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Abstract
BACKGROUND Hyperammonemia is an adverse effect that poses clinical uncertainty around valproic acid (VPA) use. The prevalence of symptomatic and asymptomatic hyperammonemia and its relationship to VPA concentration is not well established. There is also no clear guidance regarding its management. This results in variability in the monitoring and treatment of VPA-induced hyperammonemia. To inform clinical practice, this systematic review aims to summarize evidence available around VPA-associated hyperammonemia and its prevalence, clinical outcomes, and management. METHODS An electronic search was performed through Ovid MEDLINE, Ovid Embase, Web of Science, and PsycINFO using search terms that identified hyperammonemia in patients receiving VPA. Two reviewers independently performed primary title and abstract screening with a third reviewer resolving conflicting screening results. This process was repeated during the full-text review process. RESULTS A total of 240 articles were included. Prevalence of asymptomatic hyperammonemia (5%-73%) was higher than symptomatic hyperammonemia (0.7%-22.2%) and occurred within the therapeutic range of VPA serum concentration. Various risk factors were identified, including concomitant medications, liver injury, and defects in carnitine metabolism. With VPA discontinued, most symptomatic patients returned to baseline mental status with normalized ammonia level. There was insufficient data to support routine monitoring of ammonia level for VPA-associated hyperammonemia. CONCLUSIONS Valproic acid-associated hyperammonemia is a common adverse effect that may occur within therapeutic range of VPA. Further studies are required to determine the benefit of routine ammonia level monitoring and to guide the management of VPA-associated hyperammonemia.
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Affiliation(s)
- Yiu-Ching Jennifer Wong
- From the Department of Pharmacy, St Paul's Hospital; and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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2
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A novel method for predicting the unbound valproic acid concentration. Drug Metab Pharmacokinet 2023; 50:100503. [PMID: 37080137 DOI: 10.1016/j.dmpk.2023.100503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/26/2023] [Accepted: 03/02/2023] [Indexed: 03/07/2023]
Abstract
In this study, we constructed a prediction formula for unbound valproic acid (VPA) concentration that was more accurate and widely applicable than previously reported formulae. A total of 136 datasets from 75 patients were analyzed retrospectively. The median of free fraction of VPA was 0.16 (interquartile range: 0.07; range: 0.07-0.45). The parameter that combined total VPA concentration (CtVPA) and serum albumin (SA), (CtVPA [μM] - 2 × SA [μM]), was significantly related to the free fraction of VPA (r = 0.76, p < 0.001). We constructed a combined parameter-based prediction formula for unbound VPA concentration. Analysis using external datasets from patients without severe renal failure showed that the prediction errors of the unbound VPA concentration were lower than those of previously reported formulae. Although the previous formulae showed large prediction errors, especially in the specific range of CtVPA values, the constructed formula showed a weak trend with CtVPA or SA. The formula based on (CtVPA [μM] - 2 × SA [μM]) had high prediction accuracy and wide applicability in predicting the unbound VPA concentration in patients without severe renal failure.
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Mhaimeed N, Mhaimeed N, Shad MU. Pharmacokinetic mechanisms underlying clinical cases of valproic acid autoinduction: A review. JOURNAL OF AFFECTIVE DISORDERS REPORTS 2022. [DOI: 10.1016/j.jadr.2022.100426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Brown CS, Liu J, Riker RR, Mara KC, Rabinstein AA, Fraser GL, May TL, Seder D, Gagnon DJ. Evaluation of Free Valproate Concentration in Critically Ill Patients. Crit Care Explor 2022; 4:e0746. [PMID: 37942235 PMCID: PMC10631734 DOI: 10.1097/cce.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Protein binding of valproate is variable in ICU patients, and the total valproate concentration does not predict the free valproate concentration, even when correcting for albumin. We sought to quantify valproate free concentration among ICU patients, identify risk factors associated with an increasing free valproate concentration, and evaluate the association between free valproate concentration with potential adverse drug effect. DESIGN Retrospective multicenter cohort study. SETTING Two academic medical centers. PATIENTS Patients greater than or equal to 18 years of age with concomitant free and total valproate concentrations collected in the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two-hundred fifty-six patients were included in the study, with a median age of 56 years (42-70) and 65% of patients were male. The median total valproate concentration was 53 µg/mL (38-70 µg/mL), the free valproate concentration was 12 µg/mL (7-20 µg/mL), and the free fraction was 23.6% (17.0-33.9%). Therapeutic discordance between the free and total valproate concentration occurred in 70% of patients. On multivariable analysis, increased free valproate concentration was associated with higher total valproate concentration (per 5 µg/mL increase, increase 1.72 µg/mL, 95% CI, 1.48-1.96) and lower serum albumin (per 1 g/dL decrease, increase 4.60 µg/mL, 95% CI, 2.71-6.49). There was no association between free valproate concentration and adverse effects. CONCLUSIONS The valproate total and free concentration was discordant in the majority of patients (70%). Increased valproate free concentration was associated with hypoalbuminemia and total valproate concentration. Clinical decisions based on total valproate concentration may be incorrect for many ICU patients. Prospective, controlled studies are needed to confirm these findings and their clinical relevance.
