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Thinking out of the box: management of valproic acid toxicity with carbapenems
  1. Raghavendra Sanivarapu1,
  2. Robin Sharma2 and
  3. Jagadish Akella1
  1. 1Pulmonary & Critical Care Medicine, Nassau University Medical Center, East Meadow, New York, USA
  2. 2Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA
  1. Correspondence to Dr Raghavendra Sanivarapu; raghav.s2k7{at}


Valproic acid (VPA) is commonly used medication to treat seizure disorder and as prophylaxis for bipolar disorder. Acute VPA toxicity can cause varied symptoms ranging from mild drowsiness to severe cerebral oedema and coma. The therapeutic level of VPA is around 50–100 µg/mL and most of it is protein bound. It is mainly metabolised by liver and is eliminated via bile. The metabolites of VPA interfere with urea cycle and cause deficiency in carnitine leading to increase in ammonia levels. The use of carnitine to treat VPA toxicity is well known but it is still unclear if it lowers VPA levels. We report a case of VPA toxicity that did not respond to use of carnitine at 6000 mg orally but was successfully treated using meropenem leading to lowering of VPA levels and also clinical improvement of patient.

  • drugs and medicines
  • drug interactions
  • poisoning
  • adult intensive care
  • drugs: psychiatry

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  • Contributors RSa and RSh authored the manuscript. JA edited and finalised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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