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Abhilasha P, Bhatti N, Joseph G, Badyal DK. Sodium Valproate-Induced Hyperammonemia: A Case Series in a Tertiary Care Hospital. Cureus 2024; 16:e65390. [PMID: 39184772 PMCID: PMC11344863 DOI: 10.7759/cureus.65390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Sodium valproate (VPA) is an extensively used anti-convulsant, which is an effective drug for treatment of epilepsy in adults and children, as well as for conditions like migraine, bipolar disorder, mania, and trigeminal neuralgia. Sedation, vertigo, ataxia, dose-dependent tremors, headaches, and gastrointestinal side effects are the most often reported adverse effects associated with VPA. A potential life-threatening event reported with VPA is hyperammonemia (HA), which is defined as an increase in serum level of ammonia. Only 587 reported cases of HA were found in the VigiAccess database, representing a mere 0.6% of the 95,000 reported adverse events linked to VPA. Hence, this case series was conducted with emphasis on monitoring of increased serum ammonia levels with or without hepatic enzymes increase for patients who are on VPA. AIMS AND OBJECTIVES To assess elevated serum ammonia levels following VPA administration, and to ascertain the percentage of individuals with hepatic enzymes increased who took VPA and subsequently had elevated serum ammonia levels. METHODS This study was conducted at the adverse drug reaction (ADR) monitoring centre (AMC) of the Pharmacovigilance Programme of India (PvPI) and Department of Psychiatry, Christian Medical College and Hospital (CMC&H), Ludhiana. The study comprised of 12 patients who were exclusively on VPA and exhibited symptoms related to elevated serum ammonia. An informed consent form (ICF) was provided to the patient prior to taking their personal details. Laboratory investigations were done to establish the diagnosis and liver function tests (LFTs), chiefly ALT (alanine transferase) and AST (aspartate aminotransferase) were also performed. It is a descriptive study which was for a time period of six months. Results: This study includes 12 patients who had HA confirmed by laboratory investigation. Out of these 12 patients, two patients (17%) had a corresponding increase in LFT. The average as of the patients was 53.08 years and average serum ammonia levels were 219.15. None of the patients who presented with HA progressed to hyperammonemic encephalopathy (HAE). CONCLUSION This case series on valproate-induced HA should be of interest to psychiatrists, physicians, internists, family medicine physicians, hospitalists, and surgeons who will have patients on VPA. Delay in recognition of HA can result in the development of potentially life-threatening complications. Rapid diagnosis and management will help in reducing the number of cases which progress to encephalopathy which is highly fatal.
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Affiliation(s)
| | - Neena Bhatti
- Pharmacology, Christian Medical College and Hospital, Ludhiana, IND
| | - Girish Joseph
- Pharmacology, Christian Medical College and Hospital, Ludhiana, IND
| | - Dinesh K Badyal
- Pharmacology, Christian Medical College and Hospital, Ludhiana, IND
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Hannah N, Vasic D, Kansal A, Al-Ani A, Hebbard G, Sood S. Serum ammonia does not guide management and is overutilised in patients with cirrhosis in hospital settings. Intern Med J 2023; 53:2057-2064. [PMID: 36891668 DOI: 10.1111/imj.16053] [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: 08/03/2022] [Accepted: 02/12/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Hepatic encephalopathy is a confusional state associated with cirrhosis. Serum ammonia levels are neither sensitive nor specific for the diagnosis. AIMS We audited the ordering location and hospital unit whilst assessing the impact on management at a major Australian tertiary centre. METHODS We conducted a single-centre retrospective chart review of the ordering of serum ammonia levels between 1 March 2019 and 29 February 2020 at The Royal Melbourne Hospital, a tertiary-referral centre in Melbourne, Victoria. Demographic, medication and pathology results, including serum ammonia measurements, were collected. The main outcomes assessed were ordering location, sensitivity, specificity and impact on management. RESULTS A total of 1007 serum ammonia tests were ordered in 425 patients. Nearly all ammonia ordering was by non-gastroenterologists, 24.2% by the intensive care unit, 23.1% by general medicine and 19.5% by the emergency department (ED). Only 21.6% of patients had a history of cirrhosis, with hepatic encephalopathy diagnosed in 13.6%. On subgroup analysis, 217 ammonia tests were performed in 92 patients with cirrhosis. Cirrhotic patients were older (64 vs 59 years, P = 0.012) and had higher median ammonia levels (64.46 vs 59 μmol/L, P < 0.001) compared with non-cirrhotic patients. In cirrhotic patients, the sensitivity and specificity for serum ammonia and diagnosis of hepatic encephalopathy were 75% and 52.3% respectively. CONCLUSION We affirm the poor utility of serum ammonia levels for guiding management of hepatic encephalopathy within the Australian context. ED and general medical units account for the majority of test ordering within the hospital. Understanding where ordering occurs provides a target for targeted education.
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Affiliation(s)
- Nicholas Hannah
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Dubravka Vasic
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Abhik Kansal
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Aysha Al-Ani
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoff Hebbard
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Siddharth Sood
- Department of Gastroenterology and Hepatology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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Alsukhni RA, Johnson J, Nashef L. Valproate-induced reversible cognitive decline presenting as dementia and associated clinical features: A literature review. Seizure 2023; 111:45-50. [PMID: 37515866 DOI: 10.1016/j.seizure.2023.07.018] [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: 04/02/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND/AIM Valproate (VPA) is an effective broad-spectrum anti-seizure medication. Both VPA induced encephalopathy and reversible cognitive decline (VIRCD) have been reported as rare side effects. While the former is well-described in terms of risk factors, mechanism and management, the latter is less recognised and can be easily mistaken for neurodegenerative dementia. In this paper, we present a literature review of VIRCD, describe its clinical features and compare our findings to those in VPA-induced encephalopathy. METHODS We used PubMed search for valproate induced (dementia OR cognitive impairment OR cognitive decline OR cognitive dysfunction). Patients included were those with normal or well-defined cognitive baseline who presented with dementia after valproate therapy, in whom cognitive decline reversed after VPA dose reduction or discontinuation. Clinical features were compared to published descriptions of VPA-induced encephalopathy. RESULTS A total of 33 cases in 11 publications were included. Mean age was 51.2 years. Most were being treated for epilepsy on VPA with good seizure control and no encephalopathic features. VPA levels were within the usual quoted range. Mean latency after VPA initiation and symptoms was 6.87 years. Most had parkinsonian features. The most commonly reported cognitive deficits were in short-term memory and processing speed. All recovered fully on VPA discontinuation. CONCLUSION VIRCD mimics neurodegenerative dementia but is reversible on VPA discontinuation. The absence of encephalopathic features and good seizure control in addition to the prolonged latency make it easy to miss. VIRCD should be considered in relevant patient groups, especially in the presence of extrapyramidal signs.
