Valproic acid
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Hyperammonaemic encephalopathy in an elderly patient: case report A 78-year-old woman, with a history of monoclonal gammopathy, developed hyperammonaemic encephalopathy during treatment with valproic acid [valproate] for tonic-clonic seizures. The woman, who had been receiving valproic acid 1 g/day for 10 months, was hospitalised with a Glasgow Coma Scale score of 11/15 (confused verbal response, eye opening in response to pain, able to localise pain) and nystagmus when looking sideways. She had been hospitalised three times in 4 months with brief episodes of sensory deterioration with spontaneous recovery. A brain CT scan revealed sequelae in her left occipital region and an EEG showed continuous slow generalised activity compatible with metabolic encephalopathy. Tests showed an ammonia level of 123 µg/dL and she was diagnosed with valproate-induced hyperammonaemic encephalopathy. Valproic acid was replaced with lamotrigine and the woman was treated with IV lactulose and levocarnitine. She recovered completely, and her ammonia levels normalised, 48 hours after discontinuing valproic acid. At 5-months’ follow-up, the woman had remained free from hyperammonaemic encephalopathy. Author comment: Hyperammonaemia may be a result of a reduction in hepatic urea production caused by valproic acid. Young P, et al. Valproate-associated hyperammonemic encephalopathy. Report of one case. Revista Medica de Chile 135: 1446-1449, No. 11, Nov 2007 [Spanish; 801103226 summarised from a translation] - Argentina
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Reactions 22 Mar 2008 No. 1194
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