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Zhu QM, Singh AK, Chang HER, Konka SA. Hyperammonemic encephalopathy induced by valproic acid. BMJ Case Rep 2024; 17:e257144. [PMID: 38350699 PMCID: PMC10868277 DOI: 10.1136/bcr-2023-257144] [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] [Indexed: 02/15/2024] Open
Abstract
Valproate (VPA) is broad-spectrum antiepileptic drug. Several adverse reactions including hepatotoxicity, fetal risk and pancreatitis are well known and labelled as boxed warnings in the USA. One adverse reaction that is less well known but clinically significant for its severe morbidity is hyperammonemic encephalopathy. We present a case of woman with hyperammonemic encephalopathy following the initiation of VPA therapy; she had a favourable outcome with discontinuation of the drug and prompt treatment with lactulose and L-carnitine.
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Affiliation(s)
- Qiuyu M Zhu
- Internal Medicine, Kaiser Permanente Mid-Atlantic States, Gaithersburg, Maryland, USA
| | - Amitosh K Singh
- Internal Medicine, Kaiser Permanente Mid-Atlantic States, Gaithersburg, Maryland, USA
| | - Huai-En Rachel Chang
- Internal Medicine, Kaiser Permanente Mid-Atlantic States, Gaithersburg, Maryland, USA
| | - Sandeep A Konka
- Hospital Medicine, Mid-Atlantic Permanente Medical Group, Rockville, Maryland, USA
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2
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Sammar A, Tawfik M, Fatima F, Butler A, Aylor-Lee K. Valproate-Induced Hyperammonemic Encephalopathy Causing New-Onset Seizures. Cureus 2023; 15:e47288. [PMID: 38021840 PMCID: PMC10656206 DOI: 10.7759/cureus.47288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Valproate-induced hyperammonemic encephalopathy (VHE) is a rare and severe side effect that can occur with valproic acid (VPA) therapy, despite therapeutic doses and normal serum levels of valproate. The typical signs of this condition include a sudden onset of impaired consciousness, focal neurologic symptoms, and an increase in seizure frequency. The exact cause of VHE is unknown, but it is believed to be related to the accumulation of toxic VPA metabolites and increased levels of ammonia that can cause swelling of the astrocytes and cerebral edema. We present a case of a 19-year-old male patient with a history of bipolar disorder on valproic acid 250 mg daily, admitted to the hospital after a new-onset seizure. He was found to have elevated levels of ammonia in his blood, despite having therapeutic levels of valproate and no liver dysfunction. His symptoms improved with discontinuation of the medication and his ammonia levels decreased. We discuss possible mechanisms and risk factors leading to encephalopathy while on valproate therapy. VHE should be considered a possibility when patients treated with valproate show signs of impaired consciousness.
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Affiliation(s)
- Aleena Sammar
- Internal Medicine, Parkview Medical Center, Pueblo, USA
| | - Mena Tawfik
- Internal Medicine/Gastroenterology, Parkview Medical Center, Pueblo, USA
| | - Fareha Fatima
- Internal Medicine, Parkview Medical Center, Pueblo, USA
| | - Adam Butler
- Internal Medicine, Parkview Medical Center, Pueblo, USA
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Chen Y, Chen J, Zhuang X, Chen X, Zeng J, Wang R, Miao J. Risk factors of elevated blood ammonia level in epilepsy patients treated with lamotrigine. Medicine (Baltimore) 2022; 101:e29780. [PMID: 35776999 PMCID: PMC9239605 DOI: 10.1097/md.0000000000029780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
AbstractThe aim of this study was to explore the effect of lamotrigine (LTG) on blood ammonia level in patients with epilepsy and identify risk factors affecting blood ammonia level. This study included 91 epilepsy patients who were treated with LTG at Department of Neurology, Zhongshan Hospital, Xiamen University from January 2011 to April 2016, and were followed up for 3 years. Blood samples were taken during the interictal state and analyzed for blood LTG and ammonia levels. Total of 46.1% of the samples exceeded the median blood ammonia level, and 2.1% of patients had hyperammonemia. Blood ammonia level was positively correlated with LTG blood concentration. LTG combined with valproic acid therapy, seizure within 1 year, and elevated neutrophils affected blood ammonia level. Blood ammonia level was significantly correlated with plasma concentration of LTG. LTG combined with valproic acid therapy, seizure within 1 year, and elevated neutrophils may be risk factors for elevated blood ammonia level in epilepsy patients treated with LTG.
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Affiliation(s)
- Yiqian Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jingzhen Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xiaorong Zhuang
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Xingyu Chen
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Jianqi Zeng
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
| | - Ru Wang
- Department of Neurology, Weinan Central Hospital, Weinan, China
| | - Jiayin Miao
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, China
- *Correspondence: Jiayin Miao, Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen 361004, China (e-mail )
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Benić MS, Nežić L, Vujić-Aleksić V, Mititelu-Tartau L. Novel Therapies for the Treatment of Drug-Induced Liver Injury: A Systematic Review. Front Pharmacol 2022; 12:785790. [PMID: 35185538 PMCID: PMC8847672 DOI: 10.3389/fphar.2021.785790] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/30/2021] [Indexed: 12/15/2022] Open
Abstract
Many drugs with different mechanisms of action and indications available on the market today are capable of inducing hepatotoxicity. Drug-induced liver injury (DILI) has been a treatment challenge nowadays as it was in the past. We searched Medline (via PubMed), CENTRAL, Science Citation Index Expanded, clinical trials registries and databases of DILI and hepatotoxicity up to 2021 for novel therapies for the management of adult patients with DILI based on the combination of three main search terms: 1) treatment, 2) novel, and 3) drug-induced liver injury. The mechanism of action of novel therapies, the potential of their benefit in clinical settings, and adverse drug reactions related to novel therapies were extracted. Cochrane Risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment approach was involved in the assessment of the certainty of the evidence for primary outcomes of included studies. One thousand three hundred seventy-two articles were identified. Twenty-eight articles were included in the final analysis. Eight randomized controlled trials (RCTs) were detected and for six the available data were sufficient for analysis. In abstract form only we found six studies which were also anaylzed. Investigated agents included: bicyclol, calmangafodipir, cytisin amidophospate, fomepizole, livina-polyherbal preparation, magnesium isoglycyrrhizinate (MgIG), picroliv, plasma exchange, radix Paeoniae Rubra, and S-adenosylmethionine. The primary outcomes of included trials mainly included laboratory markers improvement. Based on the moderate-certainty evidence, more patients treated with MgIG experienced alanine aminotransferase (ALT) normalization compared to placebo. Low-certainty evidence suggests that bicyclol treatment leads to a reduction of ALT levels compared to phosphatidylcholine. For the remaining eight interventions, the certainty of the evidence for primary outcomes was assessed as very low and we are very uncertain in any estimate of effect. More effort should be involved to investigate the novel treatment of DILI. Well-designed RCTs with appropriate sample sizes, comparable groups and precise, not only surrogate outcomes are urgently welcome.
