Valproic acid, first manufactured as an anticonvulsant, is commonly used to treat both neurological and psychiatric conditions. A rare and deadly side effect of this medication is hyperammonemia, presenting as lethargy, confusion, seizure, and, ultimately, coma. In rare circumstances, hyperammonemia can be recurrent and devastating, especially in patients with an underlying N-acetyl glutamate synthase (NAGS) deficiency, as the valproic acid can enhance this enzyme deficiency and inhibit the conversion of ammonia into urea in the liver. For these subtypes of patients, the United States Food and Drug Administration (US FDA) has recently approved carglumic acid, a medication that can act as a scavenger by effectively increasing the levels of NAGS, ultimately enhancing the conversion of ammonia to urea. In our case report, we have mentioned a patient with treatment-resistant bipolar disorder, who presented with elevated ammonia levels secondary to valproic acid treatment. Valproic acid was the only drug that was effective in his case, so we initiated therapy to reduce his elevated ammonia levels. After a thorough evaluation, we found the patient had a genetic NAGS deficiency. Carglumic acid was initiated and proved efficacious in our patient.
Dyslipidemia is a disease of abnormal lipid levels in the blood that contributes to the atherosclerotic process. This atherogenic process leads to the formation of plaque and also leads to thromboembolic events and other vascular accidents. It is known that high-density lipoprotein cholesterol serves as a protective effect on the vessel wall and causes the reduction in the progression of atherosclerosis. And multiple interventions are directed in maintaining a higher level of the aforementioned lipoprotein cholesterol. While the low-density lipoprotein stays controversial but lowering its levels through various therapeutic agents is the main goal in the management of dyslipidemia. A newer group of drugs, PCSK9 inhibitors lowers the levels of low-density lipoprotein through modulating PCKS9 gene involved in cholesterol metabolism and affects the levels of the lipoproteins by controlling the receptors. The inhibitors of this gene decrease PCSK9-induced low-density lipoprotein receptor degradation in the lysosomes of hepatocytes increasing its recycling and expression on the cell surface, causing increased clearance of low-density lipoprotein from the circulation. These drugs Alicuromab, Evolocumab and along with other agents can be a novel approach in controlling dyslipidemic state. This review revisits the literature in understanding the pathophysiology of dyslipidemia along with its management by PCKS9 inhibitors, its mechanism of action, its pharmacokinetics, the results of the clinical trials and the limitations in its application.
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