Valproate history

Several studies suggest that valproate is effective in patients with a history of lithium treatment failure. In the study by Pope et al. [1991), 71% of patients receiving valproate exhibited an antimanic response, even though all of the patients had a history of lithium treatment failure or intolerance. Sixty-four percent of the patients with rapid-cycling bipolar disorder studied by Galabrese and Delucchi [1990) had a history of lithium failure, and the majority of these subsequently responded to valproate. Similarly, the six patients with rapid-cycling bipolar disorder described by McElroy et al. 

Bowden et al. [1994b] observed that a history of lithium nonresponse predicted lithium nonresponse, but not valproate nonresponse. Taken together, these studies suggest that a history of lithium nonresponse does not predict valproate nonresponse. Notably, no studies have examined whether a history of valproate treatment failure predicts future valproate or lithium response. 

ECT should be considered for more severe forms of depression (e.g., those associated with melancholic and psychotic features, particularly when the patient exhibits an increased risk for self-injurious behavior) or when there is a past, well-documented history of nonresponse or intolerance to pharmacological intervention. Limited data indicate that bipolar depressed patients may be at risk for a switch to mania when given a standard TCA. A mood stabilizer alone (i.e., lithium, valproate, carbamazepine, lamotrigine), or in combination with an antidepressant, may be the strategy of choice in these patients. Some elderly patients and those with acquired immunodeficiency syndrome may also benefit from low doses of a psychostimulant only (e.g., methylphenidate) (see also Chapter 14, The HIV-Infected Patient ). Fig. 7-1 summarizes the strategy for a patient whose depressive episode is insufficiently responsive to standard therapies. 

The authors commented that the manic symptoms had probably been caused by glucocorticoids or glucocorticoid withdrawal. They concluded that patients with cluster headache and a history of affective disorder should not be treated with glucocorticoids, but with valproate or lithium, which are effective in both conditions. Lamotrigine, an anticonvulsive drug with mood-stabilizing effects, may prevent glucocorticoid-induced mania in patients for whom valproate or lithium are not possible (101). 

A 30-year-old man with a history of major depression and panic disorder had been in remission for a year with citalopram 20 mg/day, valproate 600 mg/day, and alprazolam 3 mg/day (23). The citalopram was tapered over 3 weeks to 5 mg/day and then withdrawn. The day after the last dose he experienced anxiety and irritability together with frequent short-lasting bursts of dizziness, not having had the latter previously panic and depression did not recur and after a week the symptoms resolved spontaneously. 

A 55-year-old man who had taken lithium and halo-peridol for 11 years developed hyperkeratotic follicular papules on his scalp, extremities, and trunk, which on biopsy were suggestive of follicular mycoses fungoides (409). He also had a 1-year history of scalp, axillary, and pubic hair loss. Following replacement of lithium with valproate, his hair regrew and the papules cleared almost completely in 3 months. 

Valproate should be avoided in patients with a personal or family history of liver disorders or pancreatic dysfunction (75,119). 

At least 132 patients have died of liver failure (and/or pancreatitis) (75). Risk factors include mental retardation, congenital abnormalities, neurological disorders, a family history of hepatic disease, the addition of valproate within 3 months of liver dysfunction, and concomitant salicylate use. 

The medications known as anticonvulsants are often used as front-line treatment of the bipolar disorders. The most common of these medications include Tegretol (carbamazepine), Depakene or Depakote (valproate or valproic acid), and Klonopin (clonazepam), and they are used under the following circumstances (a) inadequate response or intolerance to antipsy-chotics or lithium (b) manic symptoms (c) rapid cycling of the condition (d) EEG abnormalities and (e) head trauma (Kaplan Sadock, 1996). In practice, these medications seem particularly effective for clients who suffer from schizoaffective disorders or agitated depression of a cyclic nature. They are considered the medication of choice if an individual has a history of brain damage or of severe or rapid mood swings (Dulcan, 1999). Furthermore, if an individual has atypical features of the mental... 

An isolated report deseribes a 20-year-old woman, with a 7-year history of epilepsy (bilateral myoelonus and generalised tonic-clonic seizures) controlled with sodium valproate 1.3 g daily, who developed tonic-clonic seizures 8 hours after taking the second of 3 prophylactic doses of mefloquine 250 mg. It is not clear whether this resulted from a drug-drug or a drug-disease interaction. The manufacturers of mefloquine advise its avoidance in those with a history of convulsions as it may increase the risk of convulsions. In these patients mefloquine should he used only for curative treatment if compelling reasons exist. ... 

Drug overdose In a study of 9809 consecutive adults and adolescents with self-poisoning during a 6-month period, there were 474 with non-benzodiazepine antiepileptic drug intoxication [103. The most frequent motivation was intentional intoxication (95.3%). There was no association between antiepileptic drug intoxication and a history of parasuidde, sex, age, or occupation. The most frequent drug involved was carbamazepine ( = 117), followed by phenobarbital ( =77) and sodium valproate ( = 51). 

Drug overdose A 38-year-old man with alcoholism and a history of drug abuse attempted suicide with valproate and developed a... 

Carbapenems An old Chinese man with epilepsy had seizures when meropenem was added to treatment with valproate [407 ]. In a retrospective study of six critically ill patients taking valproate who concurrently received meropenem (n = 4), imipenem (n = 1), or ertapenem (n = 1) mean plasma valproate trough concentrations fell by 58% and estimated mean valproate clearance increased by 191% compared with values obtained while they were not receiving a carbapenem five patients had generalized seizures during concurrent valproate -b carbapenem treatment, including two with no prior history of seizures [408 ]. Meropenem is an enzyme inducer. Because of this pharmacokinetic interaction, concurrent use of these medications should be avoided. 

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