Download Nicotinic acid deficiency induced by sodium valproate The use

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SA MEDIESE TYDSKRIF DEEL 65 23 JUNIE 1984
operasies. Daar moet· dus dringend aandag gegee word aan die
agterstand en wanaangepaste narkosetariewe en 'n nuwe waardebepaling vir narkoseprosedures moet uitgewerk word.
Aangesien 'n algemene praktisyn 80% van die spesialisfooie mag
vra, beteken dit dat 'n narkotiseur ongeveer RIO,OO per uur
vergoeding kry vir die ekstra 4 jaar opleiding.
J. H. Loots
Parkrylaan Mediese Sentrum
Pon Elizabeth
L Espag RH, Bekker JH. Tariewe van narkotiseurs. S Afr MedJ 1984; 65: 633.
To the Editor: I wish to thank the SAMJ for allowing the use of its
correspondence pages for discussion of the grievances of specialist
anaesthetists in private practice.
At the Critical Care Medicine Congress, held in Durban in May
1984, concerned anaesthetists from all provinces discussed co=on
problems. It became clear that there is a genuine sense offrustration
and a groundswell of feeling that changes must be instituted as soon
as possible.
Discussion centred on two aspects. Firstly, anention must be
given to closing the gap between the salaries ofspecialist anaesthetists
and those of surgical specialists in general - an overall percentage
increase would only widen this gap. This could be done by increasing
the monetary value of the anaesthetic unit, by upgrading the time
unit after 30 minutes so that longer, more complex anaesthetic
procedures are more fairly rewarded, and by linking the fee to the
physical status of the patient. Secondly, the status of the specialist
anaesthetist must be elevated in recognition of the fact that
anaesthetics is no longer merely an ancillary service. Central to this is
the acceptance of the anaesthetist's role in critical care medicine and
his ability to judge pre-operatively firness for anaesthesia and
surgery. His potential as regards postoperative management as well
as his training in the management of chronic pain must be
appreciated.
A tangible result of such recognition would be an increase in the
tariff differential between specialist anaesthetists and general practitioners to that existing between general practitioners and other
specialties. Also, allowing only those general practitioners who have
taken the trouble to achieve the equivalent of the Diploma in
Anaesthetics of the College of Medicine of South Mrica to
administer anaesthetics would raise the standard.
It is also imponant that members of the public realize the
difference between specialist anaesthetists and general practitioners
who administer anaesthetics. Patients are often not given a choice in
the maner of who administers the anaesthetic, and some general
practitioners may even pressurize the surgical specialist.
In conclusion, I challenge fellow specialist anaesthetists in private
practice to address themselves to these problems.
D.J. Comyn
Central Hill
Walmer
Pon Elizabeth
Nicotinic acid deficiency induced by
sodium valproate
To the Editor: Sodium valproate (Epilim) has been shown to be
effective in the· treatment of epilepsy, and to exen few serious
adverse effects. I Its most common side-effects are nausea, abdominal
cramps, vomiting and diarrhoea. 2 Less co=on side-effects are
usually transient, dose-related hepatic dysfunction, 3 pancreatitis'
and platelet dysfunction. 5 Here we repon on a patient in whom the
drug was associated with the development ofa pellagra-like syndrome.
A 10-year-old boy with primary generalized epilepsy was treated
with sodium valproate 500 mg/d. Apan from the epilepsy he was
well, and the results of routine laboratory tests before administration of the drug were normal. Approximately 6 weeks after
initiation of therapy he developed abdominal cramps and anhralgia
in both knees and wrists. A striking erythema resembling severe
sunburn was present symmetrically over the pans of the body
exposed to sunlight. The affected areas were well demarcated from
the surrounding normal skin. Some of the facial lesions revealed
vesiculation, exudation and crusting with ulceration. The tongue
had a 'raw beef appearance and was painful on palpation. Small
vesicular lesions were noted on the tongue and gingival surfaces.
Neurological examination revealed diminished tendon jerks in all
limbs and a mild, coarse tremor of the tongue and upper limbs. No
other deficit was detected. The results of laboratory analysis were
normal and thyroid smdies and urinalysis were negative. An ECG
was normal. Nicotinic acid deficiency was suspected and the patient
was given nicotinamide in a dose of 400 mg/d orally. The rc;sponse
was dramatic and within 48 hours the erythema diminished, the
tongue became paler and less painful and the abdominal cramps
ceased.
.
The exact mechanism by which sodium valproate aruses a
pellagra-like syndrome is not well understood. In particular it is
difficult to pinpoint a specific aetiological factor, since the condition
may result from a multifactorial nutritional deficiency. However, a
deficiency of nicotinic acid is thought to be one of the main factors
involved in causing pellagra. This repon suggests that sodium
valproate may interfere with nicotinic acid utilization in cenaip
circumstances. Patients receiving sodium valproate should therefore
be watched for possible development of nicotinic acid deficiency,
and prophylactic administration of this vitamin may be necessary.
M. A. Gillman
R. Sandyk
Highlands House
Orange Grove
Johannesburg
1. Lesis JR. Valproic acid (Depakene): a new anticonvulsant agent.JAMA 1979;
240: 2190-2192.
2. Simon D, Penry JK. Sodium di-N-propylacerate (DPA) in the treatment of
epilepsy: a review. Epilepsia 1975; 16: 549-573.
3. Willmore LJ, Wilder BJ, Bruni J er al. Effect of valproic acid on hepatic
function. Neurology 1978; 28: 961-964.
.
4. Batalden PB, van Dyke BJ, Cloyd J. Pancreatitis associated with valproic acid
therapy. Pediacrics 1979; 64: 520-522.
5. Sussman MN, McLain LW jun. A direct hepatotoxic effect of valproic acid.
JAMA 1979; 242: 1173-1174.
The use ofveterinary medicines in humans
To the Editor: At its recent meeting the South Mrican Medical and
Dental Council considered leners from the Director-General of
Health and Welfare and the Registrar of Medicines regarding the
sale of veterinary medicines to medical practitioners for use in
human patients.
The SAMDC resolved that the Director-General and the Registrar
be advised that the SAMDC believes that practitioners may use in
human patients only those medicines intended for that purpose; the
use of veterinary medicines in human patients is therefore not
permined.
N. M. Prinsloo
Registrar
South African Medical and
Dental Council
Pretoria
Erratum
In the article by Dr E. Jacka et al., 'Coping with chronic illness: Pan
1', which appeared on pp. 850-853 of the SAMJ of26 May 1984, the
foornote to Table III should have read: 'This included workmen's
compensation, disabiliry grants, Unemployment Insurance Fund
benefits and Government pensions.'