgow Coma Scale (GCS) score of six. Brain imaging and blood tests were also normal, except for high plasma ammonia. His past medical history included epilepsy, hypertension and colitis. He was taking multiple antiepileptic medications, including sodium valproate, with no recent dose alterations. Medical intervention led to the sodium valproate being stopped and naloxone being administered. The patient's level of responsiveness and ammonia levels gradually improved. The patient was also being treated with ciprofloxacin for a urinary tract infection and a newly developed syndrome of inappropriate antidiuretic hormone secretion treated with demeclocycline. There is an association between long-term sodium valproate use and low carnitine levels, especially in the setting of polypharmacy. This in turn precipitates hyperammonaemia and encephalopathy. This case highlights the importance of an adequate drug history and the awareness of serious but uncommon adverse effects.
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Gandolfo F, Parodi MN, Corsini GP, Odetti P, Serafini G, Monacelli F. Valproate-induced encephalopathy in a comorbid elderly woman. Psychogeriatrics 2017; 17:208-209. [PMID: 28093879 DOI: 10.1111/psyg.12215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 07/01/2016] [Accepted: 07/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Federica Gandolfo
- Department of Internal Medicine and Medical Specialties, DIMI, Section of Geriatrics, Genoa, Italy
| | - Maria N Parodi
- Department of Internal Medicine and Medical Specialties, DIMI, Section of Geriatrics, Genoa, Italy
| | - Giovanni P Corsini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetic and Pediatrics Science (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy
| | - Patrizio Odetti
- Department of Internal Medicine and Medical Specialties, DIMI, Section of Geriatrics, Genoa, Italy
| | - Gianluca Serafini
- Institute of Research and Treatment, University Hospital San Martino, Genoa, Italy
| | - Fiammetta Monacelli
- Department of Internal Medicine and Medical Specialties, DIMI, Section of Geriatrics, Genoa, Italy
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Valproic Acid Induced Hyperammonemia in a Long Time Treated Patient. Case Rep Psychiatry 2016; 2016:6242314. [PMID: 27516916 PMCID: PMC4969522 DOI: 10.1155/2016/6242314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/22/2016] [Indexed: 11/26/2022] Open
Abstract
We report a case of a patient who had been on long time valproic acid for treatment of bipolar affective disorder. While being an inpatient, serology ammonia level testing revealed a very high ammonia level despite being asymptomatic. Dual therapy of carnitine and lactulose was provided to the patient for treatment of the hyperammonemia. It should also be noted that, during this treatment, valproic acid was not stopped. Consequently, this case illustrates that patients can present asymptomatically despite very high ammonia levels and hyperammonemia can occur in chronic valproic acid despite not increasing the dose of the medication and psychiatrists do not need to discontinue valproic acid in the presence of elevated levels of ammonia if the patient shows no signs of encephalopathy or delirium.
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Dixit S, Namdeo M, Azad S. Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma. J Clin Diagn Res 2015; 9:VD01-VD02. [PMID: 26023626 PMCID: PMC4437142 DOI: 10.7860/jcdr/2015/11830.5758] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/20/2015] [Indexed: 11/24/2022]
Abstract
Divalproex sodium is commonly used drug to treat variety of psychiatric and neurological disorders. Hyperammonemia is infrequent adverse affect of treatment with divalproex sodium. It needs high degree of clinical suspicion or else can lead to delirium of non hepatic origin in some group of patients and to medication errors or even death. We hereby report a case of mania who developed hyperammonemia with normal sodium valproate levels and liver function tests where delirium lead to diagnostic and medication errors. Withdrawal of divalproex sodium led to clinical recovery but delirium prolonged his hospital stay. This case report cautions the clinicians about hyperammonemia as the uncommon side effects and emphasizes the need of doing blood ammonia testing in patients treated with divalproex sodium where recovery is halted or clinical condition worsens despite normal liver function test and EEG.
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Affiliation(s)
- Siddharth Dixit
- Classified Specialist, Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi; Assisstant Professor, Department of Psychiatry, Army College of Medical Sciences, New Delhi, India
| | - Mayank Namdeo
- Resident, Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi, India
| | - Sudip Azad
- Resident, Department of Psychiatry, Base Hospital Delhi Cantt, New Delhi, India
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Larsen EP, Ostergaard JR. Valproate-induced hyperammonemia in juvenile ceroid lipofuscinosis (Batten disease). Seizure 2014; 23:429-34. [PMID: 24647346 DOI: 10.1016/j.seizure.2014.02.011] [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: 01/07/2014] [Revised: 02/17/2014] [Accepted: 02/22/2014] [Indexed: 11/08/2022] Open
Abstract
PURPOSE Valproate-induced hyperammonemia (VHA) and hyperammonemic encephalopathy (VHE) are well-known complications of valproate (VPA) treatment. Currently recognised risk factors for VHE include a high VPA dosage, the need for polytherapy and long duration of treatment. Despite the severe nature of the epilepsy, presence of concomitant psychiatric manifestations, and frequent need for poly-pharmacy associated with juvenile ceroid lipofuscinosis (JNCL, Batten disease) neither this disorder nor other subtypes of neuronal ceroid lipofuscinosis have previously been identified as risk factors for VHA/VHE. The aim of the present publication is to describe four cases with VHE in a well-defined Danish population of JNCL. METHOD An examination of medical records of all 35 patients with JNCL in Denmark was conducted and revealed fourteen patients treated with VPA. RESULTS Four patients treated with VPA developed VHE. All patients were prescribed VPA in standard dosages, had normal plasma concentrations of VPA and received antiepileptic drug (AED) polytherapy. Symptoms occurred shortly after commencement or increase in dose of VPA, and were quickly reversible upon discontinuation of VPA. Carnitine supplement was administrated in two patients, which resulted in resolution of symptoms and normalized ammonium levels. CONCLUSION Patients with JNCL are in great risk of developing VHA and VHE due to a high rate of polytherapy. Furthermore, studies have shown that carnitine level can be depressed in JNCL, which may increase the risk of VHA and VHE. We recommend that increased attention should be given to these patients.