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Affiliation(s)
- Mirjana Stanić Benić
- Department of Clinical Pharmacology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Lana Nežić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Vesna Vujić-Aleksić
- Department of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
- The Republic of Srpska Agency for Certification, Accreditation and Quality Improvement in Health Care, Banja Luka, Bosnia and Herzegovina
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Nguyen P, Chevillard L, Gouda AS, Gourlain H, Labat L, Malissin I, Deye N, Voicu S, Mégarbane B. L-carnitine does not improve valproic acid poisoning management: a cohort study with toxicokinetics and concentration/effect relationships. Ann Intensive Care 2022; 12:7. [PMID: 35092514 PMCID: PMC8800998 DOI: 10.1186/s13613-022-00984-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/14/2022] [Indexed: 12/14/2022] Open
Abstract
Background Valproic acid (VPA) poisoning is responsible for life-threatening neurological and metabolic impairments. Despite only low-level evidence of effectiveness, L-carnitine has been used for years to prevent or reverse VPA-related toxicity. We aimed to evaluate the effects of L-carnitine used to treat acute VPA poisoning on the time-course of plasma VPA concentrations and VPA-related toxicity. We designed a single-center cohort study including all VPA-poisoned patients admitted to the intensive care unit. We studied VPA toxicokinetics using a nonlinear mixed-effects model-based population approach and modeled individual plasma VPA/blood lactate concentration relationships. Then, we evaluated L-carnitine-attributed effects by comparing VPA elimination half-lives and time-courses of blood lactate levels and organ dysfunction [assessed by the Sequential Organ Failure Assessment (SOFA) score] between matched L-carnitine-treated and non-treated patients using a multivariate analysis including a propensity score. Results Sixty-nine VPA-poisoned patients (40F/29 M; age, 41 years [32–47]) (median [25th–75th percentiles]; SOFA score, 4 [1–6]) were included. The presumed VPA ingested dose was 15 g [10–32]. Plasma VPA concentration on admission was 231 mg/L [147–415]. The most common manifestations were coma (70%), hyperlactatemia (3.9 mmol/L [2.7–4.9]) and hyperammonemia (127 mmol/L [92–159]). VPA toxicokinetics well fitted a one-compartment linear model with a mean elimination half-life of 22.9 h (coefficient of variation, 28.1%). Plasma VPA (C)/blood lactate concentration (E) relationships were well described by an exponential growth equation [\documentclass[12pt]{minimal}
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\begin{document}$$E={E}_{0}\times {e}^{k\cdot C}$$\end{document}E=E0×ek·C; with baseline E0 = 1.3 mmol/L (43.9%) and rate constant of the effect, k = 0.003 L/mg (59.5%)]. Based on a multivariate analysis, peak blood lactate concentration was the only factor independently associated with L-carnitine administration (odds ratio, 1.9, 95% confidence interval, 1.2–2.8; P = 0.004). We found no significant contribution of L-carnitine to enhancing VPA elimination, accelerating blood lactate level normalization and/or preventing organ dysfunction. Conclusions VPA poisoning results in severe toxicity. While L-carnitine does not contribute to enhancing VPA clearance, its impact on accelerating blood lactate level normalization and/or preventing organ dysfunction remains uncertain. Investigating VPA toxicokinetics and concentration/effect relationships may help understanding how to improve VPA-poisoned patient management. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00984-z.
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Nicholson C, Fowler M, Mullen C, Cunningham B. Evaluation of levocarnitine, lactulose, and combination therapy for the treatment of valproic acid-induced hyperammonemia in critically ill patients. Epilepsy Res 2021; 178:106806. [PMID: 34763268 DOI: 10.1016/j.eplepsyres.2021.106806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 10/05/2021] [Accepted: 10/29/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Critically ill patients treated with valproic acid are at risk for hyperammonemic encephalopathy. Both levocarnitine and lactulose, either alone or in combination, have been used for the treatment of hyperammonemia associated with valproic acid, however they have not been directly compared in the literature. The aim of this study was to compare the effect of levocarnitine, lactulose, and combination therapy for the treatment of valproic acid-induced hyperammonemia in critically ill patients. METHODS This was a retrospective, system-wide, cohort study of critically ill patients who received valproic acid and levocarnitine, lactulose, or combination therapy from January 1, 2012 to October 31, 2019. The primary outcome of the study was the change in ammonia level from baseline to the lowest point within the first 48 h of treatment. Secondary outcomes included the change in ammonia levels within the first 7 days, the incidence of a clinically significant reduction, ICU length of stay, hospital length of stay, and hospital mortality. RESULTS A total of 371 charts were reviewed and 114 patients (levocarnitine [n = 15], lactulose [n = 72], and combination [n = 27]) were included. No difference in the primary outcome was observed (levocarnitine [11umol/L] vs. lactulose [20 umol/L] vs. combination [23 umol/L], p = 0.605). The incidence of a clinically significant reduction in ammonia levels at 48 h did not differ between groups, nor did mortality. CONCLUSION In critically ill patients with valproic acid-induced hyperammonemia, there was no significant difference in the reduction in ammonia levels in the first 48 h of treatment between levocarnitine, lactulose, and combination therapy.
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Affiliation(s)
- Carli Nicholson
- Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, United States; Licking Memorial Health System, 1320 West Main Street, Newark, OH 43055, United States.
| | - Melissa Fowler
- Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, United States.
| | - Chanda Mullen
- Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, United States.
| | - Brittany Cunningham
- Cleveland Clinic Akron General, 1 Akron General Avenue, Akron, OH 44307, United States.
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Talmasov D, Kelly SM, Lewis A, Taylor AD, Gurin L. Altered Mental Status in Patients Hospitalized with COVID-19: Perspectives from Neurologic and Psychiatric Consultants. Harv Rev Psychiatry 2021; 29:422-430. [PMID: 33965986 PMCID: PMC8575114 DOI: 10.1097/hrp.0000000000000298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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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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McMorris T, Chu A, Vu L, Bernardini A. Hyperammonemia in patients receiving valproic acid in the hospital setting: A retrospective review. Ment Health Clin 2021; 11:243-247. [PMID: 34316420 PMCID: PMC8287865 DOI: 10.9740/mhc.2021.07.243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/07/2021] [Indexed: 01/09/2023] Open
Abstract
Introduction Valproic acid (VPA) is widely used for the treatment of epilepsy, migraine, and a variety of psychiatric conditions. The reported incidences of hyperammonemia induced by VPA use is variable. The purpose of this study is to evaluate the incidence of VPA-induced hyperammonemia in the general adult inpatient population. Methods Adult patients who received at least 1 dose of VPA and derivatives between June 1, 2017 to December 31, 2017 were included. Patients were excluded if they did not have VPA administered during their inpatient stay or if they had elevated ammonia levels (>33 μmol/L) prior to initiation of VPA. Patients with a confirmed diagnosis of liver cirrhosis were also excluded. The primary endpoint was the incidence of hyperammonemia. Secondary outcomes included symptoms of hyperammonemia, diagnosis of VPA-induced hyperammonemia, and treatment of VPA-induced hyperammonemia. Results A total of 162 patients were included in this study. A total of 33 (20.4%) patients were identified as having the primary outcome of hyperammonemia; 26 (16.0%) patients had symptoms of hyperammonemia, and 13 (8.0%) patients were diagnosed with VPA-induced hyperammonemia. Treatment modalities included administration of lactulose, levocarnitine, discontinuing VPA, or decreasing the VPA dose. Discussion The administration of VPA in the general adult inpatient population resulted in a 20.4% incidence of hyperammonemia, with a lower rate of diagnosed VPA-induced hyperammonemia. Clinicians should be encouraged to obtain ammonia levels in patients receiving VPA if symptoms of altered mental status or encephalopathy develop.