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Affiliation(s)
| | - JiTong Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA
| | - Richard R Riker
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | - Teresa L May
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | - David Seder
- Department of Critical Care Services, Maine Medical Center, Portland, ME
- Tufts University School of Medicine, Boston, MA
| | - David J Gagnon
- Tufts University School of Medicine, Boston, MA
- Department of Pharmacy, Maine Medical Center, Portland, ME
- Maine Medical Center Research Institute, Portland, ME
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Lin K, Cao VFS, Au C, Dahri K. Clinical Pharmacokinetic Monitoring of Free Valproic Acid Levels: A Systematic Review. Clin Pharmacokinet 2022; 61:1345-1363. [PMID: 36040614 DOI: 10.1007/s40262-022-01171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Current guidelines recommend therapeutic drug monitoring as a critical component of valproic acid (VPA) therapy. Due to high protein binding, the active unbound (free) portion of VPA can be misrepresented by total VPA serum levels in certain clinical scenarios. Monitoring free VPA serum levels may be warranted when assessing the clinical response to VPA therapy. OBJECTIVES The aims were to conduct a systematic review to identify a therapeutic range for free VPA serum levels; to explore the correlation of free VPA serum levels with clinical toxicity and therapeutic benefit; and to examine predictors of discordance between free and total VPA levels. METHODS Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, BIOSIS Previews, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from the time of database inception to June 20, 2021. Randomized controlled trials and observational studies that evaluated any patient receiving VPA with free VPA level monitoring were included. RESULTS Of 189 citations, we identified 27 relevant studies, which included 14 observational studies, two case series, and 11 case reports. Three studies provided a therapeutic range for free VPA levels between 20 and 410 μmol/L. Two studies suggested the occurrence of hyperammonemia and thrombocytopenia at free VPA serum levels above 60 µmol/L and 103.3 µmol/L, respectively. Two studies suggested an upper limit for neurotoxicity at free VPA serum levels of 70 µmol/L and 207.9 µmol/L. Hypoalbuminemia was identified as a predictor of therapeutic discordance. CONCLUSIONS This review demonstrates a paucity of data informing the clinical utility of free VPA serum levels. Further high-quality trials are needed to validate an optimal therapeutic range for free VPA levels.
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Affiliation(s)
- Kevin Lin
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
| | - Vivien F S Cao
- Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada.
| | - Charles Au
- Lower Mainland Pharmacy Services, Vancouver, BC, Canada
| | - Karen Dahri
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada.,Department of Pharmacy, Vancouver General Hospital, Vancouver, BC, Canada
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Szczygieł-Pilut EE, Zajączkowska-Dutkiewicz A, Pilut D, Dutkiewicz J. HYPERAMMONAEMIA AND COGNITIVE IMPAIRMENT IN EPILEPSY PATIENTS TREATED WITH VALPROIC ACID - PRELIMINARY STUDY. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2022; 75:1459-1465. [PMID: 35907216 DOI: 10.36740/wlek202206106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE The aim: To determine whether VPA pharmacotherapy, mainly in the group of patients using subtherapeutic doses of VPA, could contribute to the occurrence of cognitive impairment. PATIENTS AND METHODS Materials and methods: The study involved 14 patients: six women and eight men, aged 24 - 77 years (mean SD ± - 52.36±13.71) diagnosed with epilepsy in accordance with the ILAE criteria (International League Against Epilepsy), in whom the main clinical complaint, in addition to poor control of epileptic seizures, were impaired concentration, attention and memory impairment. RESULTS Results: Mild cognitive impairment - MCI was diagnosed in 4 patients (28.57%) (3 with elevated ammonia levels, 1 without), in 1 patient (7.14%) there was a mild level of dementia. In only one MCI case, elevated serum concentrations of valproic acid were also recorded. It is very important to highlight that cognitive impairment has never been diagnosed before (prior to VPA therapy) in this group. Of these 5 patients, in four cases, after discontinuation of the drug, an improvement in the clinical condition was achieved. In a patient with mild level dementia, the termination of therapy did not give a similar effect. This proves the possibility of other mechanisms responsible for generating these sometimes irreversible disorders. CONCLUSION Conclusions: Regardless of the dose and concentration of ammonia in blood serum of patients diagnosed with epilepsy, VPA therapy may cause various, significant dysfunctions that significantly impair quality of life.
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Affiliation(s)
- Elżbieta Ewa Szczygieł-Pilut
- DEPARTMENT OF NEUROLOGY WITH STROKE AND NEUROLOGICAL REHABILITATION SUB-UNIT, JOHN PAUL II SPECIALIST HOSPITAL, CRACOW, POLAND
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Wu X, Li H, Dong W, Yang X, Jin Y, Gong Y, Zhang Z, Liu X. Determination of Free Valproic Acid Concentration in 569 Clinical Samples by LC-MS/MS After Hollow Fiber Centrifugal Ultrafiltration Treatment. Ther Drug Monit 2021; 43:789-796. [PMID: 33990504 DOI: 10.1097/ftd.0000000000000903] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To perform therapeutic drug monitoring of total and free plasma valproic acid (VPA) concentrations in clinical samples and to analyze the related factors. METHODS The total VPA concentration in plasma was determined by ultrahigh-performance liquid chromatography with precolumn derivatization with α-bromoacetophenone, and the free VPA concentration was determined by liquid chromatography-tandem mass spectrometry after the plasma was treated by hollow fiber centrifugal ultrafiltration. Regression analysis was performed to examine the associations between free plasma VPA, total plasma VPA, and the plasma protein binding rate. The impact of individual situations, outpatient or inpatient factors, and drug combinations on VPA concentrations were examined. RESULTS Of the 569 clinical samples, 268 were inpatients and 301 were outpatients, and the total VPA concentration in 138 cases (24.2%) was lower than the effective treatment concentration range; the total and free VPA concentrations in outpatient samples were 11.0% and 26.1% higher than those of inpatients, respectively. There was no linear relationship between the free and total VPA concentrations. The relationship equation between the plasma protein binding rate and free VPA concentrations was as follows: Y = 0.0255X2 - 1.1357X + 97.429 (r = 0.8011). The total and free VPA concentrations were significantly decreased after the coadministration of phenobarbital (83.7% and 64.3% of the control group, P < 0.05) or carbapenem antibiotics (32.0% and 32.7% of the control group, P < 0.05). CONCLUSIONS The total VPA concentrations in patients with epilepsy at our hospital was lower than the effective treatment concentration range, which was inadequate for epilepsy control; the total VPA concentrations of outpatients were higher than those of inpatients; as phenobarbital affects VPA metabolism, therapeutic drug monitoring is recommended. Carbapenem antibiotic coadministration with VPA should be avoided because carbapenem antibiotics can lead to the failure of VPA antiepileptic treatment.
