Valproate-induced Hyperammonaemia

Raja, Michele; Azzoni, Antonella

doi:10.1097/00004714-200212000-00019

Cited by 55 publications

(32 citation statements)

References 7 publications

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“…Raja and Azzoni assessed adult patients admitted to a psychiatric unit receiving a mood stabilizer such as VPA and found that 51.2% of patients receiving VPA had asymptomatic hyperammonemia [9]. While the prevalence of asymptomatic hyperammonemia in this study is high, it is important to note that VHE is rare and often hard to distinguish from the development of acute psychosis.…”

Section: Discussionmentioning

confidence: 78%

Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction

Twilla

Pierce

2014

Case Reports in Psychiatry

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Valproic acid-induced hyperammonemic encephalopathy is a rare yet serious adverse drug reaction. Medication interactions such a valproic acid and topiramate can precipitate an event. We present the case of a 52-year-old female that presented with acute mental status change and hypersomnolence due to hyperammonemia caused by a valproic acid derivative. The patient improved after withdrawal of the offending medications and treatment with lactulose. Clinicians should remain hypervigilant in monitoring for valproic acid-induced hyperammonemic encephalopathy and risk factors such as polypharmacy.

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Section: Discussionmentioning

confidence: 78%

Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction

Twilla

Pierce

2014

Case Reports in Psychiatry

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“…Rarely valproate induced hyperammonemia produces delirium like state of non hepatic origin and if not timely suspected may also lead to valproate induced encephalopathy or even death [2]. Hyperammonemia could be asymptomatic [3] or may progress to focal neurological deficit, seizure, marked sedation, coma, due to encephalopathy [4].…”

Section: Discussionmentioning

confidence: 99%

“…The Naranjo adverse drug reaction probability scale [6] of this case scored nine on this scale which was categorized as definite adverse drug reaction. Valproate induced hyperammonemia can baffle the treating psychiatrist and confuse the case with psychosis or worsening of mania and can induce improper management [2,3] as happened with us when delirium due to hyperammonemia in mania was mistaken for delirious mania and treated with ECT.…”

Section: Discussionmentioning

confidence: 99%

Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma

Dixit¹

2015

JCDR

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A 31-year-old male with no past history of any significant medical illness manifested with acute onset of behavioural problems of seven-eight days duration in form of increased psychomotor activity, elated mood, verbosity, distractibility, enhanced self esteem, hyper-religiosity, delusion of grandiosity, impaired biodrives (sleep, appetite and libido) in absence of any perceptual disturbance and with intact sensorium. There was no history of fever, altered sensorium, neurological deficit and significant weight loss prior to onset of behavioural abnormalities. There were no developmental issues. Physical examination revealed pulse 82/min, BP 130/82 mm of Hg, afebrile, respiratory rate was 16/min, no digital tremors or hyperhydrosis. Lab investigations including heamogram, LFT, urea, creatinine, blood sugar, lipid profile, serum electrolyte, X-ray chest, CT Scan Brain, T3, T4, and TSH was within normal limits and HIV status was negative. He was diagnosed as a case of mania with psychotic symptoms as per International Classification of Diseases 10 (ICD10) [1] and started on mood-stabilizer tab divalproex sodium 500 mg BD and olanzapine 5 mg BD. Patient started showing improvement. By 10 th day his symptoms remitted to about 40% however his hyper-religiosity, self esteem and grandiose manners though less severe persisted, however on 13 th day patient complained of headache right hemi-cranium lasting for half hour to one hour accompanied by nausea and vomiting. His pulse, BP and temp were normal. MRI brain and fundoscopy revealed no abnormality. A neurophysician referral resulted in prescription of tab topiamate 25 mg BD in view of vascular headache and the same evening (15 th day of admission) after receiving tab topiramate patient developed disorientation, confusion, unsteadiness of gait, irrelevant talks and agitation which continued for next three-five days. His topiramate was stopped immediately. His MMSE score was 13/30. Subsequently divalproex sodium was increased to 1500 mg along with 15 mg of olanzapine by 22 nd day. EEG revealed normal bilateral symmetrical 9-12 Hz posteriorly dominant alfa rhythms. Patient did not show any improvement and continued to remain puzzled, dazed, confused and disoriented during day time with irrelevant talk and exhibited more hyperactivity towards evening with altered sleep-Wake schedule. His physical examination revealed pulse 88/min, BP 136/88 mm of Hg, respiratory rate 18/ min. There were no menningeal, cerebellar or extra pyramidal signs. keywords: Bipolar disorder, Encephalopathy, Non hepatic hyperammonemia, Valproic acidHis neurological examination was non contributory. His repeat liver function, electrolyte, urea, creatinine and CPK levels were within normal range. A pre-anesthetic check up was done and after taking appropriate consent of patient and relatives, he was taken up for electroconvulsive therapy (ECT) on 29 th day suspecting it to be a case of Delirious mania. ECT was planned twice a week. Before starting ECT dose of divalproex sodium was reduced to 250 mg BD t...

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“…There remains controversy as to whether symptoms have any relationship to daily dose or plasma concentration of valproic acid. In a prospective study, the significantly higher prevalence of asymptomatic hyperammonemia was found in the psychiatric patients treated with valproate than in the control, and there was a positive correlation between serum valproic acid concentrations and ammonia levels (Raja & Azzoni, 2002). Nevertheless, it should be noted that many cases with symptomatic encephalopathic symptoms reported up to date have serum valproic acid concentrations within therapeutic range (Carr & Shrewsbury, 2007;Marie-José, 2007).…”

Section: Valproate-induced Hyperammonemic Encephalopathymentioning

confidence: 98%

Encephalopathy Associated with Psychotropic Drug Therapy

Odagaki¹

2012

Miscellanea on Encephalopathies - A Second Look

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Valproate-induced Hyperammonaemia

Cited by 55 publications

References 7 publications

Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction

Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction

Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma

Encephalopathy Associated with Psychotropic Drug Therapy

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