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Affiliation(s)
- Tressa McMorris
- Assistant Professor of Pharmacy Practice, College of Pharmacy, Roseman University of Health Sciences, South Jordan, Utah.,Pharmacist, CVS Pharmacy, Tuscon, Arizona; previously: Roseman University of Health Sciences College of Pharmacy.,Pharmacist, Raley's Pharmacy, Reno, Nevada; previously: Roseman University of Health Sciences College of Pharmacy
| | - Angela Chu
- Assistant Professor of Pharmacy Practice, College of Pharmacy, Roseman University of Health Sciences, South Jordan, Utah
| | - Lynn Vu
- Pharmacist, CVS Pharmacy, Tuscon, Arizona; previously: Roseman University of Health Sciences College of Pharmacy
| | - Amanda Bernardini
- Pharmacist, Raley's Pharmacy, Reno, Nevada; previously: Roseman University of Health Sciences College of Pharmacy
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Valproic acid-induced encephalopathy: A review of clinical features, risk factors, diagnosis, and treatment. Epilepsy Behav 2021; 120:107967. [PMID: 34004407 DOI: 10.1016/j.yebeh.2021.107967] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 11/23/2022]
Abstract
Valproic acid (VPA), or sodium valproate, is a commonly used medication for seizure disorders, migraines, and mental illness. Although VPA is relatively safe, it still has several adverse effects; among these, VPA-induced encephalopathy is the most serious. Valproic acid-induced encephalopathy mainly manifests as acute or subacute encephalopathy and has been associated with hyperammonemia, L-carnitine deficiency, and urea cycle enzyme dysfunction. Delayed identification of VPA-induced encephalopathy could be potentially fatal. Here, we perform an extensive review of relevant literature pertaining to VPA-induced encephalopathy, including its epidemiology, clinical features, possible pathophysiology, risk factors, diagnosis, and treatment.
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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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12
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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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13
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Celecoxib Decrease Seizures Susceptibility in a Rat Model of Inflammation by Inhibiting HMGB1 Translocation. Pharmaceuticals (Basel) 2021; 14:ph14040380. [PMID: 33921725 PMCID: PMC8073600 DOI: 10.3390/ph14040380] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 01/09/2023] Open
Abstract
The risk of developing epilepsy is strongly linked to peripheral inflammatory disorders in humans. High-mobility group box protein 1 (HMGB1) has the most focus for being a suspect in this scenario. The current study aimed to detect the celecoxib effect, an anti-inflammatory drug, on decreasing seizure susceptibility and organ damage in lipopolysaccharides (LPS)/pilocarpine (PILO) pretreated Wistar rats. Rats were divided into 6 groups (8 each): group 1 (control), group 2 (PILO), group 3 (PILO+LPS), group 4 (PILO+LPS+(VPA) Valproic acid), group 5 (PILO+LPS+Celecoxib), and group 6 (PILO+LPS+VPA+Celecoxib). LPS was used to induce sepsis and PILO to induce seizures. Oxidative stress markers, pro-inflammatory cytokines, and HMGB1 levels in serum and brain homogenate were evaluated. Histopathological studies were conducted on the hippocampus, liver, lung, and kidney. Treatment with celecoxib either alone or in combination with VPA significantly reduced Racine score and delays latency to generalized tonic-clonic seizures onset with a significant decrease in hippocampal levels of pro-inflammatory cytokines, oxidative stress markers, and increase in reduced glutathione. In addition, celecoxib treatment either alone or in combination with VPA suppressed HMGB1translocation into peripheral circulation more than treatment with VPA alone. Furthermore, hippocampus, liver, lung, and kidney histopathological changes were improved in contrast to other epileptic groups. Celecoxib either alone or combined with VPA has antiepileptic and multiorgan protective effects on acute seizures and inflammatory models induced by PILO with LPS. It decreased histopathological findings, oxidative, and inflammatory effects induced by VPA and LPS. This might be due to its anti-oxidative, anti-inflammatory and anti-HMGB1 mediated effects.
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Der-Nigoghossian C, Tesoro EP, Strein M, Brophy GM. Principles of Pharmacotherapy of Seizures and Status Epilepticus. Semin Neurol 2020; 40:681-695. [PMID: 33176370 DOI: 10.1055/s-0040-1718721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.
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Affiliation(s)
- Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Eljim P Tesoro
- Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Micheal Strein
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
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Bennett J, Gilkes C, Klassen K, Kerr M, Khan A. Two Siblings With Valproate-Related Hyperammonemia and Novel Mutations in Glutamine Synthetase (GLUL) Treated With Carglumic Acid. Child Neurol Open 2020; 7:2329048X20967880. [PMID: 33150193 PMCID: PMC7585879 DOI: 10.1177/2329048x20967880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This case report describes 2 siblings with myoclonic epilepsy who had novel mutations in the glutamine synthetase (GLUL) gene: c.316C>T, p.(Arg106*) and c.42G>C, p.(Lys14Asn). Valproic acid improved seizure control, but was associated with hyperammonemic encephalopathy. Addition of carglumic acid reduced ammonia levels but drug coverage was declined. We therefore designed a protocol to measure the reduction in plasma ammonia in response to carglumic acid therapy. After the first dose of carglumic acid, Patient 1 showed a reduction in plasma ammonia levels within 3 hours, from 114 umol/L to 68 umol/L (reference 12-47 umol/L), and Patient 2 from 108 umol/L to 80 umol/L, which was sustained over a 2 week period. Overall, there was a strong negative correlation between plasma ammonia levels and carglumic acid levels (r = -0.86, p = 0.0013), and recurrence of hyperammonemic encephalopathy was not observed while the patients were taking carglumic acid.
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Affiliation(s)
- Jennifer Bennett
- Department of Medical Genetics and Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christy Gilkes
- Department of Medical Genetics and Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karin Klassen
- Department of Medical Genetics and Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marina Kerr
- Department of Medical Genetics and Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aneal Khan
- Department of Medical Genetics and Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Henkel S, Vetterly C, Squires R, McKiernan P, Squires J. Pharmacological management of portal hypertension and its complications in children: lessons from adults and opportunities for the future. Expert Opin Pharmacother 2020; 22:291-304. [PMID: 33074032 DOI: 10.1080/14656566.2020.1825685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Portal hypertension (PHT) and its complications in children are thought to be distinct from adult PHT in several areas, including the underlying bio-physiology of a child in which PHT develops, but also because of the pediatric-specific etiologies that drive disease progression. And yet pharmacologic approaches to PHT in children are mainly based on adult data, modified for pediatric practice. This reality has been driven by a lack of data specific to children. AREAS COVERED The authors discuss current therapeutic approaches to PHT in children, including management of acute gastrointestinal variceal bleed, pharmacotherapy in prophylaxis, and established and emerging therapies to combat systemic co-morbidities that result from PHT. The few areas where pediatric-specific data exist are highlighted and the many gaps in knowledge that remain unresolved are underscored. EXPERT OPINION Despite decades of experience, optimal management of pediatric PHT remains undefined. In large part, this can be directly linked to a lack of basic understanding related to the unique pathophysiology and natural history that defines PHT in children. As a result, meaningful research into the utility and effectiveness of pharmacotherapy in children with PHT remains in its infancy. Large, multi-center, prospective studies will be needed to begin to establish an infrastructure on which a pediatric-specific research agenda can be built.