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Affiliation(s)
- Xikun Wu
- Department of Pharmacy, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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Saito M, Takizawa T, Miyaoka H. Factors associated with blood carnitine levels in adult epilepsy patients with chronic valproic acid therapy. Epilepsy Res 2021; 175:106697. [PMID: 34175794 DOI: 10.1016/j.eplepsyres.2021.106697] [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: 11/22/2020] [Revised: 05/20/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022]
Abstract
AIMS Valproic acid (VPA) is a widely used antiepileptic drug for the treatment of epilepsy, seizures, and bipolar and psychiatric disorders. A deficiency of carnitine, a compound involved in energy production, is associated with chronic VPA use. However, the clinical factors affecting blood carnitine levels and their pathophysiology remain unclear. Hence, we aimed to identify the factors that correlated with serum carnitine levels in epilepsy patients receiving chronic VPA therapy. METHODS This observational study included 138 epilepsy patients receiving chronic VPA therapy. Serum total and free carnitine levels, routine blood tests and drug concentrations were assessed. The correlation between carnitine levels and other factors were calculated using Spearman's rank correlation coefficients, and a principal component analysis (PCA) and a multiple linear regression analysis were performed. RESULTS Overall, serum free carnitine levels showed significant negative correlations with epilepsy duration, VPA treatment duration, daily VPA dose, and blood VPA concentration. A significant positive correlation was observed with erythrocyte count, hemoglobin levels, and creatinine levels. Of the 138 patients, 21 (15.2 %) with serum free carnitine levels of <20 μmol/L had significantly longer disease duration, a higher daily VPA dose, and lower blood clobazam concentrations. In the 48 VPA monotherapy patients, serum free carnitine levels showed a significant negative correlation with disease duration and duration of VPA therapy. Furthermore, in the 2.1 % patients receiving VPA monotherapy, serum free carnitine levels were <20 μmol/L. PCA resulted in seven factor solution (eigenvalue >1; 71.67 % explained variance). Component 1 clearly revealed the maximal loading for serum free carnitine level (.792) and the most negative loading for disease duration of epilepsy (-.595). A linear regression analysis revealed that the duration of epilepsy, serum creatinine level, and daily dose of VPA were significant (p < .01) factors that affected serum free carnitine levels. CONCLUSIONS The effects of combination therapy with VPA and other anti-epileptic drug(s) on carnitine levels are higher than that of VPA monotherapy. Additionally, epilepsy duration may affect serum free carnitine level.
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Affiliation(s)
- Masanori Saito
- Department of Psychiatry, Kitasato University School of Medicine, Japan.
| | - Takeya Takizawa
- Department of Psychiatry, Kitasato University School of Medicine, Japan
| | - Hitoshi Miyaoka
- Department of Psychiatry, Kitasato University School of Medicine, Japan
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Wu X, Dong W, Li H, Yang X, Jin Y, Zhang Z, Jiang Y. CYP2C9*3/*3 Gene Expression Affects the Total and Free Concentrations of Valproic Acid in Pediatric Patients with Epilepsy. Pharmgenomics Pers Med 2021; 14:417-430. [PMID: 33859491 PMCID: PMC8043849 DOI: 10.2147/pgpm.s301893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To perform therapeutic drug monitoring (TDM) of total and free plasma valproic acid (VPA) concentrations in pediatric patients with epilepsy and to analyze related factors. Patients and Methods Pediatric epileptic patients treated in 2015-2019 in our hospital were assessed. Total and free plasma VPA concentrations were obtained by UPLC and LC-MS/MS, respectively. Regression analysis was performed to examine the associations of free plasma VPA with total plasma VPA and plasma protein binding rate. The impacts of individual situation, CYP2C9 genotype, and drug combination on VPA concentration were examined. Results Of the 251 patients, 81 had lower total concentrations than effective therapeutic levels; 86 and 31 patients had infections and central nervous system dysplasia, respectively. VPA's daily doses and free drug concentrations were significantly lower in the CYP2C9 *3/*3 genotype group versus the CYP2C9 *1/*3 and CYP2C9 *1/*1 groups (P<0.05). Free and total VPA concentrations were linked by Y = 0.0004 X2 + 0.042 X + 0.3035 (r=0.6981); VPA plasma protein binding rate and free VPA concentration were related by Y = 0.0003 X2 - 0.0127 X + 0.9777 (r=0.8136). Both total and free VPA concentrations were significantly decreased in patients simultaneously administered phenobarbital, meropenem and biapenem (P<0.05), with therapeutic failure after meropenem/biapenem co-administration. Conclusion Free VPA amounts have nonlinear relationships with total VPA amounts and plasma protein binding rate in epileptic children. Additionally, CYP2C9 *3/*3 expression affects VPA metabolism. Since phenobarbital affects VPA metabolism, TDM is recommended. Meanwhile, carbapenem-co-administration with VPA should be prohibited.
