Valproate (Depakote)

Anticonvulsant (glutamate modulation, GABA-ergic)

Dosing

Start 250-500 mg at night, titrate every 2-5 days, check serum level 5 days after reaching 1,000 mg and adjust based on that. ER form is best tolerated and should be given in morning (it peaks, causing sedation, 12 hours later).

Recommend a MVI with selenium and zinc (eg, Centrum silver or selenium 200mcg with zinc 20-50mg) to prevent hair loss on it, and methylfolate (15mg/d) as depakote reduces that and works better with folate supplementation.

LOADING DOSE: For rapid stabilization, start with a dose = patient weight in lbs x9; max = weight x27

LEVELS: For full mania, levels 90-100. Otherwise ideal levels not known, likely 50-100.

INTERACTIONS: Check drug interactions, especially lamotrigine and carbamazepine.

Management

Like carbamazepine, works best in mixed states, rapid cycling, comorbid sub abuse, but also treats BP depression. Also has benzo-properties so is one of few bipolar treatments that reduces anxiety.

Side effects make it problematic for women (polycystic ovarian, male pattern baldness, and is only psych med absolutely contraindicated in pregnancy, though relatively safe in breastfeeding).

TOLERABILITY: Weight gain, fatigue, cognitive deficits.

RISKS: Rare hepatotoxicity, blood dyscrasias, low platelets (thrombocytopenia), and pancreatitis. Contraindicated pregnancy.

EMR Text