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Affiliation(s)
| | - Jeremy Johnson
- The neurology department, King's College Hospital, London, UK, SE5 9RS
| | - Lina Nashef
- The neurology department, King's College Hospital, London, UK, SE5 9RS
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Dias Alves M, Vion-Dury J. Iatrogenic encephalopathies are not so rare in psychiatry: A retrospective study about 5217 EEG examinations. Neurophysiol Clin 2023; 53:102897. [PMID: 37659137 DOI: 10.1016/j.neucli.2023.102897] [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: 11/09/2022] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 09/04/2023] Open
Abstract
OBJECTIVES Encephalopathy is a severe pathological process induced by multiple factors, which is typically associated with electroencephalogram (EEG) abnormalities. Early diagnosis, management, and treatment improve the patient's prognosis. Psychotropic treatments are a risk for drug-induced encephalopathies. In this study, the prevalence of encephalopathies in a psychiatric hospital has been studied for 5 years (2012 to 2016) using 5217 EEG records. METHODS EEGs were performed i) systematically on patient admission, ii) in response to inexplicable modifications of consciousness or behavior, or when metabolic anomalies occurred, and iii) to perform therapeutic monitoring in outpatient consultations. When encephalopathy was suspected, the clinical data (age, sex and concomitant treatment) and biological data (plasma levels of medications) were collected. RESULTS Encephalopathy was suspected in 189 patients. Following EEG examination, and monitoring of clinical course, encephalopathy was subsequently determined to be highly probable for 52 patients, (giving a prevalence of 1% per year), and low suspicion of encephalopathy in the other 137 patients. The suspicion of encephalopathy was made on both clinical (n=28) and non-clinical (n=24) signs. Involved drugs were mainly valproic acid (n=14), lithium (n=11) and clozapine (n=11) in the highly probable encephalopathy group. CONCLUSIONS Our study demonstrates the importance of EEG in the diagnosis and monitoring of encephalopathies in a psychiatric hospital. Clinical symptoms of encephalopathies are polymorphic and sometimes atypical. This diagnosis is underestimated in a context where behavior or consciousness disorders are generally not attributed to psychotropic drugs used in psychiatry.
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Affiliation(s)
- Manuel Dias Alves
- Aix Marseille Univ, CNRS, PRISM, Marseille, France; Unité Psychiatrique de Neuromodulation de Toulon (UPNT), Centre Hospitalier Intercommunal de Toulon La Seyne-sur-Mer, Toulon, France.
| | - Jean Vion-Dury
- Aix Marseille Univ, CNRS, PRISM, Marseille, France; Unité de Neurophysiologie, Psychophysiologie et Neurophénoménologie (UNPN), Pôle Universitaire de Psychiatrie, Hôpital Ste Marguerite, Marseille, France
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Valproate-Associated Hyperammonemic Encephalopathy: Clinical Correlates and Management Strategies in a Tertiary Care Center. J Clin Psychopharmacol 2023; 43:145-148. [PMID: 36795014 DOI: 10.1097/jcp.0000000000001659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Common adverse effects of valproate include sedation, tremor, gastrointestinal effects, and weight gain. Valproate-associated hyperammonemic encephalopathy (VHE) is an uncommon adverse effect of valproate therapy, which includes symptoms such as tremors, ataxia, seizures, confusion, sedation and coma. We report clinical features and management of 10 cases of VHE in a tertiary care center. METHODS In a retrospective chart review of case records from January 2018 to June 2021, 10 patients with VHE were identified and included in this case series. The data collected include demographic information, psychiatric diagnosis, comorbidities, liver function tests, serum ammonia and serum valproate levels, dosages and duration of valproate, management of hyperammonemia including dosage variations, discontinuation, adjuvant drugs used, and whether rechallenge was done. RESULTS The most common indication of starting valproate was bipolar disorder (n = 5). All the patients had more than one physical comorbidity and risk factors for developing hyperammonemia. Seven patients received valproate at a dose higher than 20 mg/kg. The duration of valproate use varied from 1 week to 19 years before developing VHE. Dose reduction or discontinuation and lactulose were the most common management strategies used. All 10 patients improved. Among the 7 patients in whom valproate was discontinued, for 2 patients valproate was reinitiated in inpatient care with careful monitoring and was found to be well tolerated. CONCLUSIONS This case series highlights the need for a high index of suspicion for VHE as it is frequently associated with a delayed diagnosis and recovery in psychiatric settings. Screening for risk factors and serial monitoring may allow earlier diagnosis and management.
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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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DeMaagd GA, DeMaagd DR, Philip A. Delirium and its Pharmacological Causes in Older People, Part Two. Sr Care Pharm 2021; 36:534-547. [PMID: 34717785 DOI: 10.4140/tcp.n.2021.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes. Part two of this series continues to review drugs and drug classes that can cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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Chen L, Xu Z, Huang H. Non-hyperammonaemia valproate-induced encephalopathy: A case report. J Clin Pharm Ther 2021; 47:415-419. [PMID: 34462930 DOI: 10.1111/jcpt.13511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Valproate sodium is an effective antiepileptic drug (AED). Serious adverse effects of valproate sodium are uncommon. This case report illustrates the existence of non-hyperammonaemia valproate-induced encephalopathy. CASE DESCRIPTION A 47-year-old woman with epilepsy who developed valproate-induced encephalopathy without hyperammonaemia after valproate sodium treatment, and the symptoms completely subsided after withdrawal of valproate sodium. WHAT IS NEW AND CONCLUSION Early diagnosis and identification of the mechanisms of non-hyperammonaemia valproate-induced encephalopathy are important. Immediate discontinuation of valproate sodium results in rapid resolution of symptoms in these patients.
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Affiliation(s)
- Ling Chen
- Department of Neurology, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Zucai Xu
- Department of Neurology, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Hao Huang
- Department of Neurology, The Affiliated Hospital of Zunyi Medical University, Zunyi, China
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Yee CS, Vázquez GH, Hawken ER, Biorac A, Tondo L, Baldessarini RJ. Long-Term Treatment of Bipolar Disorder with Valproate: Updated Systematic Review and Meta-analyses. Harv Rev Psychiatry 2021; 29:188-195. [PMID: 33795581 DOI: 10.1097/hrp.0000000000000292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
LEARNING OBJECTIVE After participating in this activity, learners should be better able to:• Evaluate the evidence regarding the effectiveness of long-term treatment of bipolar disorder with valproate. BACKGROUND Prophylactic treatment is critical for bipolar disorder (BD) patients. Valproate is commonly used for this purpose but lacks regulatory approval and carries appreciable risks. METHODS Systematic literature searching through June 2020 sought prospective trials lasting ≥12 months with adults diagnosed with BD to support comparisons of risk of new illness episodes with valproate versus placebo or other agents. RESULTS Included were 13 reports involving 9240 subjects treated for an average of 29.1 months (range, 12-124) in 21 trials: 9 were blinded, randomized trials (RCTs) of valproate versus placebo (n = 3), lithium (5), or olanzapine (1); 2 were unblinded RCTs versus lithium (1) or quetiapine (1); and 10 were open-label trials versus lithium (5), quetiapine (2), carbamazepine (1), lamotrigine (1), or olanzapine (1). Random-effects meta-analysis found valproate superior to placebo in 3 trials (odds ratio [OR] = 0.42 [95% confidence level (CI), 0.30-0.60]; p < .0001). In 11 trials, protective effects with valproate and lithium were similar (OR = 1.20 [CI, 0.81-1.79]; p = .36), as well in 5 comparisons versus antipsychotics quetiapine and olanzapine (OR = 0.96 [CI, 0.66-1.40]; p = .84), and 2 versus other mood-stabilizing anticonvulsants (carbamazepine and lamotrigine) (OR = 1.30 [CI, 0.75-2.26]; p = .34). Valproate was nonsignificantly more effective versus new mania than depression (χ2 = 3.03; p = .08). CONCLUSIONS Valproate was more effective than placebo in preventing new BD episodes of mania or depression, and not significantly different from lithium, second-generation antipsychotics, or other anticonvulsants. Overall benefits were nonsignificantly greater versus mania than bipolar depression.
