Elevated ammonia level

[nursemom75]

I started having auditory/visual disturances with headaches in my early teens. Progressively worsened until I finally spoke with my PCP last spring. Referred my to psychiatrist. Ran a barrage of blood work, MRI/MRA, and EEG. Everything was negative except for a nearly zilch B12 level. He diagnosed me with seizure disorder NOS, bipolar disorder NOS, and psychosis NOS. The psychiatrist tried a multitude of meds that either didn't work or caused very unpleasant side effects. Finally, started on Depakote ER @ HS. Seemed to be working for about 6-8 wks. Then disturbances returned. Doubled my dose of Depakote. I'm taking 2 of the 500mg @ HS. All fine & dandy until my last routine lab testing. My ammonia level was 51. I know that's not critical elevation. So I started on L-carnitine 500mg BID. My question is...When is it appropriate for me to have my ammonia rechecked? I mean, it was 51 on Dec 4th. I saw my doc on Jan 3rd. He scheduled my routine checkup in 2 months. Do I need to have my level checked before then? I am assymptomatic of the elevated ammonia. I'm not extremely concerned, but I know what can happen.

[nursemom75]

Forgot to add that MRI showed tiny lesions on brain interpreted as scarring from migraines. Yet, I don't have migraines. Dr isn't worried about MS.

[Abhijeet Deshmukh, MD]

Hello.

It is a usual practice to test for ammonia every three months. It is usually combined with the therapeutic drug monitoring for Depakote. You may repeat the test just before the appointment with your doctor, so that he has fresh ammonia reports.

The diagnosis of MS is arrived at after clinical history, examination and investigations. Your history does not hint towards MS. The lesions on MRI may not be significant.

Regards

[nursemom75]

Thank you very much.

[Godofredo MD]

Hi.

Elevated ammonia as a side-effect of divalproex sodium (Depakote) can lead to symptoms such as altered mental status, confusion, and delirium. Some people do present with such symptoms even at low plasma levels.

Ideally, when elevated levels of ammonia is found in the setting of Depakote therapy, close monitoring of plasma levels should be done every week. If the elevation should persist, discontinuation of this drug should be considered.

The interpretation of migraines as the cause of the tiny lesions on MRI are only suggestive and are not absolute. The lesions are probably non-specific and could have been caused by other conditions.

Hope this answers your query.

[Carol in PA]

What are you doing about the low level of B12.
Are you taking supplemental magnesium and Omega-3's.

Carol

[nursemom75]

Thank you for your response. I know that as medical professionals, we sometimes read too much or too little into our own health issues. I will call my doctor to discuss the time line in which I need to have my ammonia level rechecked.

[nursemom75]

Hi there. Thanks for the interest. I take a B12 injection every 2 weeks. Last lab check, it was still zilch. He said that it's due to malabsorption. Said dietary supplement would do no good.