Safe use of sodium valproate

Your article on the safe use of sodium valproate (Aust Prescr 2014;37:124-7) is an excellent brief summary on the drug’s pharmacology and uses. However, the authors have omitted to mention its use in corticosteroid-induced mania.¹ Corticosteroids in high doses are used in many conditions but cause many dysphoric symptoms, including hypomania, panic, confusion and insomnia, all of which are described as unpleasant.² In the past, treatment had to be stopped and symptoms controlled by major tranquillisers. Our work describing 20 case studies of steroid-induced mania coming to the attention of a consultation-liaison team have shown that sodium valproate can rapidly reduce manic-like symptoms while treatment with corticosteroids continued. We think that this is a worthwhile point which should be brought to the attention of your readers.Your article on the safe use of sodium valproate (Aust Prescr 2014;37:124-7) is an excellent brief summary on the drug’s pharmacology and uses. However, the authors have omitted to mention its use in corticosteroid-induced mania.¹ Corticosteroids in high doses are used in many conditions but cause many dysphoric symptoms, including hypomania, panic, confusion and insomnia, all of which are described as unpleasant.² In the past, treatment had to be stopped and symptoms controlled by major tranquillisers. Our work describing 20 case studies of steroid-induced mania coming to the attention of a consultation-liaison team have shown that sodium valproate can rapidly reduce manic-like symptoms while treatment with corticosteroids continued. We think that this is a worthwhile point which should be brought to the attention of your readers.

Milton Roxanas
Associate professor of Psychiatry
Sydney Adventist Medical School

Glenn Hunt
Associate professor
Psychiatry
University of Sydney

Ahamed Zawab and John Carmody, the authors of the article, comment:

We thank Drs Roxanas and Hunt for their kind interest in our brief review. Their recent case series addressed the important issue of pharmacological management of corticosteroid-induced psychiatric symptoms. In their study, using a standardised mania rating scale over a four-day period, a statistically significant reduction in mania was attributed to sodium valproate. However, 16 of the 20 patients were simultaneously prescribed a lower dose of corticosteroid. We agree with the authors’ conclusion that the findings need to be replicated in a controlled trial. Until then, we would suggest that corticosteroid dose reduction in concert with formal psychiatric review is preferable.