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Affiliation(s)
- Caitlin S Yee
- From the Department of Psychiatry (Drs. Yee, Vázquez, and Hawken) and Centre for Neuroscience Studies (Drs. Vázquez and Biorac), Queen's University School of Medicine, Kingston, Ontario; International Consortium for Mood & Psychotic Disorder Research, McLean Hospital, Belmont, MA (Drs. Vázquez, Tondo, and Baldessarini); Harvard Medical School (Drs. Tondo and Baldessarini); Lucio Bini Mood Disorder Centers, Cagliari and Rome (Dr. Tondo)
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Pagali S, Edquist C, O'Rourke N. Managing valproic acid toxicity-related hyperammonaemia: an unpredicted course. BMJ Case Rep 2021; 14:14/4/e241547. [PMID: 33875509 PMCID: PMC8057561 DOI: 10.1136/bcr-2020-241547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 20-year-old woman presented following an intentional overdose of valproic acid. Use of valproic acid, either acute or chronic, can result in hyperammonaemia. Mild hyperammonaemia with chronic use is mostly asymptomatic but can also present with concern for encephalopathy. Acute valproic acid toxicity results in significant hyperammonaemia, which can contribute to encephalopathy. Levocarnitine is the treatment of choice in valproic acid toxicity-related hyperammonaemia. For severe cases of encephalopathy, intermittent haemodialysis can also be considered. To our knowledge, this is the first case report to clearly show symptom relapse and hyperammonaemia after discontinuing levocarnitine. We recommend levocarnitine therapy for at least 72 hours, followed by an additional 24 hours of monitoring for symptom relapse and hyperammonaemia after levocarnitine discontinuation.
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Affiliation(s)
- Sandeep Pagali
- Medicine - Division of Hospital Internal Medicine & Division of Geriatric Medicine and Gerontology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Christopher Edquist
- Medicine - Division of Hospital Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Nicholas O'Rourke
- Department of Pharmacy, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Alhagamhmad M, Elarwah A, Alhassony A, Alougly S, Milad H, Dehoam A, Elbrgathy S, Shembesh N, Mousa E, ElShiky A. Valproate-Induced Hyperammonemic Encephalopathy Following Accidental Ingestion in a Toddler. J Pediatr Pharmacol Ther 2021; 26:210-212. [PMID: 33603587 DOI: 10.5863/1551-6776-26.2.210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/25/2020] [Indexed: 11/11/2022]
Abstract
Clinical manifestations of valproic acid (VPA) toxicity can range from just mild confusion and drowsiness to serious encephalopathy, leading to depressed sensorium and even coma and death. The exact cause(s) of how VPA influences the integrity of brain function remains unknown. Nevertheless, several mechanisms have been postulated including a surge in the blood ammonia concentration. Valproic acid-induced hyperammonemic encephalopathy is a rare yet serious sequalae and that can lead to grave outcomes. We report a case of hyperammonemic encephalopathy with preserved liver function following a moderate VPA intoxication in a toddler, who was successfully managed conservatively. Additionally, we briefly discuss mechanistic basis of VPA toxicity and highlight some of the available potential therapies.
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Limón ID, Angulo-Cruz I, Sánchez-Abdon L, Patricio-Martínez A. Disturbance of the Glutamate-Glutamine Cycle, Secondary to Hepatic Damage, Compromises Memory Function. Front Neurosci 2021; 15:578922. [PMID: 33584185 PMCID: PMC7873464 DOI: 10.3389/fnins.2021.578922] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
Glutamate fulfils many vital functions both at a peripheral level and in the central nervous system (CNS). However, hyperammonemia and hepatic failure induce alterations in glutamatergic neurotransmission, which may be the main cause of hepatic encephalopathy (HE), an imbalance which may explain damage to both learning and memory. Cognitive and motor alterations in hyperammonemia may be caused by a deregulation of the glutamate-glutamine cycle, particularly in astrocytes, due to the blocking of the glutamate excitatory amino-acid transporters 1 and 2 (EAAT1, EAAT2). Excess extracellular glutamate triggers mechanisms involving astrocyte-mediated inflammation, including the release of Ca2+-dependent glutamate from astrocytes, the appearance of excitotoxicity, the formation of reactive oxygen species (ROS), and cell damage. Glutamate re-uptake not only prevents excitotoxicity, but also acts as a vital component in synaptic plasticity and function. The present review outlines the evidence of the relationship between hepatic damage, such as that occurring in HE and hyperammonemia, and changes in glutamine synthetase function, which increase glutamate concentrations in the CNS. These conditions produce dysfunction in neuronal communication. The present review also includes data indicating that hyperammonemia is related to the release of a high level of pro-inflammatory factors, such as interleukin-6, by astrocytes. This neuroinflammatory condition alters the function of the membrane receptors, such as N-methyl-D-aspartate (NMDA), (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) AMPA, and γ-aminobutyric acid (GABA), thus affecting learning and spatial memory. Data indicates that learning and spatial memory, as well as discriminatory or other information acquisition processes in the CNS, are damaged by the appearance of hyperammonemia and, moreover, are associated with a reduction in the production of cyclic guanosine monophosphate (cGMP). Therefore, increased levels of pharmacologically controlled cGMP may be used as a therapeutic tool for improving learning and memory in patients with HE, hyperammonemia, cerebral oedema, or reduced intellectual capacity.
