Valproate-Associated Hyperammonemic Encephalopathy: Clinical Correlates and Management Strategies in a Tertiary Care Center.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Efficacy and safety of maintenance electroconvulsive therapy (M-ECT) in treatment-resistant schizophrenia: A case series.

BACKGROUND: Treatment-resistant schizophrenia (TRS) is a substantial burden to patients, caregivers, and the treating team. There is a lack of robust evidence to support the efficacy of various pharmacological and non-pharmacological measures to augment clozapine in this population. When used in conjunction with clozapine or other combination antipsychotic regimens, maintenance electroconvulsive therapy (M-ECT) can be a potential therapeutic option in preventing symptom exacerbation in TRS. However, there is limited evidence supporting the role of M-ECT in TRS. AIM: To evaluate the efficacy and safety of maintenance electroconvulsive therapy in patients with TRS. METHODOLOGY: Sociodemographic details, illness characteristics, details of M-ECT procedure, adverse events, and course of the illness were evaluated using a retrospective chart review at a tertiary care psychiatry centre in south India. Scores on Clinical Global Impression-Severity (CGI-S), Social and Occupational Functioning Assessment Scale (SOFAS), and Hindi Mental Status Examination were compared before and after the course of M-ECT. RESULTS: Seven male and three female patients received M-ECT in the last eight years (range of 22-172 sessions). There was a reduction in hospitalizations for acute exacerbation and significant improvement in the patient's overall functioning without significant adverse effects. CONCLUSION: Maintenance ECT can be a safe and effective treatment option for achieving symptom control in the long-term management of refractory schizophrenia. Controlled trials are needed in this area for further evidence.