Anemia secondary to valproic acid therapy in a 13-year-old boy: a case report

Valproate-Induced Metabolic Syndrome

Valproic acid (VPA) and its salts (sodium calcium magnesium and orotic) are psychotropic drugs that are widely used in neurology and psychiatry. The long-term use of VPA increases the risk of developing adverse drug reactions (ADRs), among which metabolic syndrome (MetS) plays a special role. MetS belongs to a cluster of metabolic conditions such as abdominal obesity, high blood pressure, high blood glucose, high serum triglycerides, and low serum high-density lipoprotein. Valproate-induced MetS (VPA-MetS) is a common ADR that needs an updated multidisciplinary approach to its prevention and diagnosis. In this review, we consider the results of studies of blood (serum and plasma) and the urinary biomarkers of VPA-MetS. These metabolic biomarkers may provide the key to the development of a new multidisciplinary personalized strategy for the prevention and diagnosis of VPA-MetS in patients with neurological diseases, psychiatric disorders, and addiction diseases.

Evaluation of efficacy and safety of clobazam as an add-on drug in the treatment of generalized tonic-clonic seizure not controlled with valproic acid monotherapy

BACKGROUND

Epilepsy is one of the major neuron-damaging neurological disorders. Generalized tonic-clonic seizure (GTCS) is the commonest one. Refractory patterns cannot be controlled by simple monotherapy with antiepileptic drugs (AEDs). Valproic acid (VPA) is one of the widely prescribed AEDs but it may not control many cases up to its maximum tolerable doses. In this study, we have seen the safety and efficacy of clobazam to control seizure in the adult population as an add-on drug over valproate, in cases of valproate uncontrolled seizures.

MATERIALS AND METHODS

Patients on VPA monotherapy but not responding to it were recruited after applying inclusion and exclusion criteria and clobazam was added. There were two follow-ups at the interval of 6 months each. Seizure frequency and quality of life inventory in epilepsy-31 items (QOLIE-31) score were recorded to denote efficacy, and the occurrence of any adverse effect was also noted to elicit safety.

RESULTS

Out of 101 patients, 78 were male and 23 were female. The most common age group was 18-30 y. Seizure frequency from 2.99 ± 0.95 decreased significantly on the third visit to 0.25 ± 0.43. QOLIE-31 scores of seizure worry, overall quality, emotional well-being, and cognition improved in the second follow-up. Fatigue, somnolence, and weight gain were the major side effects.

CONCLUSION

Clobazam could be a good choice as an add-on in GTCS not controlled with VPA monotherapy. Clobazam definitely reduces seizure frequency and seizure worry and improves cognitive function and overall quality of life.

Hematological Consequences of Valproic Acid in Pediatric Patients: A Systematic Review with a Mechanistic Approach

PURPOSE

Although valproate (VPA) has several advantages in controlling seizures, it may cause serious hematological consequences. Hematotoxicity of VPA is particularly important in pediatrics because patients at this age are at a growing risk of leukemia. For a conclusive agreement about the toxicity of VPA, in this study, we systematically reviewed the literature in which the hematological consequences of VPA had been emphasized. <P> Methods: A systematic literature search was performed in June 2021 on electronic databases to find original research on the association between VPA therapy and hematotoxicity in pediatric patients. For this purpose, the following search terms "hematotoxicity", "valproic acid" and "pediatrics" with different spellings and similar terms, were searched in the title, keywords, and abstracts of articles. The data were collected and used for qualitative data description. <P> Results: A total of 36 relevant articles with an overall 1381 study population were included. The results showed that VPA could cause severe hematotoxicity in children even at therapeutic doses. Neutropenia, thrombocytopenia, and bone marrow depression are the most common complications associated with VPA therapy. Also, findings showed that after discontinuation of VPA and starting other antiepileptic drugs or reducing the administered VPA dose, hematologic damages were entirely resolved, and all the hematological parameters improved during two weeks. <P> Conclusions: This review showed that VPA therapy could cause hematotoxicity in children; hence, it is recommended to monitor hematological indices during VPA therapy. Also, according to the suggested mechanistic pathways of VPA side effects, a combination of VPA with antioxidants may reduce hematological side effects.