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Affiliation(s)
| | - Isael Angulo-Cruz
- Laboratorio de Neurofarmacología, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Lesli Sánchez-Abdon
- Laboratorio de Neurofarmacología, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Aleidy Patricio-Martínez
- Laboratorio de Neurofarmacología, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
- Facultad de Ciencias Biológicas, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
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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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14
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Imbert-Bismut F, Payet PE, Alfaisal J, Munteanu M, Rudler M, Sultanik P, Alkouri R, Sakka M, Djavoudine S, Dever S, Mestari F, Bonnefont-Rousselot D, Poynard T, Thabut D. Transportation and handling of blood samples prior to ammonia measurement in the real life of a large university hospital. Clin Chim Acta 2020; 510:522-530. [DOI: 10.1016/j.cca.2020.07.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 01/28/2023]
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15
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Non-convulsive status epilepticus secondary to valproate-induced hyperammonaemic encephalopathy. NEUROLOGÍA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.nrleng.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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16
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Estatus epiléptico no convulsivo secundario a encefalopatía hiperamonémica inducida por valproato. Neurologia 2020; 35:603-606. [DOI: 10.1016/j.nrl.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/10/2019] [Accepted: 05/10/2019] [Indexed: 11/22/2022] Open
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Habhab SF, Ulvin LB, Taubøll E, Svalheim S, Olsen KB, Horn MA, Heuser K. Influence of valproate-induced hyperammonemia on treatment decision in an adult status epilepticus cohort. Epilepsy Behav 2020; 111:107193. [PMID: 32759060 DOI: 10.1016/j.yebeh.2020.107193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/24/2020] [Accepted: 05/24/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency in which immediate intervention is required to prevent permanent brain damage and death. Intravenous (IV) valproic acid (VPA) is often used for the treatment of SE. However, IV VPA frequently increases the blood ammonia level. In this study, we explore the impact of IV VPA-induced hyperammonemia (HA) on treatment management of SE and discuss the challenges related to this particular condition. METHODS We used data from medical records of 31 adult patients (≥18 years) treated with IV VPA for SE at Oslo University Hospital between January 2006 and October 2019. Clinical and blood sample data and information about the influence of HA on treatment were collected. Correlations between ammonia levels and other continuous or categorical variables were tested using the Pearson's correlation coefficient. The Kruskal-Wallis H-test was used to analyze associations between different variables and treatment decisions. RESULTS Thirty of 31 patients had increased ammonia level during IV VPA treatment. In 16/30 patients, VPA was discontinued, and in 6/30 patients, the dose was reduced. We found a difference in the median peak ammonia level among the groups where VPA was discontinued (99 μmol/l), reduced (71 μmol/l), and continued (55.5 μmol/l) (P = 0.008). Also clinical status, measured by West Haven Criteria, varied among the groups where VPA was discontinued (3.5), reduced (2.5), and continued (2.0) (P = 0.01). Treatment decisions at peak ammonia were not associated with the level of liver enzymes and bilirubin. CONCLUSION Hyperammonemia had a substantial impact on further management. To date, no recommendations exist on how to manage VPA-induced HA in SE. We call for systematic prospective studies and evidence-based guidelines.
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Affiliation(s)
- Sarah Folkestad Habhab
- Department of Neurology, Oslo University Hospital, Oslo, Norway; University of Southern Denmark, Odense, Denmark
| | | | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Sigrid Svalheim
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Ketil Berg Olsen
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | | | - Kjell Heuser
- Department of Neurology, Oslo University Hospital, Oslo, Norway.
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18
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Hyperammonemic Encephalopathy Associated with Perampanel: Case Report and Discussion. Can J Neurol Sci 2020; 48:438-439. [PMID: 32959734 DOI: 10.1017/cjn.2020.203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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19
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Valproic Acid-Induced Hyperammonemic Encephalopathy in a Patient with Bipolar Disorder: A Case Report. Brain Sci 2020; 10:brainsci10030187. [PMID: 32213827 PMCID: PMC7139302 DOI: 10.3390/brainsci10030187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/13/2020] [Accepted: 03/22/2020] [Indexed: 11/16/2022] Open
Abstract
Valproic acid (VPA) is widely used to control various seizure disorders and psychiatric disorders. Valproic acid-induced hyperammonemic encephalopathy (VHE) is a rare but dangerous complication of VPA-induced toxicity. For this case report, several risk factors were identified, including young age, polytherapy regimens, VPA overdose, poor liver function, and carnitine deficiency. The detailed mechanisms of VHE remained unclear. Hyperammonemia may be caused by hypocarnitinemia, leading to imbalanced VPA metabolism. VHE may initially cause gastrointestinal symptoms, followed by a decreased level of consciousness and seizure. Early diagnosis of VHE is important for physicians for the timely reversal of VHE by discontinuing administration of VPA and administering lactulose or levocarnitine. Here, we describe a patient with a bipolar disorder who presented with VHE after receiving a strict vegetarian diet in our hospital. We recommend that VHE be included in the differential diagnosis of patients with high serum VPA levels and strictly vegetarian diets, especially those presenting with acute gastrointestinal symptoms.
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20
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An Uncommon Case of Hyperammonemic Encephalopathy. Neurocrit Care 2019; 31:439-442. [DOI: 10.1007/s12028-019-00715-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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Membrane Stabilizer Medications in the Treatment of Chronic Neuropathic Pain: a Comprehensive Review. Curr Pain Headache Rep 2019; 23:37. [DOI: 10.1007/s11916-019-0774-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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22
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A Review of the Pharmacological and Clinical Profile of Newer Atypical Antipsychotics as Treatments for Bipolar Disorder: Considerations for Use in Older Patients. Drugs Aging 2018; 35:887-895. [PMID: 30187288 DOI: 10.1007/s40266-018-0579-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Bipolar disorder prevalence rates vary in the older adult population (defined as age ≥ 65 years), ranging from 1% in community dwellers to as high as 8-10% in hospital inpatients. Although older agents, including lithium and valproic acid, offer significant antimanic efficacy, as supported by a recent randomized controlled trial (RCT), there is growing interest in using atypical antipsychotics to treat bipolar disorder in older adults. Newer atypical antipsychotics are of interest based on their tolerability and efficacy in the general adult bipolar population. The aim of this review was to systematically examine efficacy and tolerability of newer atypical antipsychotics for older adult bipolar disorder (OABD). We conducted a systematic search utilizing the MEDLINE, EMBASE, PsycINFO and Cochrane Library electronic databases, with the aim of identifying all RCTs comparing newer atypical antipsychotics approved by the US FDA since 2002 (including brexpiprazole, cariprazine, lurasidone, iloperidone, asenapine, paliperidone, and aripiprazole) with placebo or another comparator, in the treatment of any phase of bipolar disorder (including mania, depression or mixed episodes while used as an acute or maintenance treatment) in older adults (> 65 years). We found no RCT data on any of the examined agents. Hence, we changed our search criteria to include studies with a lower age cut-off (≥ 55 years), as well as the inclusion of post hoc studies. Two post hoc studies on lurasidone suggest its reasonable safety and efficacy profile in the acute and maintenance treatment of OABD; however, there are no pharmacoeconomic data on the use of lurasidone in the treatment of OABD. Research data from open-label studies on oral asenapine and aripiprazole as add-on therapy suggest that these two agents are adequately tolerated and improved symptoms of depression and mania in OABD; hence, there is an urgent need to conduct RCTs on these two agents. Lastly, we found no studies for the treatment of OABD with brexpiprazole, cariprazine, iloperidone, or paliperidone.