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Affiliation(s)
- Xikun Wu
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Weichong Dong
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Haoran Li
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Xiuling Yang
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Yiran Jin
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Zhiqing Zhang
- The Second Hospital of Hebei Medical University, Shijiazhuang City, People's Republic of China
| | - Ye Jiang
- Pharmacy College, Hebei Medical University, Shijiazhuang City, People's Republic of China
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Makuch-Kocka A, Andres-Mach M, Zagaja M, Śmiech A, Pizoń M, Flieger J, Cielecka-Piontek J, Plech T. Effect of Chronic Administration of 5-(3-chlorophenyl)-4-Hexyl-2,4 -Dihydro-3 H-1,2,4-Triazole-3-Thione (TP-315)-A New Anticonvulsant Drug Candidate-On Living Organisms. Int J Mol Sci 2021; 22:ijms22073358. [PMID: 33805962 PMCID: PMC8037910 DOI: 10.3390/ijms22073358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/20/2021] [Accepted: 03/22/2021] [Indexed: 12/12/2022] Open
Abstract
About 70 million people suffer from epilepsy—a chronic neurodegenerative disease. In most cases, the cause of the disease is unknown, but epilepsy can also develop as the result of a stroke, trauma to the brain, or the use of psychotropic substances. The treatment of epilepsy is mainly based on the administration of anticonvulsants, which the patient must most often use throughout their life. Despite significant progress in research on antiepileptic drugs, about 30% of patients still have drug-resistant epilepsy, which is insensitive to pharmacotherapy used so far. In our recent studies, we have shown that 4-alkyl-5-aryl-1,2,4-triazole-3-thiones act on the voltage-gated sodium channels and exhibit anticonvulsant activity in an MES (maximal electroshock-induced seizure) and 6Hz test in mice. Previous studies have shown their beneficial toxic and pharmacological profile, but their effect on a living organism during chronic use is still unknown. In the presented study, on the basis of the previously conducted tests and the PAMPA (parallel artificial membrane permeability assay) BBB (blood–brain barrier) test, we selected one 1,2,4-triazole-3-thione derivative—TP-315—for further studies aimed at assessing the impact of its chronic use on a living organism. After long-term administration of TP-315 to Albino Swiss mice, its effect on the functional parameters of internal organs was assessed by performing biochemical, morphological, and histopathological examinations. It was also determined whether the tested compound inhibits selected isoforms of the CYP450 enzyme system. On the basis of the conducted tests, it was found that TP-315 does not show nephrotoxic nor hepatotoxic effects and does not cause changes in hematological parameters. In vitro tests showed that TP-315 did not inhibit CYP2B6, CYP2D6, CYP3A4, or CYP3A5 enzymes at the concentration found in the serum of mice subjected to long-term exposure to this compound.
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Affiliation(s)
- Anna Makuch-Kocka
- Department of Pharmacology, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
- Correspondence:
| | - Marta Andres-Mach
- Isobolographic Analysis Laboratory, Institute of Rural Health, 20-090 Lublin, Poland; (M.A.-M.); (M.Z.)
| | - Mirosław Zagaja
- Isobolographic Analysis Laboratory, Institute of Rural Health, 20-090 Lublin, Poland; (M.A.-M.); (M.Z.)
| | - Anna Śmiech
- Sub-Department of Pathomorphology and Forensic Veterinary Medicine, Department and Clinic of Animal Internal Diseases, University of Life Sciences in Lublin, 20-612 Lublin, Poland;
| | - Magdalena Pizoń
- Department of Analytical Chemistry, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (M.P.); (J.F.)
| | - Jolanta Flieger
- Department of Analytical Chemistry, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (M.P.); (J.F.)
| | - Judyta Cielecka-Piontek
- Department of Pharmacognosy, Faculty of Pharmacy, Poznan University of Medical Sciences, 61-781 Poznań, Poland;
| | - Tomasz Plech
- Department of Pharmacology, Faculty of Health Sciences, Medical University of Lublin, 20-093 Lublin, Poland;
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Safety range of free valproic acid serum concentration in adult patients. PLoS One 2020; 15:e0238201. [PMID: 32877431 PMCID: PMC7467252 DOI: 10.1371/journal.pone.0238201] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 08/11/2020] [Indexed: 01/09/2023] Open
Abstract
Background Therapeutic drug monitoring (TDM) is recommended during valproic acid (VPA) use, and total serum concentration has been widely adopted. However, the free form of VPA is responsible for its pharmacologic and toxic effects, and the total and free concentrations are highly discordant because of VPA’s highly protein bound and saturable binding characteristics. Therefore, free VPA monitoring is increasingly advocated. Nevertheless, the correlation between free VPA concentration and associated adverse effects remains unknown. Objective To determine the optimal safety range of free VPA concentration in adult patients. Materials and methods This prospective cohort study enrolled adult patients undergoing VPA therapy with TDM. Patient characteristics, VPA use, and adverse effects (thrombocytopenia, hyperammonemia, and hepatotoxicity) were recorded. A multivariate logistic regression model was applied to identify the predictors of adverse effects, and the receiver operating characteristic curve was applied to locate the cutoff point of free VPA concentration. Results A total of 98 free serum concentrations from 51 patients were included for final analysis. In total, 31 (31.6%), 27 (27.6%), and 4 (4.1%) episodes of hyperammonemia, thrombocytopenia, and hepatotoxicity were observed, respectively. Free VPA concentration was a predicting factor for thrombocytopenia but not for hyperammonemia. A free VPA concentration of >14.67 mcg/mL had the greatest discriminating power (area under the curve = 0.77) for the occurrence of thrombocytopenia. Conclusions A free VPA serum concentration of 14.67 mcg/mL had the optimal discriminating power for the occurrence of thrombocytopenia. Ammonemia should be monitored even if free VPA concentration is within the safety range.
