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Fátima Lopes F, Sitta A, de Moura Coelho D, Schmitt Ribas G, Lamberty Faverzani J, Gomes Dos Reis B, Wajner M, Vargas CR. Clinical findings of patients with hyperammonemia affected by urea cycle disorders with hepatic encephalopathy. Int J Dev Neurosci 2022; 82:772-788. [PMID: 36129623 DOI: 10.1002/jdn.10229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/21/2022] [Accepted: 09/15/2022] [Indexed: 11/10/2022] Open
Abstract
Urea Cycle Disorders (UCD) are a group of genetic diseases caused by deficiencies in the enzymes and transporters involved in the urea cycle. The impairment of the cycle results in ammonia accumulation, leading to neurological dysfunctions and poor outcomes to affected patients. The aim of this study is to investigate and describe UCD patients principal clinical and biochemical presentations to support professionals on urgent diagnosis and quick management, aiming better outcomes for patients. We explored medical records of thirty patients diagnosed in a referral center from Brazil to delineate UCD clinical and biochemical profile. Patients demonstrated a range of signs and symptoms, such as altered levels of consciousness, acute encephalopathy, seizures, progressive loss of appetite, vomiting, coma, and respiratory distress, in most cases combined with high levels of ammonia, which is an immediate biomarker, leading to an UCD suspicion. The most prevalent UCD detected were ornithine transcarbamylase deficiency (11), followed by citrullinemia type I (10), hyperargininemia (5), carbamoyl phosphate synthase 1 deficiency (2) and argininosuccinic aciduria (2). Clinical symptoms were highly severe, being the majority developmental and neurological disabilities, with 20% of death rate. Laboratory analysis revealed high levels of ammonia (mean ± SD: 860 ± 470 μmol/L; reference value: ≤ 80 μmol/L), hypoglycemia, metabolic acidosis, and high excretion of orotic acid in the urine (except in CPS1 deficiency). We emphasize the need of urgent identification of UCD clinical and biochemical conditions, and immediate measurement of ammonia, to enable the correct diagnosis and increase the chances of patients survival, minimizing neurological and psychomotor damage caused by hepatic encephalopathy.
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Affiliation(s)
- Franciele Fátima Lopes
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Angela Sitta
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - Jéssica Lamberty Faverzani
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Bianca Gomes Dos Reis
- Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Moacir Wajner
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Carmen Regla Vargas
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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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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Sattar Y, Wasiq S, Yasin W, Khan AM, Adnan M, Shrestha S, Patel NB, Latchana S. Carglumic Acid Treatment of a Patient with Recurrent Valproic Acid-induced Hyperammonemia: A Rare Case Report. Cureus 2018; 10:e3292. [PMID: 30443462 PMCID: PMC6235635 DOI: 10.7759/cureus.3292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Valproic acid, first manufactured as an anticonvulsant, is commonly used to treat both neurological and psychiatric conditions. A rare and deadly side effect of this medication is hyperammonemia, presenting as lethargy, confusion, seizure, and, ultimately, coma. In rare circumstances, hyperammonemia can be recurrent and devastating, especially in patients with an underlying N-acetyl glutamate synthase (NAGS) deficiency, as the valproic acid can enhance this enzyme deficiency and inhibit the conversion of ammonia into urea in the liver. For these subtypes of patients, the United States Food and Drug Administration (US FDA) has recently approved carglumic acid, a medication that can act as a scavenger by effectively increasing the levels of NAGS, ultimately enhancing the conversion of ammonia to urea. In our case report, we have mentioned a patient with treatment-resistant bipolar disorder, who presented with elevated ammonia levels secondary to valproic acid treatment. Valproic acid was the only drug that was effective in his case, so we initiated therapy to reduce his elevated ammonia levels. After a thorough evaluation, we found the patient had a genetic NAGS deficiency. Carglumic acid was initiated and proved efficacious in our patient.
