Influence of glutamine synthetase gene polymorphisms on the development of hyperammonemia during valproic acid-based therapy

Purpose: Valproic acid (VPA), which is widely used to treat epilepsy, migraine, and bipolar disorder, can causes severe hyperammonemia. However, the mechanism responsible for this adverse effect is not readily apparent. We previously reported that phenytoin coadministration is a strong risk factor for the development of hyperammonemia during VPA-based therapy. In this study, we focused on glutamine synthetase, which catalyzes the synthesis of glutamine from glutamate and ammonia and examined the association with the development of hyperammonemia during VPA-based therapy. Methods: For this study, we recruited 202 Japanese pediatric patients having epilepsy. We selected three polymorphisms (rs10911070, rs10797771, and rs10911021) in the glutamine synthetase (GLUL) gene. Hyperammonemia was defined as a plasma ammonia level exceeding 200 or 170 mu g/dL. We evaluated the association between the development of hyperammonemia during VPA-based therapy and the patient characteristics, including three GLUL polymorphisms. Results: The number of patients who developed hyperammonemia during VPA-based therapy was 20 (9.9%) using the 200 mu g/dL cutoff value and 30 (14.9%) using the 170 mu g/dL cutoff value. Using a multivariate logistic regression analysis, the GLUL rs10797771 polymorphism and phenytoin coadministration in the 200 mu g/dL cutoff value, and female in addition to two factors in the 170 mu g/dL cutoff value, had significant associations with a plasma ammonia level elevation during VPA-based therapy. Conclusion: Phenytoin coadministration, GLUL rs10797771 polymorphism in the 200 mu g/dL cutoff value, and female in addition to two factors in the 170 mu g/dL cutoff value, are independent risk factors for elevated plasma ammonia levels during VPA-based therapy. (C) 2015 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.