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Affiliation(s)
- Sarah Henkel
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - Carol Vetterly
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Pharmacy , Pittsburgh, PA
| | - Robert Squires
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - Patrick McKiernan
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
| | - James Squires
- Division of Gastroenterology and Hepatology, UPMC Children's Hospital of Pittsburgh , Pittsburgh, PA
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Orsolini L, Pompili S, Volpe U. The ‘collateral side’ of mood stabilizers: safety and evidence-based strategies for managing side effects. Expert Opin Drug Saf 2020; 19:1461-1495. [DOI: 10.1080/14740338.2020.1820984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Laura Orsolini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Simone Pompili
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
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Zhao T, Chen S, Wang B, Cai D. L-Carnitine Reduces Myocardial Oxidative Stress and Alleviates Myocardial Ischemia-Reperfusion Injury by Activating Nuclear Transcription-Related Factor 2 (Nrf2)/Heme Oxygenase-1 (HO-1) Signaling Pathway. Med Sci Monit 2020; 26:e923251. [PMID: 32452468 PMCID: PMC7271686 DOI: 10.12659/msm.923251] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Myocardial ischemia-reperfusion injury (IRI) is an important injury mechanism of myocardial infarction. The purpose of this study was to explore the effects of L-carnitine (LC) on myocardial IRI and its mechanism. Material/Methods The IRI model was made by ligating the left anterior descending coronary artery. Then, we injected LC intraperitoneally into the rats of the experimental group to assess the effect of LC on IRI rats by use of serum markers, Western blot, and qRT-PCR. H9c2 cells were cultured and then treated with hypoxia-reoxygenation. The effect of LC on oxidative stress, apoptosis, and nuclear transcription-related factor 2/heme oxygenase-1 (Nrf2/HO-1) signaling pathway of H9c2 cells were detected by Western blot, RT-PCR, and flow cytometry. Results LC significantly reduced malondialdehyde (MDA), creatine kinase (CK), and lactate dehydrogenase (LDH) levels in rat myocardial tissue and increased superoxide dismutase (SOD) expression. LC also increased the expression of SOD1/2 and Bcl-2 in rat myocardial tissue and H9c2 cells and decreased the expression of caspase3/8 and Bax. In addition, LC increased the expression of Nrf2/HO-1 signaling pathway-related molecules in H9c2 cells and increased the activity of the Nrf2/HO-1 signaling pathway. Moreover, inhibition of the Nrf2/HO-1 signaling pathway attenuated the protective effect of LC on H9c2 cells. Conclusions LC can activate the Nrf2/HO-1 signaling pathway and reduce oxidative stress and apoptosis in cardiomyocytes, thereby reducing myocardial IRI.
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Affiliation(s)
- Tana Zhao
- Second Department of Pediatric, First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China (mainland)
| | - Shangjun Chen
- Department of Geratology, First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China (mainland)
| | - Bingxin Wang
- Department of Orthopedics, First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China (mainland)
| | - Dongliang Cai
- Department of Geratology, First Affiliated Hospital of Jiamusi University, Jiamusi, Heilongjiang, China (mainland)
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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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Shah S, Wang R, Vieux U. Valproate-induced hyperammonemic encephalopathy: a case report. J Med Case Rep 2020; 14:19. [PMID: 31980035 PMCID: PMC6982381 DOI: 10.1186/s13256-020-2343-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/02/2020] [Indexed: 01/17/2023] Open
Abstract
Background Hyperammonemic encephalopathy is a rare and serious adverse reaction to valproate. Although there is documentation of this reaction in previous reports, very little is still known about the exact mechanism of action. In addition, there are no established guidelines of the next steps needed when a patient does develop this reaction. Therefore, this case report highlights what is known as well as the areas of research still needed. Case presentation Our patient was a 57-year-old Caucasian woman with a medical history of bipolar I disorder, opioid use disorder, benzodiazepine use disorder, and Crohn’s disease who was admitted to our behavioral health unit for suicidal ideation. She had been experiencing multiple panic attacks for 2.5 weeks along with poor sleep, increased energy, excessive spending, and feelings of helplessness. The patient was diagnosed with bipolar I disorder, manic episode without psychotic features, and benzodiazepine use disorder. She was started on valproic acid, citalopram, propranolol, and quetiapine. By day 6 of her hospitalization, the patient had altered mental status, varying levels of consciousness, confusion, and ataxic gait. Her ammonia levels were found to be elevated. All of her medications were discontinued, and lactulose was initiated. She returned to her baseline mentation within 48 hours and was discharged with lithium and quetiapine. The treatment team concluded that this patient had valproate-induced hyperammonemic encephalopathy, a rare but reversible reaction to valproate. Conclusion Fortunately, rapid identification of this rare condition led to a favorable outcome in our patient. This case report illustrates the course of treatment in a patient who experienced this reaction and reviews current knowledge as well as areas of needed research in regard to valproate-induced hyperammonemic encephalopathy.
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Affiliation(s)
- Suhal Shah
- Orange Regional Medical Center, Middletown, NY, USA.
| | - Richard Wang
- Orange Regional Medical Center, Middletown, NY, USA
| | - Ulrick Vieux
- Orange Regional Medical Center, Middletown, NY, USA
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Levocarnitine for the Treatment of Valproic Acid-Induced Hyperammonemic Encephalopathy in Children: The Experience of a Large, Tertiary Care Pediatric Hospital and a Poison Center. Am J Ther 2019; 26:e344-e349. [PMID: 29232283 DOI: 10.1097/mjt.0000000000000706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although rare, symptomatic hyperammonemia is sometimes associated with valproic acid (VPA), especially in children. L-carnitine (levocarnitine), sometimes classified as an essential amino acid, is vital to mitochondrial utilization of fatty acids and can be helpful in treating this condition. The data supporting this, however, are limited. STUDY QUESTION The aim of the study was to illustrate the role of L-carnitine in the treatment of patients with VPA-induced hyperammonemic encephalopathy (VPE) at 2 different institutions. METHODS Medical records of affected patients were reviewed; data collected included exposure history, clinical manifestations, physical examination, and laboratory values. RESULTS There were 13 cases of VPE; 12 were associated with therapeutic dosing and 1 with an overdose. The maximum ammonia concentration was 557 μmol/L, and blood concentrations of VPA ranged from 68 to 600 μg/mL (therapeutic range 50-100 μg/mL). In all cases, liver function tests were normal or only mildly increased. In this study, 12 patients received a daily dose of L-carnitine 100 mg/kg, and 1 received 200 mg/kg (intravenous infusion over 30 minutes) divided every 8 hours until clinical improvement. All patients made a full recovery. None developed adverse effects or reactions, and no cases of toxicity were reported. CONCLUSION Our series suggests that intravenous L-carnitine, at a dose of 100 mg·kg·d in 3 divided doses each over 30 minutes until clinical improvement occurs, is a safe and effective treatment in the management of VPE in children.