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23
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Oldham MA, Flaherty JH, Maldonado JR. Refining Delirium: A Transtheoretical Model of Delirium Disorder with Preliminary Neurophysiologic Subtypes. Am J Geriatr Psychiatry 2018; 26:913-924. [PMID: 30017237 DOI: 10.1016/j.jagp.2018.04.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/21/2018] [Accepted: 04/04/2018] [Indexed: 12/21/2022]
Abstract
The development of delirium indicates neurophysiologic disruption and predicts unfavorable outcomes. This relationship between delirium and its outcomes has inspired a generation of studies aimed at identifying, predicting, and preventing both delirium and its associated sequelae. Despite this, evidence on delirium prevention and management remains limited. No medication is approved for the prevention or treatment of delirium or for its associated psychiatric symptoms. This unmet need for effective delirium treatment calls for a refined approach. First, we explain why a one-size-fits-all approach based on a unitary biological model of delirium has contributed to variance in delirium studies and prevents further advance in the field. Next, in parallel with the shift from dementia to "major neurocognitive disorder," we propose a transtheoretical model of "delirium disorder" composed of interactive elements-precipitant, neurophysiology, delirium phenotype, and associated psychiatric symptoms. We explore how these relate both to the biopsychosocial factors that promote healthy cognition ("procognitive factors") and to consequent neuropathologic sequelae. Finally, we outline a preliminary delirium typology of specific neurophysiologic disturbances. Our model of delirium disorder offers several avenues for novel insights and clinical advance: it univocally differentiates delirium disorder from the phenotype of delirium, highlights delirium neurophysiology as a treatment target, separates the core features of delirium from associated psychiatric symptoms, suggests how procognitive factors influence the core elements of delirium disorder, and makes intuitive predictions about how delirium disorder leads to neuropathologic sequelae and cognitive impairment. Ultimately, this model opens several avenues for modern neuroscience to unravel this disease of antiquity.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
| | | | - Jose R Maldonado
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA
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24
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De Michele G, Sorrentino P, Nesti C, Rubegni A, Ruggiero L, Peluso S, Antenora A, Quarantelli M, Filla A, De Michele G, Santorelli FM. Reversible Valproate-Induced Subacute Encephalopathy Associated With a MT-ATP8 Variant in the Mitochondrial Genome. Front Neurol 2018; 9:728. [PMID: 30214424 PMCID: PMC6125373 DOI: 10.3389/fneur.2018.00728] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/09/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: There are several reported cases of patients developing motor and cognitive neurological impairment under treatment with valproic acid (VPA). We describe a woman who developed a subacute encephalopathy after VPA intake, harboring a mitochondrial DNA variant, previously described as causing VPA sensitivity in one pediatric patient. Material and Methods: A 65-year old woman developed a progressive, severe neurological deterioration after a 3 month treatment with valproate sodium, 800 mg daily. Magnetic resonance spectroscopy (MRS), muscle histochemical analysis and assay of mitochondrial enzymatic activities, and mitochondrial DNA sequencing were performed. Results: Neurological examination showed drowsiness, vertical gaze palsy, inability to either stand or walk, diffuse weakness, increased tendon reflexes. Blood lactate was increased, EEG showed diffuse theta and delta activity, MRI subcortical atrophy and leukoencephalopathy, MRS marked reduction of the NAA spectrum, with a small signal compatible with presence of lactate. Muscle biopsy evidenced presence of ragged red fibers (20%) and reduced COX reactivity. Assay of the muscle enzymatic activities showed multiple deficiencies of the electron transport chain and reduced ATP production. The mt.8393C>T variant in the MT-ATP8 gene was found in homoplasmy. The patient considerably improved after valproate withdrawal. Conclusion: The variant we found has been reported both as a polymorphism and, in a single patient, as related to the valproate-induced encephalopathy. The present case is the first bearing this mutation in homoplasmy. In case of neurological symptoms after starting VPA therapy, once hyperammonemia and liver failure have been ruled out, mtDNA abnormalities should be considered.
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Affiliation(s)
- Giovanna De Michele
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Pierpaolo Sorrentino
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Claudia Nesti
- Molecular Medicine, IRCCS Fondazione Stella Maris, Pisa, Italy
| | - Anna Rubegni
- Molecular Medicine, IRCCS Fondazione Stella Maris, Pisa, Italy
| | - Lucia Ruggiero
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Silvio Peluso
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Antonella Antenora
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Mario Quarantelli
- Institute of Biostructure and Bioimaging, National Research Council, Naples, Italy
| | - Alessandro Filla
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
| | - Giuseppe De Michele
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli Federico II, Napoli, Italy
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25
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Abstract
Hyperammonemic encephalopathy secondary to the use of valproate is rare without evidence of hepatotoxicity, and it usually presents with confusion, agitation, irritability, cognitive disturbances, lethargy, coma, and death. We present the case of a 21-year-old woman presenting with catatonia as a manifestation of hyperammonemic encephalopathy that resolved with the normalization of ammonia and suspension of valproate.
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26
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Dinçer M, Akgün A, Bodur Ş, Gül H, Taş Torun Y, Bolu A, Çelik C, Çetinkaya M, Kara H, Cöngöloğlu MA. Hyperammonemic encephalopathy without hepatic dysfunction due to treatment with valproate: four cases and a mini review. PSYCHIAT CLIN PSYCH 2018. [DOI: 10.1080/24750573.2018.1448133] [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: 02/07/2023] Open
Affiliation(s)
- Mustafa Dinçer
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Abdullah Akgün
- Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Şahin Bodur
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Hesna Gül
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Yasemin Taş Torun
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Abdullah Bolu
- Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Cemil Çelik
- Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
| | - Miray Çetinkaya
- Child and Adolescent Psychiatry Department, Sami Ulus Child Hospital, Ankara, Turkey
| | - Halil Kara
- Child and Adolescent Psychiatry Department, Aksaray State Hospital, Aksaray, Turkey
| | - M. Ayhan Cöngöloğlu
- Child and Adolescent Psychiatry Department, Gülhane Research and Training Hospital, Ankara, Turkey
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27
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Borreggine KL, Hosker DK, Rummans TA, Manning DM. Psychiatric Manifestations of Hyperammonemic Encephalopathy Following Roux-en-Y Gastric Bypass. PSYCHOSOMATICS 2017; 59:90-94. [PMID: 28844450 DOI: 10.1016/j.psym.2017.07.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/24/2017] [Accepted: 07/24/2017] [Indexed: 12/12/2022]
Affiliation(s)
| | - Daniel K Hosker
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN.
| | - Teresa A Rummans
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN
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28
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Strickler N, Balabanov S, Casauro K, Schanz U, Manz MG, Gerber B. Acute central nervous system complications and ammonium levels in adult patients with acute lymphoblastic leukemia receiving l-asparaginase. Leuk Lymphoma 2017; 59:855-862. [PMID: 28728499 DOI: 10.1080/10428194.2017.1352090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We analyzed ammonium levels and acute central nervous complications in adult patients receiving chemotherapy for acute lymphoblastic leukemia with or without asparaginase (l-asp). Twenty patients with a median age of 40.3 years were included. Ammonium-levels were measured during 88 chemotherapy cycles, 60 cycles (68%) with l-asp, and 28 cycles (32%) without l-asp. Ammonium was elevated in 87% of all l-asp containing cycles, with median ammonium levels of 169 μmol/l (interquartile range (IQR) 91-269 μmol/l). These values were higher when compared to ammonium levels at baseline (31.5 μmol/l, IQR 24-40 μmol/l, p < .001), and when compared to levels in cycles without l-asp (30 μmol/l, IQR 19-41 μmol/l, p < .001). Acute hyperammonemic encephalopathy was diagnosed in one patient, and encephalopathy for other reasons, but with hyperammonemia as a possible contributing factor in four patients. In conclusion, ammonium levels are elevated in all adult patients receiving l-asparaginase, but only some patients will present symptoms of encephalopathy.
