Esra SAĞLAM, Gül ERYILMAZ, Barış Önen ÜNSALVER, Gül Işıl GÖĞCEGÖZ, Celal SALÇİNİ

Valproik Asit Kullanımına Bağlı Gelişen Hiperamonyemik Ensefalopati: Vaka Sunumu

Hiperamonyemi, valproik asit tedavisinin bilinen bir yanetkisidir. Son yıllarda valproik asit kullanımına bağlı hiperamonyeminin tetiklediği ensefalopati gelişen olgular yayınlanmakta ve kan amonyak düzeyinin takip edilmesi önerilmektedir. Semptomatik hiperamonyemi gelişimi için çokluilaç kullanımı, yetersiz beslenme ve üre döngüsü bozuklukları risk etmenleridir. Bu olgu sunumunda, eşzamanlıvalproik asit ve elektrokonvülsif tedavi (EKT) uygulananbir olguda semptomatik non-hepatik ensefalopati gelişimibildirilmiştir. Anestezik ajan olan propofol ile valproik asitkullanımı non-hepatik hiperamonyemik ensefalapati içinrisk olabilir. Eş zamanlı valproik asit ve propofol uygulanılarak yapılan EKT sırasında hiperamonyemik ensefalopati içindikkatli olunması önerilebilir.

Valproic acid induced hyperammonaemic encephalopathy: case report

Hyperammonemia is a well-known adverseeffect of valproic acid therapy. In the recent years,encephalopathy cases triggered by vaproic acid use- related hyperammonemia have been reported andregular blood ammonium level follow-up is suggested.Polypharmacy, malnutrition, urea cycle disorders arerisk factors for encephalopathy triggered by vaproic acidrelated hyperammonemia. Here, we report a case ofsymptomatic non-hepatic encephalopathy during valproicacid treatment combined with electroconvulsive therapy(ECT). Valproic acid may have induced hyperammonemicencephalopathy in combination with the anestheticagent propofol. We may suggest that patients receivingcombination of valproic acid and propofol as inductionagents for ECT, clinicians should be careful for thedevelopment of hyperammonaemic encephalopathy.