Antioxidant and anti-inflammatory properties of alpha-lipoic acid protect against valproic acid-induced liver injury

Valproic acid (VPA) is one of the most used antiepileptic drugs despite of its many adverse effects such as anemia, leucopenia, thrombocytopenia, and liver toxicity. The hepatoprotective effect of alpha-lipoic acid (ALA) was confirmed. The aim of this study was to detect the protective effect of ALA against the adverse effects of VPA. To study this, 30 white albino Wistar male rats were divided into four groups. Group I was the control group; Group II included rats that received ALA (100 mg·kg-1·day-1) orally for 14 days; Group III and Group IV included rats that received VPA (500 mg·kg-1·day-1) for 15 days intraperitoneally, but Group IV rats received ALA (100 mg·kg-1·day-1) orally for 14 days prior to VPA. Blood samples were collected and livers were excised from rats for colorimetric analysis and quantitative real-time PCR. The rats that received VPA showed leucopenia, thrombocytopenia, a significant decrease of superoxide dismutase, glutathione, nuclear factor erythroid 2-related factor 2, and sirtuin 1, besides a significant increase of malondialdehyde and tumor necrosis factor α. Prior treatment with ALA prevented all these results; ALA protected against VPA-induced liver damage and hematological disturbance via antioxidant and anti-inflammatory properties.

Association between antiseizure medication use and risk of urinary tract infection: A case-control study

AIM

The aim of this study was to analyze the association between antiseizure medication (ASM) and the risk of urinary tract infections (UTI) in patients with epilepsy treated in general practices in Germany.

METHODS

This study includes a total of 2201 patients (mean age: 61.4) whose first documented UTI diagnosis occurred between January 2015 and December 2019 (index date) and who were prescribed at least one ASM in 1198 general practices in Germany within one year prior to the index date. Based on a case-control design, the association between predefined criteria and UTI was investigated by matching (1:1) controls without UTI to cases with UTI by sex, age, and codiagnoses. Logistic regression models were used to analyze the association between ASM use and UTI risk.

RESULTS

In the first regression model, phenytoin (PHT), primidone, carbamazepine (CBZ), and valproate (VPA) were associated with an increased risk of UTI. In the second model, these associations were confirmed with effects per prescription for PHT, primidone, CBZ, and VPA use. Additionally, the effect per prescription was significant for oxcarbazepine (OXC), topiramate, and gabapentin.

CONCLUSION

The study found that PHT, primidone, CBZ, and VPA in particular are associated with an increased risk of infections of the urinary tract. Oxcarbazepine, topiramate, and gabapentin are also associated with increased risk of UTI, albeit to a less significant extent. In general, the immunological and hematological side effects of these molecules may play an important role in the development of UTI under anticonvulsant therapy.

Dextromethorphan Protect the Valproic Acid Induced Downregulation of Neutrophils in Patients with Bipolar Disorder

Objective

Valproic acid (VPA) is an anticonvulsant and commonly long term used as a mood stabilizer for patients with mood disorders. However its chronic effects on the hematological changes were noticed and need to be further evaluated. In this study, we evaluated, in Taiwanese Han Chinese patients with bipolar disorders (BD), the chronic effects of VPA or VPA plus dextromethorphan (DM) on the hematological molecules (white blood cell [WBCs], red blood cells [RBCs], hemoglobin, hematocrit, and platelets).

Methods

In a 12-week, randomized, double-blind study, we randomly assigned BD patients to one of three groups: VPA plus either placebo (VPA＋P, n = 57) or DM (30 mg/day, VPA＋DM30, n = 56) or 60 mg/day (VPA＋DM60, n = 53). The Young Mania Rating Scale and Hamilton Depression Rating Scale were used to evaluate symptom severity, and the hematological molecules were checked.

Results

Paired t test showed that the WBC, neutrophils, platelets and RBCs were significantly lowered after 12 weeks of VPA＋P or VPA＋DM30 treatment. VPA＋DM60 represented the protective effects in the WBCs, neutrophils, and RBCs but not in the platelets. We further calculated the changes of each hematological molecules after 12 weeks treatment. We found that combination use of DM60 significantly improved the decline in neutrophils induced by the long-term VPA treatment.