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Affiliation(s)
- Nicole Strickler
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Stefan Balabanov
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Katharina Casauro
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland.,b Division of Hematology , Spital Maennedorf , Männedorf , Switzerland
| | - Urs Schanz
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Markus G Manz
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Bernhard Gerber
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland.,c Division of Hematology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
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29
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Valproate-Induced Hyperammonemic Encephalopathy in General Hospital Patients With One or More Psychiatric Disorders. PSYCHOSOMATICS 2017; 58:415-420. [DOI: 10.1016/j.psym.2017.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 02/08/2017] [Accepted: 02/09/2017] [Indexed: 11/15/2022]
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30
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Guo X, Wei J, Gao L, Xing B, Xu Z. Hyperammonemic coma after craniotomy: Hepatic encephalopathy from upper gastrointestinal hemorrhage or valproate side effect?: Case report and literature review. Medicine (Baltimore) 2017; 96:e6588. [PMID: 28403092 PMCID: PMC5403089 DOI: 10.1097/md.0000000000006588] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Postoperative coma is not uncommon in patients after craniotomy. It generally presents as mental state changes and is usually caused by intracranial hematoma, brain edema, or swelling. Hyperammonemia can also result in postoperative coma; however, it is rarely recognized as a potential cause in coma patients. Hyperammonemic coma is determined through a complicated differential diagnosis, and although it can also be induced as a side effect of valproate (VPA), this cause is frequently unrecognized or confused with upper gastrointestinal hemorrhage (UGH)-induced hepatic encephalopathy. We herein present a case of valproate-induced hyperammonemic encephalopathy (VHE) to illustrate the rarity of such cases and emphasize the importance of correct diagnosis and proper treatment. PATIENT CONCERNS AND DIAGNOSES A 61-year-old woman with meningioma was admitted into our hospital. Radical resection of the tumor was performed, and the patient recovered well as expected. After administration of valproate for 7 days, the patient was suddenly found in a deep coma, and her mental state deteriorated rapidly. The diagnoses of hepatic encephalopathy was confirmed. However, whether it origins from upper gastrointestinal hemorrhage or valproate side effect is uncertain. INTERVENTIONS AND OUTCOMES The patient's condition fluctuated without improvement during the subsequent 3 days under the treatment of reducing ammonia. With the discontinuation of valproate treatment, the patient regained complete consciousness within 48 hours, and her blood ammonia decreased to the normal range within 4 days. LESSONS SUBSECTIONS VHE is a rare but serious complication in patients after craniotomy and is diagnosed by mental state changes and elevated blood ammonia. Thus, the regular perioperative administration of VPA, which is frequently neglected as a cause of VHE, should be emphasized. In addition, excluding UGH prior to providing a diagnosis and immediately discontinuing VPA administration are recommended.
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31
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Dawson LP, Lee SJ, Hollander YS. Valproate-induced hyperammonemic encephalopathy associated with urinary tract infection and urinary retention in the psychiatric setting. Aust N Z J Psychiatry 2016; 50:1110. [PMID: 27056174 DOI: 10.1177/0004867416640906] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Luke P Dawson
- Department of Psychiatry, The Alfred, Melbourne, VIC, Australia
| | - Stuart J Lee
- Department of Psychiatry, The Alfred, Melbourne, VIC, Australia.,Monash Alfred Psychiatry Research Centre, The Alfred and Monash University Central Clinical School, Melbourne, VIC, Australia
| | - Yitzchak S Hollander
- Department of Psychiatry, The Alfred, Melbourne, VIC, Australia .,Department of Psychology, Faculty of Health, Arts and Design, Swinburne University, Melbourne, VIC, Australia
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32
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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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33
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Ostergaard JR. Juvenile neuronal ceroid lipofuscinosis (Batten disease): current insights. Degener Neurol Neuromuscul Dis 2016; 6:73-83. [PMID: 30050370 PMCID: PMC6053093 DOI: 10.2147/dnnd.s111967] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The present review is focused on juvenile neuronal ceroid lipofuscinosis (JNCL; Batten disease) due to a mutation in CLN3. Functional vision impairment occurring around 5-6 years of age is the first symptom in more than 80% of patients. Approximately 2 years later (though sometimes simultaneously), obvious signs of cognitive impairment appear. Behavior problems can occur in advance, especially in boys. These include anxious and depressed mood, aggressive behavior, and hallucinations, and even psychotic symptoms. Following the teens, severe dementia is present, including loss of memory, attention, and general reasoning abilities, as well as loss of independent adaptive skills such as mobility, feeding, and communicating. Sleep abnormalities, such as settling problems, nocturnal awakenings, and nightmares, are reported in more than half of patients. The vast majority, if not all, patients develop seizures, starting at approximately 10 years of age. Generalized tonic-clonic seizure occurs as the only type of seizure in approximately half of patients, and in combination with partial seizures in a third of patients. There seems to be no difference in seizure severity according to sex or genotype, and there is great variation in seizure activity among patients. Soon after diagnosis, patients begin to have slight ataxic symptoms, and at adolescence extrapyramidal symptoms (rigidity, bradykinesia, slow steps with flexion in hips and knees) occur with increasing frequency. Chewing and swallowing difficulties emerge as well, and food intake is hampered in the late teens. Disabling periodically involuntary movements may occur as well. A progressive cardiac involvement with repolarization disturbances, ventricular hypertrophy, and sinus-node dysfunction, ultimately leading to severe bradycardia and/or other conduction abnormalities, starts in the mid-teens. Patients are usually bedridden at 20 years of age, and death usually occurs in the third decade of life.
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Affiliation(s)
- John R Ostergaard
- Department of Paediatrics, Aarhus University Hospital, Centre for Rare Diseases, Aarhus, Denmark,
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34
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Abstract
Valproate was first approved as an antiepileptic drug in 1962 and has since also become established as a mood stabiliser and as prophylaxis for migraine. In 1979, Lautin published the first description of a valproate-associated extrapyramidal syndrome. Many cases of valproate-associated parkinsonism have subsequently been published, but uncertainties remain concerning its prevalence, risk factors and prognosis. The aim of this paper is to provide a critical review of the existing literature on valproate-associated parkinsonism and to discuss possible mechanisms. Literature databases were searched systematically: we identified a total of 116 patients with valproate-associated parkinsonism published in case reports, case series and systematic analyses. Prevalence rates ranged widely, between 1.4 and 75 % of patients taking valproate. There was great heterogeneity with regard to clinical presentation, age of onset, valproate dose, concomitant conditions and imaging findings. In all patients apart from three, valproate plasma concentrations were within or even below the recommended reference range when the parkinsonism occurred. Parkinsonism was reversible in the majority of patients, although recovery was often prolonged and sometimes incomplete. A dopaminergic deficit was confirmed in three of six patients investigated with dopamine transporter imaging. Seven of 14 patients who were treated with dopaminergic medication had a good response. The quality of the evidence was assessed and probability of causation was examined using the Naranjo score, which ranged from 0 to 7 (median: 5.0). Several pathophysiological mechanisms, including altered gene expression and neurotransmitter signalling, enhanced neurodegeneration or unmasking subclinical dopaminergic degeneration, could theoretically lead to valproate-associated parkinsonism. Further studies are warranted to elucidate this entity and its underlying pathophysiology.