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Bassett JT, Rodriguez B, Mulligan L, Fontana RJ. Acute liver failure in a military recruit treated with valproic acid and harboring a previously unrecognized POLG-1 mutation. Epilepsy Behav Rep 2019; 12:100342. [PMID: 31799506 PMCID: PMC6883298 DOI: 10.1016/j.ebr.2019.100342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 10/13/2019] [Accepted: 10/18/2019] [Indexed: 02/07/2023] Open
Abstract
Patients with mutations in the POLG-1 gene often are afflicted with drug-resistant seizures at an early age and have an increased risk of valproic acid-induced acute liver failure. Severe valproate hepatotoxicity most commonly arises in children within the first 3 months of treatment with an overall estimated incidence of 1 in 40,000 treated patients. Due to high mortality rates among transplanted children, many experts consider valproic acid-induced acute liver failure in patients with mitochondrial disorders to be a contraindication to liver transplant. We report the successful use of liver transplantation in a young man with valproic acid-associated acute liver failure harboring a previously unrecognized POLG-1 mutation. Patients with mutations in the POLG-1 gene often have an increased risk of valproic acid (VPA) induced acute liver failure. Severe valproate hepatotoxicity most commonly arises in children within the first 3 months of treatment. Many experts consider VPA induced acute liver failure with mitochondrial disorders a contraindication to liver transplant. We report a case of acute liver failure associated with VPA treated successfully with a liver transplant
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Affiliation(s)
| | | | - Lisa Mulligan
- Naval Medical Center Portsmouth, Portsmouth, VA, United States of America
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Effects of levocarnitine on cardiac function, urinary albumin, hs-CRP, BNP, and troponin in patients with coronary heart disease and heart failure. Hellenic J Cardiol 2018; 61:99-102. [PMID: 30195728 DOI: 10.1016/j.hjc.2018.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate the effects of levocarnitine on cardiac function, urinary albumin (ALB), high-sensitivity C-reactive protein (hs-CRP), brain natriuretic peptide (BNP), and troponin in patients with coronary heart disease (CHD) and heart failure (HF). METHODS In total, 246 patients with CHD-caused HF were selected and randomly divided into Group A and Group B. A fully automatic biochemical analyzer was used to measure the levels of ALB, hs-CRP, BNP, and troponin in both groups of patients, and the expression levels of LVDD and LVEF were detected by cardiac color ultrasonography. Patients in Group B were intravenously injected with 3.0 g of levocarnitine, once per day. After 14 days, changes in levels of ALB, hs-CRP, BNP, troponin, LVDD, and LVEF in Group A patients were detected. RESULTS The effective cure rates of patients in both groups were 65.8% and 81.3%, respectively, and there was a statistically significant difference between the two groups (p < 0.05). After administration of levocarnitine, all indicators showed decreasing trends, but the LVEF level increased. Among them, patients treated with levocarnitine showed the most evident decrease in LVEF. Decrease in BNP was the largest (p < 0.05). Additionally, there was no statistical difference in incidence rate between the two groups (5.8% vs. 2.5%, p = 0.222). CONCLUSION Levocarnitine can effectively improve ALB, hs-CRP, BNP, troponin, and LVDD levels to improve cardiac function rating and thus improve cardiac function.
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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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Akimova D, Wlodarczyk BJ, Lin Y, Ross ME, Finnell RH, Chen Q, Gross SS. Metabolite profiling of whole murine embryos reveals metabolic perturbations associated with maternal valproate-induced neural tube closure defects. Birth Defects Res 2018; 109:106-119. [PMID: 27860192 DOI: 10.1002/bdra.23583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Valproic acid (VPA) is prescribed therapeutically for multiple conditions, including epilepsy. When taken during pregnancy, VPA is teratogenic, increasing the risk of several birth and developmental defects including neural tube defects (NTDs). The mechanism by which VPA causes NTDs remains controversial and how VPA interacts with folic acid (FA), a vitamin commonly recommended for the prevention of NTDs, remains uncertain. We sought to address both questions by applying untargeted metabolite profiling analysis to neural tube closure (NTC) stage mouse embryos. METHODS Pregnant SWV dams on either a 2 ppm or 10 ppm FA supplemented diet were injected with a single dose of VPA on gestational day E8.5. On day E9.5, the mouse embryos were collected and evaluated for NTC status. Liquid chromatography coupled to mass spectrometry metabolomics analysis was performed to compare metabolite profiles of NTD-affected VPA-exposed whole mouse embryos with profiles from embryos that underwent normal NTC from control dams. RESULTS NTDs were observed in all embryos from VPA-treated dams and penetrance was not diminished by dietary FA supplementation. The most profound metabolic perturbations were found in the 10ppm FA VPA-exposed mouse embryos, compared with the other three treatment groups. Affected metabolites included amino acids, nucleobases and related phosphorylated nucleotides, lipids, and carnitines. CONCLUSION Maternal VPA treatment markedly perturbed purine and pyrimidine metabolism in E9.5 embryos. In combination with a high FA diet, VPA treatment resulted in gross metabolic changes, likely caused by a multiplicity of mechanisms, including an apparent disruption of mitochondrial beta-oxidation. Birth Defects Research 109:106-119, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Darya Akimova
- Department of Pharmacology, Weill Cornell Medical College, New York, New York.,Program in Pharmacology, Weill Cornell Medical College, New York, New York
| | - Bogdan J Wlodarczyk
- Department of Nutritional Sciences, Dell Pediatric Research Institute, The University of Texas at Austin, Austin, Texas
| | - Ying Lin
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
| | - M Elizabeth Ross
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
| | - Richard H Finnell
- Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
| | - Qiuying Chen
- Department of Pharmacology, Weill Cornell Medical College, New York, New York
| | - Steven S Gross
- Department of Pharmacology, Weill Cornell Medical College, New York, New York
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Khobrani MA, Dudley SW, Huckleberry YC, Kopp BJ, Biggs AD, French RNE, Shirazi FM, Erstad BL. Intentional use of carbapenem antibiotics for valproic acid toxicity: A case report. J Clin Pharm Ther 2018; 43:723-725. [DOI: 10.1111/jcpt.12705] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 04/10/2018] [Indexed: 11/30/2022]
Affiliation(s)
- M. A. Khobrani
- Department of Pharmacy Practice & ScienceCollege of PharmacyThe University of Arizona Tucson AZ USA
- Department of Pharmacy Practice & ScienceCollege of PharmacyKing Khalid University Abha Saudi Arabia
| | - S. W. Dudley
- Arizona Poison & Drug Information CenterCollege of PharmacyThe University of Arizona Tucson AZ USA