Conclusion

Hematological molecule levels were lower after long-term treatment with VPA. VPA＋DM60, which yielded the protective effect in hematological change, especially in the neutrophil counts. Thus, DM might be adjunct therapy for maintaining hematological molecules in VPA treatment.

Anemia secondary to the use of sodium valproate for preventing postoperative seizures in a 79-year-old man: A case report

RATIONALE

Sodium valproate is a widely used antiepileptic drug and also used to prevent postoperative seizures in neurosurgery. Anemia caused by sodium valproate is occasionally reported and most are from pediatric patients.

PATIENT CONCERNS

We present the case of a 79-year-old man who developed anemia in the setting of a short-term sodium valproate therapy for the prevention of postoperative seizures.

DIAGNOSIS

By testing complete blood count we found anemia and hepatic enzyme elevations arising after 3-week standard dose sodium valproate therapy for preventing postoperative seizures. Our investigations ruled out most of the known causes of anemia including infection, uncontrolled bleeding, underlying systemic disease, malnutrition, immune hemolytic anemia, and neoplasia. On the drug's discontinuation as diagnostic therapy the patient's hemoglobin began to rise spontaneously and liver function returned to normal. Thus anemia secondary to sodium valproate was considered as the most likely diagnosis.

INTERVENTIONS

Sodium valproate was suspended and the patient was transfused with concentrated red blood cells.

OUTCOMES

The hemoglobin recovered obviously on the drug's discontinuation.

LESSONS

Hematologic toxicity of sodium valproate can occur quickly. Regular complete blood count test helps to make prompt diagnosis and drug discontinuation leads to the recovery.

Dispensability of Annual Laboratory Follow-Up After More than 2 Years of Valproic Acid Use: A Systematic Review

BACKGROUND

The necessity of annual laboratory follow-up in patients treated with valproic acid (VPA) is controversial.

OBJECTIVE

We investigated the need for annual laboratory follow-up of liver enzymes, electrolytes, and full blood count (FBC) in patients treated with VPA.

PATIENTS AND METHODS

A systematic search in Evidence-Based Medicine Reviews (EBMR), MEDLINE, and EMBASE was undertaken in December 2016 to identify all published articles investigating or citing valproic acid, liver function disorders, electrolyte disorders, and FBC deviations.

RESULTS

This review included 108 articles. As the number of participants and duration of the study was not adequate in most studies to detect rare adverse events, studies did not demonstrate a clear prevalence of hepatotoxicity. While a transient increase of transaminases is common and seldom harmful, severe hepatotoxicity is a rare phenomenon and is not prevented by routine laboratory monitoring. VPA had no relevant effect on serum calcium, sodium, potassium, and albumin. The prevalence of FBC varied from 0.6 to 27.8%, occurred mostly in the first 2 years of therapy, and was usually asymptomatic.

CONCLUSIONS

Long-term monitoring in VPA treatment is only necessary when there have been dose adjustments, co-medication switches, or co-morbidity. In uncomplicated cases, annual laboratory follow-up may be discontinued after 2 years of VPA treatment. Encouraging patients to be vigilant is more effective in the detection of hepatotoxicity than laboratory testing. Follow-up of FBC at 3-6 months, 1 year, and 2 years after start or after a dose increase of VPA or interacting medication is sufficient.

Adverse drug reactions induced by valproic acid

Valproic acid is a widely-used first-generation antiepileptic drug, prescribed predominantly in epilepsy and psychiatric disorders. VPA has good efficacy and pharmacoeconomic profiles, as well as a relatively favorable safety profile. However, adverse drug reactions have been reported in relation with valproic acid use, either as monotherapy or polytherapy with other antiepileptic drugs or antipsychotic drugs. This systematic review discusses valproic acid adverse drug reactions, in terms of hepatotoxicity, mitochondrial toxicity, hyperammonemic encephalopathy, hypersensitivity syndrome reactions, neurological toxicity, metabolic and endocrine adverse events, and teratogenicity.