From the Department of Psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India.
J Clin Psychopharmacol. 2023;43(2):145-148. doi: 10.1097/JCP.0000000000001659. Epub 2023 Feb 16.
Common adverse effects of valproate include sedation, tremor, gastrointestinal effects, and weight gain. Valproate-associated hyperammonemic encephalopathy (VHE) is an uncommon adverse effect of valproate therapy, which includes symptoms such as tremors, ataxia, seizures, confusion, sedation and coma. We report clinical features and management of 10 cases of VHE in a tertiary care center.
In a retrospective chart review of case records from January 2018 to June 2021, 10 patients with VHE were identified and included in this case series. The data collected include demographic information, psychiatric diagnosis, comorbidities, liver function tests, serum ammonia and serum valproate levels, dosages and duration of valproate, management of hyperammonemia including dosage variations, discontinuation, adjuvant drugs used, and whether rechallenge was done.
The most common indication of starting valproate was bipolar disorder (n = 5). All the patients had more than one physical comorbidity and risk factors for developing hyperammonemia. Seven patients received valproate at a dose higher than 20 mg/kg. The duration of valproate use varied from 1 week to 19 years before developing VHE. Dose reduction or discontinuation and lactulose were the most common management strategies used. All 10 patients improved. Among the 7 patients in whom valproate was discontinued, for 2 patients valproate was reinitiated in inpatient care with careful monitoring and was found to be well tolerated.
This case series highlights the need for a high index of suspicion for VHE as it is frequently associated with a delayed diagnosis and recovery in psychiatric settings. Screening for risk factors and serial monitoring may allow earlier diagnosis and management.
丙戊酸盐的常见不良反应包括镇静、震颤、胃肠道效应和体重增加。丙戊酸盐相关高氨血症性脑病（VHE）是丙戊酸盐治疗的一种罕见不良反应，包括震颤、共济失调、癫痫发作、意识混乱、镇静和昏迷等症状。我们报告了在一家三级护理中心的 10 例 VHE 患者的临床特征和治疗方法。
在对 2018 年 1 月至 2021 年 6 月的病例记录进行回顾性图表审查中，确定了 10 例 VHE 患者，并将其纳入本病例系列。收集的数据包括人口统计学信息、精神科诊断、合并症、肝功能检查、血清氨和血清丙戊酸盐水平、丙戊酸盐的剂量和持续时间、高氨血症的治疗管理，包括剂量变化、停药、使用的辅助药物以及是否进行再挑战。
开始使用丙戊酸盐的最常见指征是双相情感障碍（n=5）。所有患者都有不止一种身体合并症和发生高氨血症的危险因素。7 名患者的丙戊酸盐剂量高于 20mg/kg。发生 VHE 之前，丙戊酸盐的使用时间从 1 周到 19 年不等。减少剂量或停药和乳果糖是最常用的治疗策略。所有 10 名患者均有所改善。在 7 名停止使用丙戊酸盐的患者中，有 2 名患者在住院期间重新开始使用丙戊酸盐，并进行了仔细监测，发现耐受良好。
本病例系列强调了在精神科环境中，需要高度怀疑 VHE 的存在，因为它通常与延迟诊断和恢复有关。筛查危险因素和定期监测可能有助于更早诊断和治疗。