| | - Y. C. Huckleberry
- Department of Pharmacy ServicesBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - B. J. Kopp
- Department of Pharmacy ServicesBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - A. D. Biggs
- Department of Pharmacy ServicesFroedtert Hospital Milwaukee WI USA
| | - R. N. E. French
- Arizona Poison & Drug Information CenterCollege of PharmacyThe University of Arizona Tucson AZ USA
- Department of Emergency MedicineBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - F. M. Shirazi
- Arizona Poison & Drug Information CenterCollege of PharmacyThe University of Arizona Tucson AZ USA
- Department of Emergency MedicineBanner University Medical Center ‐ Tucson Tucson AZ USA
| | - B. L. Erstad
- Department of Pharmacy Practice & ScienceCollege of PharmacyThe University of Arizona Tucson AZ USA
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Maines E, Piccoli G, Pascarella A, Colucci F, Burlina AB. Inherited hyperammonemias: a Contemporary view on pathogenesis and diagnosis. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2018.1409108] [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: 10/18/2022]
Affiliation(s)
- Evelina Maines
- Pediatric Unit, Provincial Centre for Rare Diseases, Department of Women’s and Children’s Health, Azienda Provinciale per i Servizi Sanitari, Trento, Italy
| | - Giovanni Piccoli
- CIBIO - Centre for integrative biology, Università degli Studi di Trento, Italy & Dulbecco Telethon Institute, Trento, Italy
| | - Antonia Pascarella
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Francesca Colucci
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
| | - Alberto B. Burlina
- Division of Inherited Metabolic Diseases, Reference Centre Expanded Newborn Screening, Department of Women’s and Children’s Health, University Hospital, Padova, Italy
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Muñiz AE. Valproic Acid Overdose Review of a Case With Electrocardiographic Changes. J Emerg Med 2017; 53:333-338. [PMID: 28992869 DOI: 10.1016/j.jemermed.2016.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 07/14/2016] [Accepted: 07/19/2016] [Indexed: 10/18/2022]
Abstract
BACKGROUND Valproic acid (VPA) is increasingly used to treat a variety of medical disorders, such as seizures, psychiatric disorders, and headaches. Therefore, accidental and intentional ingestions with valproic acid are increasing. OBJECTIVES A case is presented in an adolescent with ischemic electrocardiographic changes after an acute overdose with VPA. DISCUSSION Major features of a valproic acid overdose include respiratory depression, progressive coma, hepatotoxicity, thrombocytopenia, and hemodynamic instability. Electrocardiographic abnormalities usually consist of tachycardia and nonspecific changes. Supportive care is indicated in most overdoses and involves the monitoring and correction of electrolyte abnormalities, coagulopathies, and acid-base imbalances. Treatment may include activated charcoal, naloxone, l-carnitine, and extracorporeal detoxification. CONCLUSIONS Valproic acid overdose is a relatively rare and electrocardiographic changes usually consist of tachycardia and nonspecific changes, but ischemic changes may occur and usually transient and require only recognition.
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Cattaneo CI, Ressico F, Valsesia R, D’Innella P, Ballabio M, Fornaro M. Sudden valproate-induced hyperammonemia managed with L-carnitine in a medically healthy bipolar patient: Essential review of the literature and case report. Medicine (Baltimore) 2017; 96:e8117. [PMID: 28953637 PMCID: PMC5626280 DOI: 10.1097/md.0000000000008117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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 Valproic Acid is a commonly used psychiatric drug primarily used as a mood stabilizer. Mild hyperammonemia is a Valproic Acid common adverse effect. This report presents an example of treated hyperammonemia on Valproic acid therapy managed with L-carnitine administration in BD patients characterized by sudden vulnerability. PATIENT CONCERNS We report the case of a 29-year-old man suffering from bipolar disorder (BD) and substance use disorder who exhibited sudden altered mental status upon admittance to the inpatient unit. The patient was started on Valproic acid with no improvement. DIAGNOSES The patient had remarkably high ammonia levels (594 μg/dL) without hepatic insufficiency, likely due to his valproate treatment. INTERVENTIONS The patient was administered lactulose, intravenous hydration, and i.v. levocarnitine supplementation 4.5 g/day. OUTCOMES The administration leads to reduction of ammonia levels to 99 μg/dL within 12 hours upon initiation of carnitine therapy and progressive restore of his mental status within 24 hours. LESSONS Resolution of hyperammonemia caused by Valproic acid therapy may be enhanced with the administration of L-carnitine. An interesting aspect of this case was how rapidly the patient responded to the carnitine therapy.
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Affiliation(s)
| | | | - Roberta Valsesia
- Asl Novara, Department of Mental Health – Inpatient Unit- Borgomanero, Novara
| | - Pierluigi D’Innella
- Asl Novara, Department of Mental Health – Inpatient Unit- Borgomanero, Novara
| | | | - Michele Fornaro
- Department of Neuroscience, University School of Naples “Federico II”, Naples, Italy
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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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Schrettl V, Felgenhauer N, Rabe C, Fernando M, Eyer F. L-Arginine in the treatment of valproate overdose - five clinical cases. Clin Toxicol (Phila) 2017; 55:260-266. [PMID: 28152637 DOI: 10.1080/15563650.2017.1284333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Valproic acid and its metabolites - particularly valproyl-CoA - are inhibitors of the enzyme N-acetylglutamate synthetase. The amino acid l-arginine can stimulate N-acetylglutamate synthetase activity and could be potentially used therapeutically to correct hyperammonemia caused by valproate therapy or overdose. Severely valproic-acid-poisoned patients are usually treated with l-carnitine or hemodialysis in order to decrease hyperammonemia. We herein report of five cases, in which l-arginine was administered. METHODS Observational study on five cases. Patients with hyperammonemia (i.e., ammonia 80 > μg/dL) and symptoms consistent with valproate overdose (i.e., drowsiness, coma) were selected for treatment with l-arginine. Data was collected retrospectively. RESULTS l-Arginine decreased ammonia levels in a close temporal relation (case I ammonia in EDTA-plasma [μg/dL] decreased from 381 to 39; case II from 281 to 50; case III from 669 to 74; case IV from 447 to 56; case V from 202 to 60). In cases I and II, hemodialysis was performed and l-carnitine was given before the administration of l-arginine. In case III, hemodialysis was performed after the administration of l-arginine was already started. In cases IV and V, treatment with l-arginine was the sole measure to decrease ammonia levels in plasma. CONCLUSION The results suggest that l-arginine may be beneficial in selected cases of valproate overdose complicated by hyperammonemia. l-Arginine could extend our conventional treatment options for valproic acid overdose.