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Myers KA, Tamon U, Agnihotram RV, Berrahmoune S. Serum Levels of Valproic Acid and Carbamazepine Do Not Correlate Well with End-Organ Dysfunction. Epilepsy Res 2020; 163:106343. [PMID: 32339984 DOI: 10.1016/j.eplepsyres.2020.106343] [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: 02/09/2020] [Revised: 04/05/2020] [Accepted: 04/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Serum levels of anticonvulsants are commonly ordered; however, the clinical utility of these laboratory tests is unclear. Clarifying the significance of anticonvulsant drug levels is essential to allow physicians to make appropriate management decisions. We aimed to determine to what extent elevated serum levels of valproic acid (VPA) and carbamazepine (CBZ) correlate with laboratory indications of end-organ dysfunction. METHODS We reviewed a consecutive sample of patients 0-18 years of age who, over a 2-year period, had at least one blood collection in which (1) serum [VPA] or [CBZ] was tested; and (2) at least one of the following tests was performed: alanine aminotransferase (ALT), aspartate aminotransferase (AST), platelets, white blood cells (WBC), ammonia, sodium. RESULTS 913 and 300 blood collections met criteria for VPA and CBZ, respectively. A slight increased frequency of having any abnormal laboratory value for elevated [VPA] compared to low/normal [VPA] was observed (p = 0.02; relative risk 1.27), while there was no difference in frequency of having any abnormal lab value for CBZ, nor were there significant differences for the individual lab values. When ALT and AST were plotted against [VPA] and [CBZ], no significant correlation was observed. CONCLUSION Serum [VPA] and [CBZ] are poor indicators of risk for drug-induced end-organ dysfunction. There are likely other, individualized risk factors that explain why certain patients develop adverse effects from these medications.
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Affiliation(s)
- Kenneth A Myers
- Research Institute of the McGill University Health Centre, Canada; Division of Child Neurology, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada; Department of Neurology & Neurosurgery, Montreal Children's Hospital, McGill University, Canada.
| | - Uzziel Tamon
- Research Institute of the McGill University Health Centre, Canada
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Kipervasser S, Elger CE, Korczyn AD, Nass RD, Quesada CM, Neufeld MY. Gait instability in valproate-treated patients: Call to measure ammonia levels. Acta Neurol Scand 2017; 136:401-406. [PMID: 28436001 DOI: 10.1111/ane.12765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2017] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Hyperammonemia induced by valproate (VPA) treatment may lead to several neurological and systemic symptoms as well as to seizure exacerbation. Gait instability and recurrent falls are rarely mentioned as symptoms, especially not as predominant ones. METHODS We report five adult patients with frontal lobe epilepsy (FLE) who were treated with VPA and in whom a primary adverse effect was unstable gait and falls. RESULTS There were four males and one female patients with FLE, 25-42-year-old, three following epilepsy surgery. All of them were treated with antiepileptic drug polytherapy. Gait instability with falls was one of the principal sequelae of the treatment. Patients also exhibited mild encephalopathy (all patients) and flapping tremor (three patients) that developed following the addition of VPA (three patients) and with chronic VPA treatment (two patients). VPA levels were within the reference range. Serum ammonia levels were significantly elevated (291-407 μmole/L, normal 20-85) with normal or slightly elevated liver enzymes. VPA dose reduction or discontinuation led to the return of ammonia levels to normal and resolution of the clinical symptoms, including seizures, which disappeared in two patients and either decreased in frequency or became shorter in duration in the other three. CONCLUSIONS Gait instability due to hyperammonemia and VPA treatment is probably under-recognized in many patients. It can develop when the VPA levels are within the reference range and with normal or slightly elevated liver enzymes.
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Affiliation(s)
- S. Kipervasser
- EEG and Epilepsy Unit; Department of Neurology; Tel-Aviv Sourasky Medical Center; Tel-Aviv Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - C. E. Elger
- Department of Epileptology; University of Bonn; Bonn Germany
| | - A. D. Korczyn
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - R. D. Nass
- Department of Epileptology; University of Bonn; Bonn Germany
| | - C. M. Quesada
- Department of Epileptology; University of Bonn; Bonn Germany
| | - M. Y. Neufeld
- EEG and Epilepsy Unit; Department of Neurology; Tel-Aviv Sourasky Medical Center; Tel-Aviv Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
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14
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Development of a Simple and Rapid Method to Measure Free Fraction of Valproic Acid in Plasma Using Ultrafiltration and Ultra High Performance Liquid Chromatography–Mass Spectroscopy: Application to Therapeutic Drug Monitoring. Ther Drug Monit 2017; 39:575-579. [DOI: 10.1097/ftd.0000000000000431] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Suzuki Y, Tanaka R, Oyama N, Nonoshita K, Hashinaga K, Umeki K, Sato Y, Hiramatsu K, Kadota JI, Itoh H. Sensitive and selective quantification of total and free itraconazole and hydroxyitraconazole in human plasma using ultra-performance liquid chromatography coupled to tandem mass spectrometry. Clin Biochem 2017; 50:1228-1236. [PMID: 28928005 DOI: 10.1016/j.clinbiochem.2017.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/30/2017] [Accepted: 09/13/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Protein-free (unbound) drug concentrations have been reported to be better biomarker of pharmacodynamics compared with total drug concentrations. In this study, we developed and validated an assay for the quantification of total and free itraconazole and hydroxyitraconazole, a main metabolite with antifungal activity, in human plasma using ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS). DESIGN & METHODS Plasma sample was ultra-filtrated for the measurement of free itraconazole and hydroxyitraconazole concentrations. The samples were prepared by solid phase extraction, and then subject to UPLC-MS/MS quantification. RESULTS The assay fulfilled the requirements of the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) guidelines for assay validation, with a lower limit of quantification of 10ng/mL for total itraconazole and hydroxyitraconazole, and 0.1 and 0.5ng/mL for free itraconazole and hydroxyitraconazole, respectively. Recovery rates of total itraconazole and hydroxyitraconazole from whole plasma ranged from 53.3% to 64.0%, and recovery rates of free itraconazole and hydroxyitraconazole from ultrafiltrated plasma ranged from 81.6% to 98.7%. Matrix effect varied between 79.1% and 109.4% for total itraconazole and hydroxyitraconazole, and between 81.3% and 99.7% for free itraconazole and hydroxyitraconazole. The assay was successfully applied to therapeutic drug monitoring of itraconazole in three patients with chronic progressive pulmonary aspergillosis or invasive pulmonary aspergillosis. Plasma free hydroxyitraconazole concentrations were 8.1-, 23.3-, and 51.1-fold higher than plasma free itraconazole concentrations in the three patients. CONCLUSIONS A method for sensitive and selective quantification of plasma total and free itraconazole and hydroxyitraconazole concentrations was developed using UPLC-MS/MS. Free hydroxyitraconazole concentration may be most important in therapeutic drug monitoring of itraconazole.
