This document discusses the use of Depakote (valproic acid) as a treatment for bipolar disorder. It provides information on bipolar disorder, how Depakote works to control mood swings and symptoms, appropriate dosing and therapeutic drug levels. Potential drug interactions and adverse reactions like hepatotoxicity and pancreatitis are addressed. Common side effects ranging from 1-25% occurrence are outlined. The pharmacokinetics of Depakote and issues related to drug binding like interactions with aspirin are also summarized. The importance of monitoring patient labs when taking Depakote is stressed.

1. The Use of Depakote as
Treatment for Bipolar
Disorder
Baleigh Brown
Lamar University

2. Depakote
(Valproic Acid)
• An anticonvulsant
• Administered for treatment for Bipolar Disorder (BD)

3. Bipolar Disorder (BD)
 Mental disorder
 Characterized by constantly changing moods (mania, hypomania, major
depression)
 Psychosis occasionally occurs with mood swings
 Suicidal ideations, homicidal ideations, paranoia, hallucinations,
delusions, excessive spending, insomnia, poor judgement- all types of
behaviors associated with BD
 Actual cause is unknown
 May stem from genetics, neurochemical transmitters, or environmental
factors

4. Intended Drug Response
Remission from mood swings and/or
paranoia
 Response to symptoms
Maintenance of therapeutic serum drug
levels (50-100 mcg/ml)

5. Potential Interactions
 Lamotrigine-Depakote doubles it’s half life, increases risk of Steven Johnson’s
Syndrome and toxic epidermal necrolysis
 Topiramate-mixture increases risk for hyperammonemia and encephalopathy
 Risperidone-mixture may cause toxic affects may be enhanced as well as cause
generalized edema
 Some mixtures may increase or decrease serum concentration of Depakote
which leads to nontherapeutic levels
 Depakote may cause an increase or decrease in other medications’ serum
concentration leading to adverse affects

6. Adverse Drug Reactions
 Hepatotoxicity (life threatening)- monitor serum liver function
tests and ammonia levels, monitor LOC, encourage patients to
report symptoms of malaise, weakness, lethargy, facial edema,
anorexia, and vomiting
 Pancreatitis (life threatening)- encourage patients to report
abdominal pain, persistent nausea, vomiting, and anorexia
 Hyperammonemia- watch for unexplained lethargy, vomiting or
mental status changes; monitor liver function tests and ammonia
levels (especially in patients that frequently drink alcohol)

7. Side Effects
 1% - 25% occurrence: dizziness, insomnia, nervousness, alopecia,
drowsiness, headache, abdominal pain, dyspepsia, diarrhea, vomiting,
weakness, thrombocytopenia (dose related), and diplopia
 Dyspepsia (indigestion) is one I see most often. Most of my patients are
prescribed an antacid or protein pump inhibitor in addition to Depakote
 Nausea has a 3% - 48% incidence occurrence
 1% - 5% occurrence: chest pain, edema, palpitations, tachycardia,
anxiety, vertigo, ecchymosis, pruritus, amenorrhea, weight gain, weight
loss, constipation

8. Phamacokinetics
 Dissociates to the valproate ion in the GI tract
 Highly protein bound, concentration dependent
 Protein binding is reduced in elderly patients, patients with
chronic hepatic disease, renal impairment, and when mixed with
ASA
 Almost entirely metabolized by the liver
 Excreted through urine

9. Drug Binding Issues
 Aspirin (metabolically converted to salicyclic
acid)
 Able to inhibit metabolism of Depakote
 Protein binding displacement may result in
increased unbound drug concentration

10. Improving Communication
and Patient Safety
 Monitoring patient labs
 Allowing pharmacy to receive a copy to assist in monitoring labs
 Draw Depakote levels 3-5 days after initiation of treatment or
upon admission if patient is currently prescribed Depakote
 Draw labs every 3-5 days after changes are made to dose and
until more than one therapeutic level is accomplished
 Meet all criteria on MUE (Medication Use Evaluation)-discuss
this with multidisciplinary team at least twice a week

11. Application to the Practice
Setting
 Review labs with each chart check
 Make sure all labs are scheduled to be drawn
 Place lab results on chart and notify practitioner if results warrant
it
 Assess level of consciousness and orientation level
 Inquire about any side effects or difficulty with urination
 Educate other healthcare members and nurses about findings
 Assist with MUE criteria