PDF

___

1. Lheureux PE, Penaloza A, Zahir S, Gris M. Science review: Carnitine in the treatment of valproic acid-induced toxicity. what is the evidence? Crit Care. 2005;9:431-44.
2. Kimmel RJ, Irwin SA, Meyer JM. Valproic acid-associated hyperammonemic encephalopathy: a case report from the psychiatric setting. Int Clin Psychopharmacol. 2005;20:57-8.
3. Verotti A, Trotta D, Morgese G, Chiarelli F. Valproate-induced hyperammonemic encephalopathy. Metab Brain Dis. 2002;17:367- 73.
4. Itoh H, Suzuki Y, Fujisaki K, Sato Y, Takeyama M. Correlation between plasma ammonia level and serum trough concentration of free valproic acid in patients with epilepsy. Biol Pharm Bull. 2012;35:971-4.
5. Laub MC. Nutritional influence on serum ammonia in young patients receiving sodium valproate. Epilepsia. 1986;27:55-9.
6. Janicki PK, Bezinover D, Postula M, Thompson RS, Acharya J, Acharya V, McNew C, Bowman JD, Kurkowska-Jastrzebska I, Mirowska-Guzel. Increased Occurrence of Valproic Acid-Induced Hyperammonemia in Carriers of T1405N Polymorphism in Carbamoyl Phosphate Synthetase 1 Gene. ISRN Neurology. 2013 Aug 7. doi: 10.1155/2013/261497.
7. Oechsner M, Steen C, Sturenburg HJ, Kohlschutter A . Hyperammonaemic encephalopathy after initiation of valproate therapy in unrecognised ornithine transcarbamylase deficiency. J Neurol Neurosurg Psychiatry. 1998;64:680-2.
8. Carlson T, Reynolds C, Caplan R. Case report: valproic acid and risperidone treatment leading to development of hyperammonemia and mania. J Am Acad Child Adolesc Psychiatry. 2007;46:356-61.
9. Zaccara G, Paganini M, Campostrini R, Moroni F, Valenza T, Messori A, Bartelli M, Arnetoli G, Zappoli R. Effect of associated antiepileptic treatment on valproate-induced hyperammonemia. Ther Drug Monit. 1985;7:185-90.
10. Warter JM, Marescaux C, Brandt C, Rumbach L, Micheletti G, Chabrier G. Sodium valproate associated with phenobarbital: effects on ammonia metabolism in humans. Epilepsia. 1983;24:628-33.
11. Sandson NB, Marcucci C, Bourke DL, Smith-Lamacchia R. An interaction between aspirin and valproate: the relevance of plasma protein displacement drug-drug interactions. Am J Psychiatry. 2006;163:1891-6.
12. Petrides G, Braga RJ, Fink M, Mueller M, Knapp R, Husain M, Rummans T, Bailine S, Malur C, OConnor K, Kellner C. CORE (Consortium for Research in ECT) Group. Seizure threshold in a large sample: implications for stimulus dosing strategies in bilateral electroconvulsive therapy: a report from CORE. J ECT. 2009;25:232-7.
13. Rasmussen K. The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (second edition). J ECT. 2002;18:58-9.
14. Scott AIF. College guidelines on electroconvulsive therapy: an update for prescribers. Adv Psychiatr Treat. 2005;11:150-6.
15. Sienaert P, Peuskens J. Anticonvulsants during electroconvulsive therapy: review and recommendations. J ECT. 2007;23:120-3.
16. Balıkçı A, Bolu A, Akarsu S, Koçak N, Erdem M, Aydemir E, Uzun Ö. Practice of electroconvulsive therapy between the years of 2006- 2011 at a university hospital in Turkey. Anadolu Psikiyatri Derg. 2013;14:340-6.
17. Tomruk NB, Oral T. Elektrokonvulsif tedavinin klinik kullanımı: Bir gözden geçirme. Anadolu Psikiyatri Derg. 2007;8:302-9.
18. Carr RB, Sherwsbury K. Hyperammonemia due to valproic acid in the psychiatric setting. Am J Psychiatry. 2007;164:1020-7.
19. Altunbaşak S, Baytok V, Tasouji M, Hergüner O, Burgut R, Kayrin L. Asymptomatic hyperammonemia in children treated with valproic acid. J. Child Neurol. 1997;12:461-3.
20. Kugoh T, Yamamoto M, Hosokawa K. Blood ammonia level during valproic acid therapy. Jpn J Psychiatry Neurol. 1986;40:663-8.
21. Williams CA, Tiefenbach S, McReynolds JW. Valproic acid-induced hyperammonemia in mentally retarded adults. Neurology. 1984;34:550-3.
22. Murphy JV, Marquardt K. Asymptomatic hyperammonemia in patients receiving valproic acid. Arch. Neurol. 1982;39:591-2.
23. Halaby A, Haddad R, Naja WJ. Hyperammonemia induced by interaction of valproate and quetiapine. Curr Drug Saf. 2013;8:284- 6.
24. Modjtahedi B. Hyperammonemia and valproic acid-induced encephalopathy. Am J Psychiatry. 2007;164:1912-3.
25. Özen S, Bülbül I, Soyuçok E. Valproate induced hypoactive delirium in a bipolar disorder patient with psychotic features. Turk Psikiyatri Derg. 2010;21:79-84.
26. Cuturic M, Abramson RK. Acute hyperammonemic coma with chronic valproic acid therapy. Ann Pharmacother. 2005;39:2119- 23.
27. Jahangard L, Haghighi M, Bigdelou G, Bajoghli H, Brand S. Comparing efficacy of ECT with and without concurrent sodium valproate therapy in manic patients. J ECT. 2012;28:118-23.
28. Ishii M, Higuchi H, Maeda S, Tomoyasu Y, Egusa M T. The influence of oral VPA on the required dose of propofol for sedation during dental treatment in patients with mental retardation: A prospective observer-blinded cohort study. Epilepsia. 2012; 53:13- 6.