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Affiliation(s)
- Florian Brugger
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK.,Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, UK
| | - Frank M C Besag
- ELFT NHS Family Consultation Clinic, 24 Grove Place, Bedford, Bedfordshire, MK40 3JJ, UK. .,School of Pharmacy, University College of London, London, UK. .,Institute of Psychiatry, London, UK.
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Hung CC, Lin CH, Lane HY. Hypothyroidism may exacerbate valproate-related hyperammonemic delirium. Biomedicine (Taipei) 2016; 6:12. [PMID: 27161002 PMCID: PMC4864769 DOI: 10.7603/s40681-016-0012-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 09/16/2016] [Indexed: 11/08/2022] Open
Affiliation(s)
- Chung-Chieh Hung
- Graduate Institute of Clinical Medical Science, China Medical University, 404, Taichung, Taiwan. .,Department of Psychiatry, China Medical University Hospital, 404, Taichung, Taiwan.
| | - Chieh-Hsin Lin
- Graduate Institute of Clinical Medical Science, China Medical University, 404, Taichung, Taiwan.,Department of Psychiatry, Chang Gung Memorial Hospital, 833, Kaohsiung, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Clinical Medical Science, China Medical University, 404, Taichung, Taiwan.,Department of Psychiatry, China Medical University Hospital, 404, Taichung, Taiwan
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36
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Svendsen T, Alfstad KÅ, Lossius MI, Nakken KO. [Long-term adverse effects of anti-epileptic drugs]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:324-7. [PMID: 26905847 DOI: 10.4045/tidsskr.15.0220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Around 120,000 patients in Norway use anti-epileptic drugs daily. Their use has increased in recent years, partly because these drugs are also used for psychiatric disorders, migraine and neuropathic pain. Treatment usually lasts for many years. It is important for doctors to familiarise themselves with the adverse effect profile of these drugs, especially because the long-term adverse effects are generally insidious and are easy for both doctor and patient to overlook.
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Affiliation(s)
- Torleiv Svendsen
- Spesialsykehuset for epilepsi (SSE) Klinikk for kirurgi og nevrofag Oslo universitetssykehus
| | - Kristin Å Alfstad
- Spesialsykehuset for epilepsi (SSE) Klinikk for kirurgi og nevrofag Oslo universitetssykehus
| | - Morten I Lossius
- Spesialsykehuset for epilepsi (SSE) Klinikk for kirurgi og nevrofag Oslo universitetssykehus
| | - Karl O Nakken
- Spesialsykehuset for epilepsi (SSE) Klinikk for kirurgi og nevrofag Oslo universitetssykehus
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37
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First data on the biological variation and quality specifications for plasma ammonia concentrations in healthy subjects. ACTA ACUST UNITED AC 2016; 54:857-63. [DOI: 10.1515/cclm-2015-0591] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/01/2015] [Indexed: 12/28/2022]
Abstract
AbstractBackground:Most of the factors causing preanalytical and analytical variation in ammonia measurement have been identified. Biological variation data for ammonia is still lacking. We therefore estimated the components of biological variation (within-subject=CVMethods:Blood samples from 20 healthy subjects were collected in K2EDTA tubes daily over a period of 4 consecutive days from each subject. Each plasma sample was split into two aliquots; one was immediately analyzed as the samples were collected and the other was stored –80 °C until testing at the end of the collection period and analyzed at once in one analytical run. All samples were analyzed in duplicate. Estimations were calculated according to Fraser and Harris methods.Results:CVConclusions:The present study for the first time described the components of biological variation for ammonia in healthy individuals. These data regarding biological variation of ammonia could be useful for a better evaluation of ammonia test results in clinical interpretation and for determining quality specifications based on biological variation.
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Kowalski M, Tong EY, Yip GS, Dooley MJ. Polypharmacy: a risk factor to consider in valproate-induced hyperammonaemic encephalopathy. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/jppr.1108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Melanie Kowalski
- General Medical Unit; Alfred Health; Melbourne Australia
- Pharmacy Department; Alfred Health; Melbourne Australia
| | - Erica Y. Tong
- General Medical Unit; Alfred Health; Melbourne Australia
- Pharmacy Department; Alfred Health; Melbourne Australia
| | - Gary S. Yip
- General Medical Unit; Alfred Health; Melbourne Australia
| | - Michael J. Dooley
- Pharmacy Department; Alfred Health; Melbourne Australia
- Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Melbourne Australia
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Walker MC, Williams RSB. New experimental therapies for status epilepticus in preclinical development. Epilepsy Behav 2015; 49:290-3. [PMID: 26189787 DOI: 10.1016/j.yebeh.2015.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 06/07/2015] [Indexed: 12/26/2022]
Abstract
Starting with the established antiepileptic drug, valproic acid, we have taken a novel approach to develop new antiseizure drugs that may be effective in status epilepticus. We first identified that valproic acid has a potent effect on a biochemical pathway, the phosphoinositide pathway, in Dictyostelium discoideum, and we demonstrated that this may relate to its mechanism of action against seizures in mammalian systems. Through screening in this pathway, we have identified a large array of fatty acids and fatty acid derivatives with antiseizure potential. These were then evaluated in an in vitro mammalian system. One compound that we identified through this process is a major constituent of the ketogenic diet, strongly arguing that it may be the fatty acids that are mediating the antiseizure effect of this diet. We further tested two of the more potent compounds in an in vivo model of status epilepticus and demonstrated that they were more effective than valproic acid in treating the status epilepticus. This article is part of a Special Issue entitled "Status Epilepticus".
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Affiliation(s)
- Matthew C Walker
- Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, WC1N 3BG, UK.
| | - Robin S B Williams
- Centre for Biomedical Sciences, School of Biological Sciences, Royal Holloway University of London, Egham TW20 0EX, UK.
