Should Pharmacies Be Included in Medication Reconciliation? A Report of Recurrent Valproic Acid Toxicity

Abstract

Including outpatient pharmacies in the medication reconciliation process upon hospital discharge is not commonly performed. This case highlights the consequences of a patient refilling a discontinued prescription for valproic acid (VPA). We present a 32-year old male found unresponsive after ingesting delayed release divalproex sodium. Cerebral edema was visualized on magnetic resonance imaging. Hemodialysis and levo-carnitine treatment led to improved mental status, and VPA was discontinued. The same patient presented with VPA overdose eight months later after he continued to fill an outdated prescription. This case highlights consequences of VPA toxicity; it also demonstrates an opportunity to improve patient safety and high-value care by collaborating with outpatient pharmacies in the medication reconciliation process upon hospital discharge.

Propionate and Alzheimer’s Disease

“…It is well established that L-carnitine (CAR) supplementation as an adjuvant therapy contributes to the amelioration of blood markers of oxidative damage in patients affected by disorders of excess propionate levels, as well as in the treatment of VPA-induced hyperammonemia (Roe et al, 1984 ; Ribas et al, 2010 ; Maldonado et al, 2016 ; Cutshall et al, 2017 ). As Maldonado et al ( 2016 ) hypothesized from their study, “ In patients treated with VPA, CAR depletion followed by [acetyl-l-carnitine] ALCAR decrease could be responsible for the increase in the ammonia levels.…”