valproate (Depakote)

Depakote was originally developed as an anti-seizure medication.  In the last 2-3 years we have found that it also affects mood.  Like other œmood stabilizers?, Depakote can prevent large or rapid changes in mood.  It does not seem to have any effect on day to day mood changes, only œcyclic? or unprovoked changes.  It also has powerful effects on anxiety, agitation, insomnia, panic symptoms, and anger.  
(The FDA approved Depakote for Bipolar Disorder June 1, 1995. )

How much do I take?

           For most people it takes at least 1 gram per day to work.  Each milligram of this medication doesn™t have much œoomph? so it takes a lot of them.  This is actually about half the dose of Depakote commonly used for seizure control, though.  As a result, at œmood stabilizing? doses, many people have no side effects, or very minor ones.  œLow dose? is 1000mg; medium is 1500, high is 2000-3000 mg.

What are the common side effects?

           Most people get no side effects at all at low doses.   But weight gain is a big problem at higher doses.  See œpreventing weight gain? below on how to keep that from happening to you.  

           Some people get nausea when they first start Depakote.  This can be reduced by taking the pills with meals at first.  The œextended release? (ER) versions seem to cause nausea even less often.

            People sometimes notice more hair at the bottom of the shower after they wash their hair, especially if their hair is long.  Actual œhair loss? (which you might see on the pharmacist™s handout) is sometimes a problem at higher doses, but only very rarely an issue at œmood stabilizing? doses, and usually we will have considered switching because of weight gain by that time.   Taking a multi-vitamin with selenium and zinc (e.g. œCentrum Silver?) can prevent this problem for some people.  

           Too high a dose causes a œspacey?, foggy feeling; a mild but constant headache; and occasionally mild blurring of vision.  If you notice these, move your dose down one pill and continue that dose until your next appointment.  

Are there any serious side effects?

           Though there have been deaths due liver failure, the patients  were generally less than 2 years old, and were taking other anti-seizure medications.  In adults, on Depakote only, the rate of liver problems is the same as it is in those not taking any medications at all.   There have been reported cases of pancreatitis from Depakote also, but this too is very rare.  

If your first blood tests are ok, current practice does not require repeat blood tests.  If you find you are bruising or bleeding easily, or if you have nausea and vomiting after you™ve been used to Depakote for weeks, call for instructions.

What about pregnancy?

           This medication can definitely cause abnormalities in all trimesters of pregnancy.  You must avoid a pregnancy while taking it.  Tell your doctor how you will avoid becoming pregnant.  

Preventing weight gain
Weight gain is very common at medium or high doses, but not common at 1000mg or less.   Fortunately, it does not œsneak up? on you.   You will notice a huge increase in appetite first.  You want to eat frequently, eat a lot, and even feel hungry just after eating.  

Fortunately again, the appetite increase is like a light switch: it™s either œon?, or œoff?.   If you notice your appetite go up, then move the dose down, you will almost always find a lower dose that does not produce this effect.  As you lower the dose, the œswitch? goes œoff? for almost everyone (rarely, some just have to stop).    

Recently the makers of Depakote produced an extremely slow release version of their pills they believe causes less trouble with this unusual appetite increase, and thus does not cause weight gain.  If Depakote ER is available to you, use it.  People can get their dose higher with this version than the older one, in most cases, and it doesn't cost anymore.

How do I start?

A)    Depakote 500 mg ER
One per night to start; then 2 per night; then 3 per night.  You can increase daily if your symptoms are severe.  But if you can afford to go a bit slower, you can then evaluate what each dose level does for you, and stop at the lowest possible dose.  In that case, you should increase as slowly as every 4 to even every 7 days (there is probably not much benefit in going any slower than that).   Stop at the lowest does that controls your symptoms; go back to a lower dose if you have side effects that are not decreasing quickly.

B)     Depakote 250 mg regular tablets
This form requires both a morning and evening dose.  Increase by 1 pill per day from 1 in the morning and 1 in the evening, each taken with meals at first.  As soon as it is clear that nausea is not a problem, you may take the pills at the most convenient times (not necessarily with meals).   Add a pill to the evening dose, then the morning, then the evening again, as you go up.
Increase every 3-7 days until you™re clearly responding (continue that dose); or get a side effect (decrease until the side effect goes away and contact your doctor for a new plan).  The highest you can go before seeing your doctor is 1500mg (3 pills a.m., and 3 pills p.m.).

Does Depakote interact with other medications?  

           Depakote itself does not cause major interaction problems.  Other medications may bump Depakote off of its riding place in the blood (protein molecules) and raise the amount of Depakote that actually affects your cells.  So if you start taking another medicine after Depakote and get new side effects, it could be Depakote side effects caused by this interaction.  Moderate doses of aspirin can do this, so use Tylenol instead.  

           Most of these interactions do not pose any threat to you; most likely would be an increase in side effects from Depakote or from the other medication.  

Is this addictive?

           There is no œaddiction?: if you stop, there is no œcraving?.  You might just get your old symptoms back.  Because Depakote is an anti-seizure medication, though, it is best not to stop it suddenly.  In theory, a sudden stop can cause a seizure.  In practice, we have not seen this happen, but just to be safe, do not let yourself run out of this medication.  If you are going to stop, do so by gradually lowering the dose, one pill at a time, over a week.

 

Revised Jan 2004