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Affiliation(s)
- Verena Schrettl
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Norbert Felgenhauer
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Christian Rabe
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
| | - Malkanthi Fernando
- b Laboratory of Clinical Biochemistry and Metabolism , Center for Pediatrics and Adolescent Medicine Freiburg, University Freiburg , Freiburg , Germany
| | - Florian Eyer
- a Department of Clinical Toxicology , Klinikum Rechts der Isar, Technical University of Munich (TUM) , Munich , Germany
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Bailly P, Genestet S, Prat G, Tonnelier JM. Myoclonies post-arrêt cardiaque. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1163-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Levocarnitine induced seizures in patients on valproic acid: A negative systematic review. Seizure 2016; 36:36-39. [PMID: 26889779 DOI: 10.1016/j.seizure.2016.01.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 01/29/2016] [Accepted: 01/30/2016] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE Warnings of L-carnitine induced seizures are recorded on product monographs and pharmacy databases, without any referenced literature. This medication can potentially improve the hospital course in those patients with valproic acid (VPA) induced hyperammonemic encephalopathy, but may be withheld because of this warning. The goal was to perform an extensive systematic review of the literature to document the incidence of levocarnitine (L-carnitine) induced seizures in those patients on VPA therapy. METHODS Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to June 2015), and reference lists of relevant articles were searched. The strength of evidence was to be adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS We failed to identify a single study implicating L-carnitine supplementation leading to seizures in any patient on VPA therapy. This contradicts all quoted, but unsubstantiated, concerns on product monographs and pharmacy databases related to seizure induction/propagation with L-carnitine supplementation. CONCLUSION There is no literature available to support claims of L-carnitine induced seizures during supplementation in patients on VPA therapy for seizures. This contradicts quoted, but not referenced, concerns on the product monograph. In patients suffering from hypocarnitinemia or hyperammonemic encephalopathy while on VPA, L-carnitine supplementation can be considered knowing there is no data to support seizure propagation or induction with administration of this supplement.
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Wang SX, Tan L, Wang J, Zhong JQ. Effect of levocarnitine on TIMP-1, ICAM-1 expression of rats with coronary heart disease and its myocardial protection effect. ASIAN PAC J TROP MED 2016; 9:269-73. [PMID: 26972400 DOI: 10.1016/j.apjtm.2016.01.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 12/20/2015] [Accepted: 12/30/2015] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To study the effect of levocarnitine (L-CN) on tissue inhibitor of metalloproteinase-1 (TIMP-1) and intercellular adhesion molecule-1 (ICAM-1) expression of rats with coronary heart disease and evaluate the protective effect of L-CN on myocardial cells. METHODS High-fat diet feeding and intraperitoneal injection of pituitrin was performed on rats in model group and CHD Model of rats was built. Rats with successful model-building were selected and divided into L-CN group and Ctrl group randomly. Rats in L-CN group were given L-CN treatment, with intraperitoneal injection of 200 mg·kg(-1)·d(-1) and successive administration for 3 d. Rats in Ctrl group were given equal volumes of normal saline. Blood was collected from carotid artery at different time and expression quantity of creatine kinase-MB (CK-MB) and Troponin Ⅰ (TnⅠ) in serum was detected. Rats in each group were put to death and were separated to obtain the myocardial tissue. Real-time PCR and Western Blotting hybridization were performed to detect the TIMP-1, ICAM-1 expression in myocardial tissue in each group. Statistical analysis was employed to explore the expression changes of TIMP-1 and ICAM-1, and ELISA test was used to analyze the expression changes of myocardial necrosis marker-CK-MB and TnⅠto learn the effect of L-CN and its myocardial protective effect. RESULTS The total cholesterol, triglyceride and blood glucose levels of rats in model group were significantly higher than that in control group, which indicated that due to high-fat diet feeding, blood lipid of rats in model group was obviously higher than that in control group. In myocardial tissue of rats in model group, TIMP-1 level significantly reduced and ICAM-1 level significantly increased (P < 0.01). In model group, after L-CN treatment, TIMP-1 level had double increase, while ICAM-1 level had 43% of decrease in L-CN group compared with Ctrl group. After L-CN intervention treatment, CK-MB and TnⅠ content in L-CN group relatively reduced compared with Ctrl group. The difference among groups was obvious (P < 0.01). CONCLUSIONS L-CN could increase the TIMP-1 expression level and inhibit the ICAM-1 expression level. L-CN has a certain myocardial protective effect.
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Affiliation(s)
- Shi-Xun Wang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, China; Department of Cardiology, Weifang People's Hospital, Weifang, Shangdong 261041, China
| | - Lei Tan
- Department of Cardiology, Weifang People's Hospital, Weifang, Shangdong 261041, China
| | - Jian Wang
- Department of Cardiology, Weifang People's Hospital, Weifang, Shangdong 261041, China
| | - Jing-Quan Zhong
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital of Shandong University, Jinan, Shandong 250012, China.
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Shadnia S, Amiri H, Hassanian-Moghaddam H, Rezai M, Vasei Z, Ghodrati N, Zamani N. Favorable results after conservative management of 316 valproate intoxicated patients. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2015; 20:656-61. [PMID: 26622254 PMCID: PMC4638067 DOI: 10.4103/1735-1995.166211] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Valproic acid (VPA) is an effective antiepileptic drug widely used worldwide. Despite several studies indicating the usefulness of intravenous L-carnitine in the treatment of VPA poisoning, this drug is not readily available in Iran. The aim of this study was to determine whether supportive care without antidote would result in acceptable outcomes in VPA poisoned patients. Materials and Methods: In an observational, retrospective, single-center case series, all patients >12-year-old with VPA overdose who had referred to a tertiary center between 2009 and 2013 were consecutively enrolled. Patients’ demographic and presenting features, physical examinations, clinical management, laboratory data, and outcomes were recorded. Results: A total of 316 patients were enrolled with pure VPA toxicity. The most common presenting signs/symptoms were drowsiness, nausea and vomiting, vertigo, and headache. In the course of the disease, 14 patients (4.4%) were intubated and three (0.9%) required hemodialysis with mean dialysis sessions of two. Fourteen patients were admitted to Intensive Care Unit, and seizures occurred in five. The initial level of consciousness was lower in patients with poor outcome. The median ingested dose of VPA in patients who required dialysis was significantly higher (20 vs. 6 g; P = 0.006). Multivariate analyses revealed that coma on presentation was associated with a worse outcome (P = 0.001; odds ratio = 61.5, 95% CI = 5.8-646.7). Conclusion: Prognosis of VPA poisoned patients appears to be good even with supportive care. According to our study, older age, ingestion of higher amounts of VPA and lower PCO2, HCO3, base excess, and CPK levels prone the patients to more severe toxicities in univariate analysis, but the main poor prognostic factor is coma on presentation in multivariate analysis.
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Affiliation(s)
- Shahin Shadnia
- Toxicological Research Center, Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran ; Excellence Center of Clinical Toxicology, Shahid Beheshti University of Medical Sciences, Iranian Ministry of Health, Tehran, Iran
| | - Hasan Amiri
- Toxicological Research Center, Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran ; Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran ; Department of Emergency Medicine, Firouzgar Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Toxicological Research Center, Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran ; Excellence Center of Clinical Toxicology, Shahid Beheshti University of Medical Sciences, Iranian Ministry of Health, Tehran, Iran
| | - Mahdi Rezai
- Emergency Medicine Management Research Center, Iran University of Medical Sciences, Tehran, Iran ; Department of Emergency Medicine, Firouzgar Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Vasei
- Department of Emergency Medicine, Firouzgar Hospital, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nillofar Ghodrati
- Department of Internal Medicine, Hematology, and Oncology, Alborz University of Medical Sciences, Karaj, Iran
| | - Nasim Zamani
- Toxicological Research Center, Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran ; Excellence Center of Clinical Toxicology, Shahid Beheshti University of Medical Sciences, Iranian Ministry of Health, Tehran, Iran
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Al-sharefi A, Bilous R. Reversible weakness and encephalopathy while on long-term valproate treatment due to carnitine deficiency. BMJ Case Rep 2015; 2015:bcr-2015-210727. [PMID: 26336183 DOI: 10.1136/bcr-2015-210727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
We describe a case of a 35-year-old woman who presented with bilateral leg weakness and encephalopathy while on long-term valproate therapy. She was diagnosed with valproate-induced encephalopathy due to carnitine deficiency. Clinical improvement occurred with oral carnitine supplementation. Our case report highlights the importance of considering carnitine deficiency in patients presenting with unexplained neurological signs while on long-term valproate treatment.