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Ghannoum M, Laliberté M, Nolin TD, MacTier R, Lavergne V, Hoffman RS, Gosselin S. Extracorporeal treatment for valproic acid poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2015; 53:454-65. [PMID: 25950372 DOI: 10.3109/15563650.2015.1035441] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup presents its systematic review and clinical recommendations on the use of extracorporeal treatment (ECTR) in valproic acid (VPA) poisoning. METHODS The lead authors reviewed all of the articles from a systematic literature search, extracted the data, summarized the key findings, and proposed structured voting statements following a predetermined format. A two-round modified Delphi method was chosen to reach a consensus on voting statements and the RAND/UCLA Appropriateness Method was used to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote was conducted to determine the final workgroup recommendations. RESULTS The latest literature search conducted in November 2014 retrieved a total of 79 articles for final qualitative analysis, including one observational study, one uncontrolled cohort study with aggregate analysis, 70 case reports and case series, and 7 pharmacokinetic studies, yielding a very low quality of evidence for all recommendations. Clinical data were reported for 82 overdose patients while pharmaco/toxicokinetic grading was performed in 55 patients. The workgroup concluded that VPA is moderately dialyzable (level of evidence = B) and made the following recommendations: ECTR is recommended in severe VPA poisoning (1D); recommendations for ECTR include a VPA concentration > 1300 mg/L (9000 μmol/L)(1D), the presence of cerebral edema (1D) or shock (1D); suggestions for ECTR include a VPA concentration > 900 mg/L (6250 μmol/L)(2D), coma or respiratory depression requiring mechanical ventilation (2D), acute hyperammonemia (2D), or pH ≤ 7.10 (2D). Cessation of ECTR is indicated when clinical improvement is apparent (1D) or the serum VPA concentration is between 50 and 100 mg/L (350-700 μmol/L)(2D). Intermittent hemodialysis is the preferred ECTR in VPA poisoning (1D). If hemodialysis is not available, then intermittent hemoperfusion (1D) or continuous renal replacement therapy (2D) is an acceptable alternative. CONCLUSIONS VPA is moderately dialyzable in the setting of overdose. ECTR is indicated for VPA poisoning if at least one of the above criteria is present. Intermittent hemodialysis is the preferred ECTR modality in VPA poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal , Verdun, QC , Canada
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Villalba Martínez G, Fernández-Candil JL, Vivanco-Hidalgo RM, Pacreu Terradas S, León Jorba A, Arroyo Pérez R. Ammonia encephalopathy and awake craniotomy for brain language mapping: cause of failed awake craniotomy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:275-279. [PMID: 25475698 DOI: 10.1016/j.redar.2014.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 09/01/2014] [Accepted: 09/22/2014] [Indexed: 06/04/2023]
Abstract
We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration.
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Affiliation(s)
| | | | | | - S Pacreu Terradas
- Anesthesiology and Resuscitation Department, Hospital del Mar, Barcelona, Spain
| | - A León Jorba
- Neurophysiology Department, Hospital del Mar, Barcelona, Spain
| | - R Arroyo Pérez
- Anesthesiology and Resuscitation Department, Hospital del Mar, Barcelona, Spain
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Kumar S, Asrani SK. Non-cirrhotic Hyperammonemia—When High Ammonia Is not Always from Cirrhosis. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s11901-015-0252-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Rochester, MN, USA.
| | | | - Stephen J Traub
- Department of Emergency Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Hashim IA, Cuthbert JA. Elevated ammonia concentrations: Potential for pre-analytical and analytical contributing factors. Clin Biochem 2014; 47:233-6. [DOI: 10.1016/j.clinbiochem.2014.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 08/12/2014] [Accepted: 08/19/2014] [Indexed: 12/20/2022]
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45
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Wexler E. Clinical neurogenetics: behavioral management of inherited neurodegenerative disease. Neurol Clin 2014; 31:1121-44. [PMID: 24176427 DOI: 10.1016/j.ncl.2013.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Psychiatric symptoms often manifest years before overt neurologic signs in patients with inherited neurodegenerative disease. The most frequently cited example of this phenomenon is the early onset of personality changes in "presymptomatic" Huntington patients. In some cases the changes in mood and cognition are even more debilitating than their neurologic symptoms. The goal of this article is to provide the neurologist with a concise primer that can be applied in a busy clinic or private practice.
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Affiliation(s)
- Eric Wexler
- Department of Psychiatry, Center for Neurobehavioral Genetics, Semel Institute, University of California Los Angeles School of Medicine, 695 Charles Young Drive South, Gonda Room 2309, Los Angeles, CA 90024-1759, USA.
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Melexopoulou C, Marinaki S, Darema M, Skalioti C, Efthimiou A, Zavos G, Boletis JN. Valproate-induced hyperammonemic encephalopathy in a renal transplanted patient. Ren Fail 2014; 36:955-6. [PMID: 24665854 DOI: 10.3109/0886022x.2014.900423] [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] [Indexed: 01/19/2023] Open
Abstract
Neurological complications after renal transplantation constitute an important cause of morbidity and mortality. Their differential diagnosis is difficult and essential for subsequent patient's management. Valproate-induced hyperammonemic encephalopathy is an uncommon but serious effect of valproate treatment. Here, we describe the case of a 15-year-old girl who was on a long-term therapy with valproate due to epilepsy and revealed impaired consciousness with hyperammonemia 12 days after renal transplantation. After withdraw of valproate, patients' symptoms resolved within 24 h. Clinicians should increase their awareness for potential complication of valproate, especially in transplanted patients.
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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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Kasapkara CS, Kanğın M, Taş FF, Topçu Y, Demir R, Ozbek MN. Unusual cause of hyperammonemia in two cases with short-term and long-term valproate therapy successfully treated by single dose carglumic acid. J Pediatr Neurosci 2014; 8:250-2. [PMID: 24470826 PMCID: PMC3888049 DOI: 10.4103/1817-1745.123697] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Valproic acid (VPA) is an antiepileptic drug which is used in the treatment of various seizure disorders including tonic-clonic, myoclonic, absence, partial seizures and psychiatric disorders. VPA is usually well tolerated, but severe adverse effects may occur. Hyperammonaemic encephalopathy (HE) is a rare and potentially fatal complication of VPA treatment. The mechanism by which valproate induces hyperammonemia remains incompletely understood but is likely to relate to the urea cycle. Herein we present two cases with valproate-induced hyperammonemia at therapeutic valproate levels without signs of liver failure and were successfully treated by a single dose of carglumic acid.
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Affiliation(s)
- Ciğdem Seher Kasapkara
- Department of Pediatric Metabolism and Nutrition, Diyarbakır Children's Hospital, Diyarbakır, Turkey
| | - Murat Kanğın
- Department of Pediatrics, Diyarbakır Children's Hospital, Diyarbakır, Turkey
| | - Funda Feryal Taş
- Department of Pediatrics, Diyarbakır Children's Hospital, Diyarbakır, Turkey
| | - Yasemin Topçu
- Department of Pediatric Neurology, Diyarbakır Children's Hospital, Diyarbakır, Turkey
| | - Remezan Demir
- Department of Pediatrics, Diyarbakır Children's Hospital, Diyarbakır, Turkey
| | - Mehmet Nuri Ozbek
- Department of Pediatric Endocrinology, Diyarbakır Children's Hospital, Diyarbakır, Turkey
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Sundin JRB, Øksengård AR, Røste LS, Svendsen J, Ihle-Hansen H. Kvinne i 70-årene med raskt økende kognitiv svikt. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2014; 134:1577-80. [DOI: 10.4045/tidsskr.13.0663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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50
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Hiperamonemia en pacientes adultos sin cirrosis. Med Clin (Barc) 2013; 141:494-500. [DOI: 10.1016/j.medcli.2013.04.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/22/2013] [Accepted: 04/25/2013] [Indexed: 01/09/2023]
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