Intravenous Valproate for Rapid Stabilization of Agitation in Neuropsychiatric Disorders
Case Report
An 8-year-old Caucasian female with autistic disorder per DSM-IV criteria has been followed for 6 years for behavioral agitation. Her birth and developmental history were unremarkable until 2 years of age. There were no significant findings on laboratory tests (including fragile X testing at age 7), neurological evaluation, EEG, or imaging studies. Her ongoing medications included risperidone 2 mg po bid and benztropine 1 mg po bid. Past trials of typical neuroleptics, methylphenidate, clonidine, and naltrexone were ineffective.The most recent episode of agitation necessitated a call to paramedics to transport the patient to the emergency room. On the Overt Aggression Scale (OAS),11 she met 0 of 4 criteria for verbal aggression, 1 of 4 criteria for physical aggression against objects, 3 of 4 criteria for physical aggression toward herself, and 3 of 4 criteria for physical aggression toward others. Her overall score on the OAS was 28. Interventions included talking to the patient, holding the patient, and the use of physical restraints. Including IV valproate as mentioned below, the OAS intervention score was 13. The family provided consent for intravenous valproate administration. A dose of 2,000 mg of valproate was infused over a 10-minute period. Since the patient's weight was 53 kg, this was a rate of approximately 40 mg/kg per 10 minutes. The patient's behavior decreased to 0 of 4 on all scales within 15 minutes, and she suffered no side effects, obviating the need for hospitalization. Valproate 1,000 mg po bid was added to her routine medications the next morning. Over the next 6 months, her usual aggressive behavior and intervention scores on the OAS decreased to 10 and 4, respectively, compared with 33 and 8 during the 6 months prior to valproate treatment.In summary, intravenous valproate was effective for this patient with autistic disorder, for both acute and chronic behavioral agitation. Controlled clinical trials are needed to document whether intravenous valproate may be effective to treat agitation in children and adults.
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