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Affiliation(s)
- Yosuke Suzuki
- Department of Clinical Pharmacy, Oita University Hospital, Hasama-machi, Oita, Japan.
| | - Ryota Tanaka
- Department of Clinical Pharmacy, Oita University Hospital, Hasama-machi, Oita, Japan
| | - Nobuhiro Oyama
- Department of Clinical Pharmacy, Oita University Hospital, Hasama-machi, Oita, Japan
| | - Ko Nonoshita
- Department of Clinical Pharmacy, Oita University Hospital, Hasama-machi, Oita, Japan
| | - Kazuhiko Hashinaga
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Hasama-machi, Oita, Japan
| | - Kenji Umeki
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Hasama-machi, Oita, Japan
| | - Yuhki Sato
- Department of Clinical Pharmacy, Oita University Hospital, Hasama-machi, Oita, Japan
| | - Kazufumi Hiramatsu
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Hasama-machi, Oita, Japan
| | - Jun-Ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine, Hasama-machi, Oita, Japan
| | - Hiroki Itoh
- Department of Clinical Pharmacy, Oita University Hospital, Hasama-machi, Oita, Japan
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16
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Ando M, Amayasu H, Itai T, Yoshida H. Association between the blood concentrations of ammonia and carnitine/amino acid of schizophrenic patients treated with valproic acid. Biopsychosoc Med 2017; 11:19. [PMID: 28690671 PMCID: PMC5497353 DOI: 10.1186/s13030-017-0101-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 05/29/2017] [Indexed: 01/09/2023] Open
Abstract
Background Administration of valproic acid (VPA) is complicated with approximately 0.9% of patients developing hyperammonemia, but the pathogenesis of this adverse effect remains to be clarified. The aim of the present study was to search for mechanisms associated with VPA-induced hyperammonemia in the light of changes in serum amino acids concentrations associated with the urea cycle of schizophrenic patients. Method Blood samples (10 mL) were obtained from 37 schizophrenic patients receiving VPA for the prevention of violent behaviors in the morning after overnight fast. Blood concentrations of ammonia, VPA, free carnitine, acyl-carnitine, and 40 amino acids including glutamate and citrulline were measured for each patient. Univariate and multivariate regression analyses were performed to identify amino acids or concomitantly administered drugs that were associated with variability in the blood concentrations of ammonia. Result The blood ammonia level was positively correlated with the serum glutamate concentration (r = 0.44, p < 0.01) but negatively correlated with glutamine (r = −0.41, p = 0.01), citrulline (r = −0.42, p = 0.01), and glycine concentrations (r = −0.54, p < 0.01). It was also revealed that the concomitant administration of the mood stabilizers (p = 0.04) risperidone (p = 0.03) and blonanserin (p < 0.01) was positively associated with the elevation of the blood ammonia level. Conclusion We hypothisized that VPA would elevate the blood ammonia level of schizophrenic patients. The observed changes in serum amino acids are compatible with urea cycle dysfunction, possibly due to reduced carbamoyl-phosphate synthase 1 (CPS1) activity. We conclude that VPA should be prudently prescribed to schizophrenic patients, particularly those receiving mood stabilizers or certain antipsychotics.
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Affiliation(s)
- Masazumi Ando
- Department of Drug Metabolism and Disposition, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588 Japan.,Department of Pharmacy, Heartful Kawasaki Hospital, 2-1-3 Shimonoge, Takatsu-ku, Kawasaki, Kanagawa 213-0006 Japan.,Department of Pharmacy, the 2nd Totsuka Kyoritsu Hospital, 579-1 Yoshida-cho, Totsuka-ku, Yokohama, Kanagawa 244-0817 Japan
| | - Hideaki Amayasu
- Division of Psychiatry, Heartful Kawasaki Hospital, 2-1-3 Shimonoge, Takatsu-ku, Kawasaki, Kanagawa 213-0006 Japan
| | - Takahiro Itai
- Division of Psychiatry, Heartful Kawasaki Hospital, 2-1-3 Shimonoge, Takatsu-ku, Kawasaki, Kanagawa 213-0006 Japan
| | - Hisahiro Yoshida
- Department of Drug Metabolism and Disposition, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588 Japan
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17
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Riker RR, Gagnon DJ, Hatton C, May T, Seder DB, Stokem K, Fraser GL. Valproate Protein Binding Is Highly Variable in ICU Patients and Not Predicted by Total Serum Concentrations: A Case Series and Literature Review. Pharmacotherapy 2017; 37:500-508. [PMID: 28173638 DOI: 10.1002/phar.1912] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE The free fraction of valproate (the pharmacologically active moiety, normally 5-10%) may vary significantly in critically ill patients, but this topic is understudied, with only four prior intensive care unit (ICU) case reports. The objective of this study was to evaluate the range of valproate plasma protein binding in ICU patients. DESIGN Observational study of consecutive ICU patients. SETTING Neurocritical and medical critical care services in a nonuniversity academic medical center. PATIENTS Consecutive ICU patients treated with valproate with serum albumin less than 4 g/dl. MEASUREMENTS AND MAIN RESULTS Simultaneous total and free trough serum valproate concentrations were measured as were serum creatinine, blood urea nitrogen, albumin, platelets, and transaminase values. The reference concentration range was 50-125 mg/L (total) and 5-17 mg/L (free). Valproate concentrations were categorized as within reference range, low, or high, and as concordant if both concentrations were in the same category. Data are reported as median (interquartile range). Fifteen patients (nine men) were evaluated. The median age was 63 (34-70) years. The valproate dose was 3 g/day (35 mg/kg/day). No patient had a valproate free fraction of 5-10%; the median was 48%, and the range was 15-89%. Total and free concentrations showed poor correlation (0.43) and were concordant in only two patients (both in the reference range). Free valproate concentration was poorly predicted by an equation correcting for albumin (r = 0.45). Suspected adverse drug events occurred in 10 patients: hyperammonemia in 7 of 12 tested (58%), elevated transaminases in 2 of 15 (13%), and thrombocytopenia in 5 of 15 (33%). CONCLUSIONS Protein binding of valproate was highly inconsistent in this cohort of ICU patients, and total valproate concentrations did not predict free concentrations, even when correcting for albumin. Additional research to define best practice for dosing and monitoring valproate and the relationship between free valproate concentrations and clinical or adverse effects in ICU patients is needed.