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Affiliation(s)
- Yasar Sattar
- Internal Medicine, Icahn School of Medicine Mount Sinai, New York, USA
| | - Saad Wasiq
- Psychiatry, University of Health Sciences, Islamabad, PAK
| | - Waqas Yasin
- Psychiatry, Medical College of Wisconsin Affliated Hospitals, Milwaukee, USA
| | - Ali M Khan
- Psychiatry Resident, University of Texas Rio Grande Valley, Harlingen, USA
| | - Mahwish Adnan
- Center for Addiction and Mental Health, University of Toronto, Toronto, CAN
| | | | - Nirav B Patel
- Department of Medicine, Lasante Health, New York, USA
| | - Sharaad Latchana
- Medical Student, American University of Integrative Sciences, Bridgewater, BRB
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Brown LM, Cupples N, Moore TA. Levocarnitine for valproate-induced hyperammonemia in the psychiatric setting: A case series and literature review. Ment Health Clin 2018; 8:148-154. [PMID: 29955560 PMCID: PMC6007637 DOI: 10.9740/mhc.2018.05.148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Introduction Hyperammonemia is a potential adverse effect of valproic acid (VPA) therapy, which is often asymptomatic but can lead to severe, life-threatening encephalopathy. Carnitine deficiency due to VPA is the proposed mechanism for hyperammonemia and the development of VPA-induced hyperammonemic encephalopathy (VHE). Levocarnitine, the active form of carnitine, has been suggested for treatment and prevention of VHE. Methods Data was collected by chart review of 3 patients who received oral levocarnitine supplementation in the psychiatric setting for VPA-induced hyperammonemia. Review of the literature was performed through June 2017 using the following PubMed search terms: valproate, valproic acid, hyperammonemia, altered mental status, encephalopathy, and levocarnitine. Articles were included if they described use of levocarnitine in VPA-treated patients with psychiatric disorders. Results One patient developed encephalopathy with resolution of symptoms after VPA discontinuation. Valproic acid was restarted with the addition of levocarnitine to prevent VHE reoccurrence. In the other 2 cases, levocarnitine was started prophylactically in patients who developed hyperammonemia without emergence of any clinical symptoms. Ammonia levels were reduced to normal in all cases, and no symptoms consistent with encephalopathy were reported. The literature search identified 6 additional cases with 5 of 6 reports supporting use of levocarnitine for decreased ammonia levels as well as an observational trial. Discussion This literature review and case series illustrates successful use of levocarnitine supplementation for reduction of ammonia levels in the setting of VPA-induced hyperammonemia among patients with psychiatric disorders. However, clinical significance of ammonia reduction in asymptomatic patients is difficult to determine.
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Affiliation(s)
- Lauren M Brown
- Clinical Pharmacy Specialist, Psychiatry, South Texas Health Care System, San Antonio, Texas; UT Health San Antonio, College of Medicine, San Antonio, Texas; University of Texas at Austin, College of Pharmacy, Austin, Texas,
| | - Nicole Cupples
- Clinical Pharmacy Specialist, South Texas Health Care System, San Antonio, Texas; UT Health San Antonio, College of Medicine, San Antonio, Texas; University of Texas at Austin, College of Pharmacy, Austin, Texas
| | - Troy A Moore
- Clinical Pharmacy Specialist, South Texas Health Care System, San Antonio, Texas; UT Health San Antonio, Department of Psychiatry, Division of Community Recovery, Research and Training, San Antonio, Texas; UT Health San Antonio, College of Medicine, San Antonio, Texas; University of Texas at Austin, College of Pharmacy, Austin, Texas
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Farooq F, Sahib Din J, Khan AM, Naqvi S, Shagufta S, Mohit A. Valproate-Induced Hyperammonemic Encephalopathy. Cureus 2017; 9:e1593. [PMID: 29062625 PMCID: PMC5650254 DOI: 10.7759/cureus.1593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Valproate is the best choice drug for a variety of medical conditions. As with any other drug, it has adverse effects, and it is important to emphasize the possibility of those adverse effects to prevent complications. We present the case history of a 44-year-old male with valproate-induced hyperammonemic encephalopathy, despite having normal liver function tests. This case includes a detailed literature review of this rare adverse event. In the light of this case report, we illustrate the importance of checking ammonia levels in all psychiatric patients receiving valproate as a treatment who present with new onset neurological symptoms or altered mental status.
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Affiliation(s)
| | | | - Ali M Khan
- Psychiatry, Kings County Hospital Center
| | - Syeda Naqvi
- Jinnah Postgraduate Medical Centre, Jinnah Sindh Medical University (SMC)
| | | | - Abdul Mohit
- Behavioral Health, Kings County Hospital Center
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