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Affiliation(s)
- Erling P Larsen
- Centre for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark
| | - John R Ostergaard
- Centre for Rare Diseases, Department of Pediatrics, Aarhus University Hospital, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark.
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Increased Occurrence of Valproic Acid-Induced Hyperammonemia in Carriers of T1405N Polymorphism in Carbamoyl Phosphate Synthetase 1 Gene. ISRN NEUROLOGY 2013; 2013:261497. [PMID: 23997965 PMCID: PMC3749598 DOI: 10.1155/2013/261497] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 07/06/2013] [Indexed: 01/16/2023]
Abstract
Numerous cases of severe and life-threatening hyperammonemia (HA) related to the treatment of epileptic seizures with valproic acid (VPA) have been previously reported in the medical literature. The aim of this prospective, multicenter study was to verify the putative association between T1405 polymorphism and occurrence of VPA-induced HA in the cohort of 142 adult Caucasian patients with epilepsy treated with VPA for at least 1 year and with normal liver functions. The nonsynonymous T1405N polymorphism genotyping was performed by real-time TaqMan PCR genotyping. In addition to plasma ammonia level, concentrations of liver enzymes and total VPA were measured in plasma with standard laboratory methods. HA (defined as ammonia plasma level >65 μmol/L) was observed in total of 11 (7.7%) of patients treated with VPA, and the carrier status for the investigated polymorphism was significantly (P = 0.009, odds ratio 5.4 with 95% confidence interval of 1.58–18.43) associated with the occurrence of HA. The results of this study support a notion that in the Caucasian patients with epilepsy undergoing VPA therapy, a T1405N (4217C > A, rs1047891) nonsynonymous variant was a significant risk factor for the occurrence of HA, even in patients with normal plasma levels of VPA.
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Chan E, McQueen F. Valproate-induced hyperammonaemia superimposed upon severe neuropsychiatric lupus: a case report and review of the literature. Clin Rheumatol 2012; 32:403-7. [PMID: 23271612 DOI: 10.1007/s10067-012-2150-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/10/2012] [Indexed: 12/01/2022]
Abstract
This paper presents a case of systemic lupus erythematosus (SLE) with neuropsychiatric features, where the outcome was influenced by the development of hyperammonaemia, probably induced by sodium valproate. A case of severe SLE occurring in a 20-year-old Maori girl is described. Her disease had been characterised by neuropsychiatric features for several years, culminating in persistent seizure activity at the time of her final presentation. Her management with anticonvulsants was complicated by the development of intractable hyperammonaemia which contributed to irreversible clinical deterioration. We have reviewed the English literature for reports of valproate-related hyperammonaemia which has often been described in the setting of seizure and mood disorders. This is the first case where it has been reported, superimposed upon severe neuropsychiatric SLE (NP-SLE). The mechanism by which valproate induces hyperammonaemia remains incompletely understood but is likely to relate to the urea cycle. Under normal metabolic conditions, acyl-CoA is transported into the mitochondria via a carnitine transport system. It is then converted to acetyl-CoA via β-oxidation and eventually to N-acetyl glutamate. This pathway can be interrupted by the introduction of sodium valproate, leading to a reduction of free coenzyme A, acetyl-CoA and carnitine, and resulting in the decreased availability of cofactors necessary for the function of the urea cycle. As this is the primary means of ammonia metabolism, serious elevation in serum ammonia levels may occur in patients on this anticonvulsant medication. In this patient with active NP-SLE, the combined autoimmune and metabolic brain insult contributed to a fatal outcome.
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Affiliation(s)
- Estee Chan
- Department of Rheumatology, Greenlane Clinical Centre, Auckland District Health Board, Private Bag 92024, Auckland Mail Centre, Auckland 1142, New Zealand.
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Mahmoud F, Tampi RR. Valproic Acid–Induced Parkinsonism in the Elderly: A Comprehensive Review of the Literature. ACTA ACUST UNITED AC 2011; 9:405-12. [DOI: 10.1016/j.amjopharm.2011.09.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2011] [Indexed: 10/16/2022]
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A case of valproate induced hyperammonemic encephalopathy. Case Rep Med 2011; 2011:969505. [PMID: 21629819 PMCID: PMC3099231 DOI: 10.1155/2011/969505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 02/18/2011] [Indexed: 11/17/2022] Open
Abstract
A 36-years-old man on phenytoin, levetiracetam, and sodium valproate presented with acute confusion. Routine investigations including serum valproate and phenytoin concentration were normal. His serum ammonia concentration was raised. His valproate was held and 2 days later he recovered with concordant normalisation of serum ammonia concentration. Urea acid cycle disorder was ruled out, and a diagnosis of valproate induced hyperammonemic encephalopathy (VHE) was made. Asymptomatic hyperammonemia occurs in 15-50% of valproate-treated patients, and while the true incidence of VHE is not known, it is a recognized complication of sodium valproate treatment. VHE typically presents acutely with impaired consciousness, lethargy, and vomiting. Valproate concentrations may be in the therapeutic range, and liver function tests are typically "normal." Treatment for VHE consists of ceasing valproate and providing supportive care. Some have advocated carnitine replacement.
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