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Affiliation(s)
- Richard R Riker
- Critical Care Medicine, Maine Medical Center, Portland, Maine.,Neurocritical Care and Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - David J Gagnon
- Department of Pharmacy, Maine Medical Center, Portland, Maine
| | - Colman Hatton
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Teresa May
- Critical Care Medicine, Maine Medical Center, Portland, Maine.,Neurocritical Care and Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - David B Seder
- Critical Care Medicine, Maine Medical Center, Portland, Maine.,Neurocritical Care and Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Katie Stokem
- Critical Care Medicine, Maine Medical Center, Portland, Maine.,Neurocritical Care and Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Gilles L Fraser
- Critical Care Medicine, Maine Medical Center, Portland, Maine.,Department of Pharmacy, Maine Medical Center, Portland, Maine
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18
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Hatton C, Riker RR, Gagnon DJ, May T, Seder DB, Fraser GL. Free serum valproate concentration more reliable than total concentration in critically ill patients. Resuscitation 2016; 105:e15-6. [PMID: 27266943 DOI: 10.1016/j.resuscitation.2016.05.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/30/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Colman Hatton
- Tufts University School of Medicine, Department of Pharmacy and Critical Care Medicine, Maine Medical Center, Portland, ME 04102, United States
| | - Richard R Riker
- Tufts University School of Medicine, Department of Pharmacy and Critical Care Medicine, Maine Medical Center, Portland, ME 04102, United States.
| | - David J Gagnon
- Tufts University School of Medicine, Department of Pharmacy and Critical Care Medicine, Maine Medical Center, Portland, ME 04102, United States
| | - Teresa May
- Tufts University School of Medicine, Department of Pharmacy and Critical Care Medicine, Maine Medical Center, Portland, ME 04102, United States
| | - David B Seder
- Tufts University School of Medicine, Department of Pharmacy and Critical Care Medicine, Maine Medical Center, Portland, ME 04102, United States
| | - Gilles L Fraser
- Tufts University School of Medicine, Department of Pharmacy and Critical Care Medicine, Maine Medical Center, Portland, ME 04102, United States
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19
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Inoue K, Takahashi T, Yamamoto Y, Suzuki E, Takahashi Y, Imai K, Inoue Y, Hirai K, Tsuji D, Itoh K. Influence of glutamine synthetase gene polymorphisms on the development of hyperammonemia during valproic acid-based therapy. Seizure 2015; 33:76-80. [PMID: 26599579 DOI: 10.1016/j.seizure.2015.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 10/19/2015] [Accepted: 10/30/2015] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Valproic acid (VPA), which is widely used to treat epilepsy, migraine, and bipolar disorder, can causes severe hyperammonemia. However, the mechanism responsible for this adverse effect is not readily apparent. We previously reported that phenytoin coadministration is a strong risk factor for the development of hyperammonemia during VPA-based therapy. In this study, we focused on glutamine synthetase, which catalyzes the synthesis of glutamine from glutamate and ammonia and examined the association with the development of hyperammonemia during VPA-based therapy. METHODS For this study, we recruited 202 Japanese pediatric patients having epilepsy. We selected three polymorphisms (rs10911070, rs10797771, and rs10911021) in the glutamine synthetase (GLUL) gene. Hyperammonemia was defined as a plasma ammonia level exceeding 200 or 170 μg/dL. We evaluated the association between the development of hyperammonemia during VPA-based therapy and the patient characteristics, including three GLUL polymorphisms. RESULTS The number of patients who developed hyperammonemia during VPA-based therapy was 20 (9.9%) using the 200 μg/dL cutoff value and 30 (14.9%) using the 170 μg/dL cutoff value. Using a multivariate logistic regression analysis, the GLUL rs10797771 polymorphism and phenytoin coadministration in the 200 μg/dL cutoff value, and female in addition to two factors in the 170 μg/dL cutoff value, had significant associations with a plasma ammonia level elevation during VPA-based therapy. CONCLUSION Phenytoin coadministration, GLUL rs10797771 polymorphism in the 200μg/dL cutoff value, and female in addition to two factors in the 170μg/dL cutoff value, are independent risk factors for elevated plasma ammonia levels during VPA-based therapy.