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Affiliation(s)
| | - Rudy Bilous
- Department of Endocrinology and Diabetes, James Cook University Hospital, Middlesbrough, 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: 54] [Impact Index Per Article: 6.0] [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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Weise S, Syrbe S, Preuss M, Bertsche A, Merkenschlager A, Bernhard MK. Pronounced reversible hyperammonemic encephalopathy associated with combined valproate-topiramate therapy in a 7-year-old girl. SPRINGERPLUS 2015; 4:276. [PMID: 26090323 PMCID: PMC4469596 DOI: 10.1186/s40064-015-1057-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/22/2015] [Indexed: 11/10/2022]
Abstract
Valproate is one of the most frequently used anticonvulsive drugs in children and adults. Valproate is a generally well tolerated medication. However, encephalopathy with or without hyperammonemia is one of its rare adverse events. We present a 7-year-old girl who suffered from epilepsy with generalized tonic-clonic seizures and absence epilepsy. She was initially treated with topiramate. Methylprednisolone pulse therapy and long-term therapy with valproate were initiated due to an increase of seizure frequency. At day 5 of therapy, a further increase of seizure frequency was observed followed by lethargy and somnolence. Liver enzymes remained within normal range, but ammonia serum levels increased to a maximum of 544 mmol/l. Discontinuing valproate and starting potassium-benzoate and sodium-phenylbutyrate improved the clinical condition and ammonia serum levels. Haemodialysis was not required. Cranial magnetic resonance imaging ruled out brain edema. The patient was further on successfully treated with a combination of both, topiramate and levetiracetam. Seizures did not recur and development was normal until now (3 years later). To the best of our knowledge, we observed the highest ammonia serum levels ever reported in valproate-induced hyperammonemia with a complete remission of the subsequent encephalopathy. Topiramate might increase the risk of valproate-induced encephalopathy by carbonic anhydrase inhibition.
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Affiliation(s)
- Sebastian Weise
- Department of Women and Child Health, University Hospital for Children and Adolescents, Liebigstr. 20a, 04103 Leipzig, Germany
| | - Steffen Syrbe
- Department of Women and Child Health, University Hospital for Children and Adolescents, Liebigstr. 20a, 04103 Leipzig, Germany
| | - Matthias Preuss
- Department of Women and Child Health, University Hospital for Children and Adolescents, Liebigstr. 20a, 04103 Leipzig, Germany ; Department of Neurosurgery, Pediatric Neurosurgery, University Hospital Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany
| | - Astrid Bertsche
- Department of Women and Child Health, University Hospital for Children and Adolescents, Liebigstr. 20a, 04103 Leipzig, Germany
| | - Andreas Merkenschlager
- Department of Women and Child Health, University Hospital for Children and Adolescents, Liebigstr. 20a, 04103 Leipzig, Germany
| | - Matthias K Bernhard
- Department of Women and Child Health, University Hospital for Children and Adolescents, Liebigstr. 20a, 04103 Leipzig, Germany
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Shah UA, Henderson MC, Abourjaily P, Thaler D, Rencic J. Exercises in clinical reasoning: a confusing interaction. J Gen Intern Med 2015; 30:860-3. [PMID: 25623299 PMCID: PMC4441680 DOI: 10.1007/s11606-014-3173-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/18/2014] [Accepted: 12/30/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Urvi A. Shah
- />Department of Internal Medicine, Tufts Medical Center, 800 Washington Street, Boston, 02111 USA
| | - Mark C. Henderson
- />Department of Internal Medicine, University of California Davis Medical Center, Sacramento, 95817 USA
| | - Paul Abourjaily
- />Department of Internal Medicine, Tufts Medical Center, 800 Washington Street, Boston, 02111 USA
| | - David Thaler
- />Department of Neurology, Tufts Medical Center, 800 Washington Street, Boston, 02111 USA
| | - Joseph Rencic
- />Department of Internal Medicine, Tufts Medical Center, 800 Washington Street, Boston, 02111 USA
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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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Zhao D, Ma L, Lu K, Wu J, He J. Syntheses of valpromide dipeptide derivatives and interactions of derivatives with ctDNA. RESEARCH ON CHEMICAL INTERMEDIATES 2015. [DOI: 10.1007/s11164-014-1913-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Valproate induced hyperammonemic encephalopathy successfully treated with levocarnitine. J Clin Neurosci 2014; 21:690-1. [DOI: 10.1016/j.jocn.2013.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 04/03/2013] [Accepted: 04/21/2013] [Indexed: 11/24/2022]
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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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Abstract
Recent data support the use of nutritional agents for use as targeted medical therapy. This article reviews some of the pharmacologic roles that parenteral nutritional ingredients (selenium, lipid emulsion, insulin, and levocarnitine) can play in the setting of critical illness.
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Affiliation(s)
- Dinesh Yogaratnam
- Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, 19 Foster Street, Worcester, MA 01608, USA.
| | - Melissa A Miller
- Emergency Department, Department of Pharmacy, New York Presbyterian Hospital, Columbia University Medical Center, 622 West 168 Street, New York, NY 10032, USA
| | - Britney Ross
- Department of Pharmacy, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Michael DiNapoli
- Department of Pharmacy, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA 01655, USA
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47
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L-Carnitina en la hiperamoniemia inducida por ácido valproico. Med Intensiva 2014; 38:124-5. [DOI: 10.1016/j.medin.2012.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Accepted: 05/28/2012] [Indexed: 11/21/2022]
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48
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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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49
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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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50
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Late-onset ornithine carbamoyltransferase deficiency accompanying acute pancreatitis and hyperammonemia. Case Rep Med 2013; 2013:903546. [PMID: 24073003 PMCID: PMC3773375 DOI: 10.1155/2013/903546] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 07/31/2013] [Indexed: 12/31/2022] Open
Abstract
Hyperammonemia related to urea cycle disorders is a rare cause of potentially fatal encephalopathy that is encountered in intensive care units (ICUs). Left undiagnosed, this condition may manifest irreversible neuronal damage. However, timely diagnosis and treatment initiation can be facilitated simply by increased awareness of the ICU staff. Here, we describe a patient with acute severe pancreatitis who developed hyperammonemia and encephalopathy without liver disease. Urea cycle disorder was suspected and hemodialysis was initiated. Following reduction of ammonia levels, subsequent treatment included protein restriction and administration of arginine and sodium benzoate. The patient was discharged to home after 47 days with plasma ammonia within normal range and without neurological symptoms. In clinical care settings, patients with neurological symptoms unexplained by the present illness should be assessed for serum ammonia levels to disclose any urea cycle disorders to initiate timely treatment and improve outcome.
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