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Lupus anticoagulant induced by the combination of valproate and lamotrigine
A Echaniz-Laguna1, A Thiriaux, I Ruolt-Olivesi
1Unité d'Explorations Fonctionnelles des Epilepsies, Clinique Neurologique, Hôpital Civil, Strasbourg, France.
Insights
Valproate and lamotrigine treatment in a child with absence seizures led to a lupus anticoagulant. Discontinuing valproate resolved the lupus anticoagulant, suggesting careful monitoring is needed for combined antiepileptic drug therapy.
Area of Science:
- Neurology
- Immunology
- Pharmacology
Background:
- Generalized absence seizures require effective antiepileptic drug (AED) therapy.
- Valproate (VPA) is a common AED for absence seizures.
- Lamotrigine (LTG) is often used as an add-on therapy.
Observation:
- A 5-year-old boy on VPA developed prolonged partial thromboplastin time (PTT) and reduced fibrinogen.
- Adding LTG to VPA resolved seizures but prolonged PTT further and led to a positive lupus anticoagulant (LAC) test.
- Immunoglobulin G (IgG) anticardiolipin antibodies were detected, indicating an autoimmune response.
Findings:
- VPA initiated a mild immune response, evidenced by coagulation changes.
- LTG exacerbated this response, leading to the development of LAC.
- LAC resolved upon VPA discontinuation, suggesting VPA as the primary trigger and LTG as an exacerbating factor.
Implications:
- Combined VPA and LTG therapy may increase the risk of developing LAC.
- Close monitoring for LAC and autoimmune phenomena is recommended in patients receiving VPA and LTG.
- Further research is needed to elucidate the mechanisms of AED-induced autoimmunity.
Abstract:
A 5-year-old boy with generalized absence seizures was treated with valproate (VPA), 30 mg/kg/day. One month after VPA introduction, routine examination showed moderate reduction in fibrinogen and prolonged partial thromboplastin time (PTT). The search for lupus anticoagulant (LAC) was negative. After 10 months of VPA treatment, seizures persisted, and lamotrigine (LTG), 2 mg/kg/day, was progressively given with VPA. Seizures disappeared, but PTT was more prolonged than before LTG introduction. The search for LAC was positive, and enzyme-linked immunosorbent assays (ELISAs) for immunoglobulin G (IgG) anticardiolipid antibodies were positive. Serum autoantibody screen and rheumatoid factor were negative; serum complement was normal. LAC eventually disappeared with VPA discontinuation. We believe that LTG may have exacerbated an initially mild immune response induced by VPA without clinical evidence of systemic disease. We therefore suggest that careful surveillance for LAC and systemic disease should be instituted when VPA is used with LTG.