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Valproic acid-induced hyperammonemic encephalopathy (VIHE) in a patient with Bipolar disorder: A case report and literature review

Published online by Cambridge University Press:  01 September 2022

E. Isidahome  and
M. San Gabriel
E. Isidahome*
Affiliation:
Mount Sinai School of Medicine, Psychiatry, ELMHURST, United States of America
M. San Gabriel
Affiliation:
Mount Sinai School of Medicine, Psychiatry, ELMHURST, United States of America
*
*Corresponding author.

Abstract

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Introduction

Valproic acid (VPA) is a valuable treatment for bipolar disorder, schizoaffective disorder, and agitation1. However, potential side-effects include sedation, headaches, tremors, ataxia, gastrointestinal issues, neural tube defect, 3 and mild hyperammonemia even in normal liver function test 1 and VPA level.

Objectives

To illustrate clinical presentation of VIHE and provide literature review on post-VIHE treatment options.

Methods

A 59-year-old male with PMH of Diabetes Mellitus, Hypertension, Hyperlipidemia, LVH, COPD, s/p CVA, and PPH of schizoaffective disorder, bipolar type. Patient stable on VPA 1250mg daily and Olanzapine 5mg daily for >2years until recent manic decompensation resulting to up-titration of VPA to 1500mg H.S. Thereafter, he presented with altered mental status, with VPA level (111.4 ug/ml), hyponatremia (119 mmol/L) and hyperammonemia (84 umol/L). Subsequently, admitted as a case of VIHE and hyponatremia.

Results

VPA has shown to cause hyperammonemia alone or when combined with antipsychotics6. VIHE reported in up to 47.7% of patients on VPA1, but symptomatic in approximately 10% of patients on VPA with blood ammonia level about 2-fold the normal range8. VIHE presents with confusion, ataxia, blurred vision, delirium, and seizures3. Treatment options include VPA discontinuation, switch to other mood stabilizers (lithium carbonate, lamotrigine), utilization of medications to lower blood ammonia levels (Lactulose, Rifaximin/Neomycin) ,3 antipsychotic monotherapy, and supplements (Levocarnitine or Carglumic acid) in the prevention, maintenance, and treatment of VIHE. These supplements can be added to VPA if the benefits of re-initiating or continuing VPA outweighs the risk3.

Conclusions

Further research is needed.

Disclosure

No significant relationships.

Keywords

VIHE - Valproic acid induced hyperammonemic encephalopathybipolar disorderVPA - Valproic acidSchizoaffective disorder
Type
Abstract
Information
European Psychiatry , Volume 65 , Special Issue S1: Abstracts of the 30th European Congress of Psychiatry , June 2022 , pp. S346
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of the European Psychiatric Association
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