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Affiliation(s)
- Kazuyuki Inoue
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Toshiki Takahashi
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Yoshiaki Yamamoto
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Eri Suzuki
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Yukitoshi Takahashi
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Katsumi Imai
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Yushi Inoue
- Department of Clinical Research, National Epilepsy Center, Shizuoka Institute of Epilepsy and Neurological Disorders, 886 Urushiyama, Aoi-ku, Shizuoka City, Shizuoka 420-8688, Japan
| | - Keita Hirai
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Daiki Tsuji
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan
| | - Kunihiko Itoh
- Department of Clinical Pharmacology & Genetics, School of Pharmaceutical Sciences, University of Shizuoka, 52-1 Yada, Suruga-ku, Shizuoka City, Shizuoka 422-8526, Japan.
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20
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Fernández Colomer B, Rekarte García S, García López J, Pérez González C, Montes Granda M, Coto Cotallo G. Valproate-induced hyperammonaemic encephalopathy in a neonate: Treatment with carglumic acid. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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21
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Pegg EJ, Zaman F. Sodium valproate-related hyperammonaemic encephalopathy. BMJ Case Rep 2014; 2014:bcr-2014-203899. [PMID: 24722719 DOI: 10.1136/bcr-2014-203899] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 59-year-old man with a background of poststroke epilepsy, lung cancer, chronic obstructive pulmonary disease and hypertension, presented to the medical assessment unit with acute confusion and altered consciousness. Medications included sodium valproate, aspirin and antihypertensives. On examination he was confused, with his Glasgow Coma Scale fluctuating between 10 and 14. Routine blood tests, thyroid function tests, serum sodium valproate level, urine dip, CT of the brain and cerebrospinal fluid analysis were all normal. EEG revealed changes consistent with an encephalopathic process. Serum ammonia was elevated (75 µg/dL), consistent with a diagnosis of valproate-related hyperammonaemic encephalopathy. Sodium valproate was changed to a different antiepileptic drug and his confusion gradually resolved. Valproate-related hyperammonaemic encephalopathy is a treatable condition which should be considered as a diagnosis in anyone taking sodium valproate with new onset confusion, even in the presence of therapeutic sodium valproate levels and normal liver function tests.
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22
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Schwarz ES, Thoelke M. Altered Mental Status and Hyperammonemia after Overdose of Valproic Acid with Therapeutic Valproic Acid Concentrations. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ijcm.2014.510075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Fernández Colomer B, Rekarte García S, García López JE, Pérez González C, Montes Granda M, Coto Cotallo GD. [Valproate-induced hyperammonemic encephalopathy in a neonate: treatment with carglumic acid]. An Pediatr (Barc) 2013; 81:251-5. [PMID: 24315420 DOI: 10.1016/j.anpedi.2013.09.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 09/19/2013] [Accepted: 09/23/2013] [Indexed: 12/11/2022] Open
Abstract
Valproate-induced hyperammonemic encephalopathy (VHE) is an unusual and serious complication of valproate (VA) treatment. When an early diagnosis is made, it can be reversed with VA withdrawal and early treatment for hyperammonemia. We describe the case of a 20 days old male, who developed a serious VHE after receiving VA for refractory neonatal seizures. The VHE was resolved with VA withdrawal in association with carglumic acid and other measures for hyperammonemia treatment.
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Affiliation(s)
- B Fernández Colomer
- Servicio de Neonatología, AGC de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España.
| | - S Rekarte García
- AGC de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - J E García López
- Servicio de Neonatología, AGC de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - C Pérez González
- AGC de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - M Montes Granda
- AGC de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
| | - G D Coto Cotallo
- Servicio de Neonatología, AGC de Pediatría, Hospital Universitario Central de Asturias, Oviedo, Asturias, España
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24
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Lee YJ, Kim T, Bae SH, Kim YH, Han JH, Yun CH, Kim CY. Levetiracetam compared with valproic acid for the prevention of postoperative seizures after supratentorial tumor surgery: a retrospective chart review. CNS Drugs 2013; 27:753-9. [PMID: 23921717 DOI: 10.1007/s40263-013-0094-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Antiepileptic drugs are commonly given for perioperative prophylaxis after brain tumor surgery, and there has been growing interest in levetiracetam, a second-generation antiepileptic drug. This retrospective study compared the seizure outcomes, side effects and durability of levetiracetam with valproic acid after a craniotomy for supratentorial brain tumors. METHODS Between 2009 and 2012, 282 consecutive patients with a supratentorial brain tumor underwent a craniotomy at Seoul National University Bundang Hospital. Of these patients, 51 (18.1%) and 231 (81.9%) were pre-operatively administered levetiracetam and valproic acid, respectively. The postoperative seizure outcomes (within 1 month after surgery) and the long-term side effects of both drugs were evaluated. RESULTS Of the 51 patients in the levetiracetam group, 4 (7.8%) experienced postoperative seizures after brain tumor surgery, and 15 (6.5%) of the 231 patients in the valproic acid group experienced postoperative seizures (p = 0.728). The long-term complication rate of the valproic acid group (26.8%; 62/231) was significantly higher than that of the levetiracetam group (9.8%; 5/51) [p = 0.010]. In the valproic acid group, 10 hepatotoxicities, 20 hyperammonemias and 10 hematologic abnormalities (6 thrombocytopenias, 3 pancytopenias, and 1 leucopenia) occurred. Moreover, 89 patients (38.5%) in the valproic acid group changed or added other anticonvulsants because of side effects or uncontrolled seizures, whereas only 9 patients (17.6%) in the levetiracetam group changed or added other anticonvulsants (p = 0.005). CONCLUSIONS The postoperative seizure control rates of levetiracetam and valproic acid were not statistically significantly different; however, levetiracetam may be superior to valproic acid in terms of its safety and durability after supratentorial tumor surgery.
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Affiliation(s)
- Young Jin Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Korea
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