Yicheng Wong is a 53-year-old widowed Asian male who comes to see you in your office after he was hospitalized for 14 days for a manic episode. Yicheng has bipolar I disorder. He is currently prescribed 1500 mg of divalproex sodium (Depakote ER). He is 5’ 11” and 210 lbs. His most recent VPA level was 45 µg/ml.
What laboratory testing should be ordered prior to starting Depakote?
What is the normal reference range for monitoring Depakote level?
Based on his depakote level and how he presents to you, what changes (if any) would you make with Yicheng’s Depakote ER? Why or why not? Provide the dose, route, and timing/frequency for all medication changes
When would you check another Depakote level (that is, how many days after starting or changing the dose, what time of day/how long after the last dose would you check it)?
Depakote Case Analysis
Valproic acid (VPA) is normally utilized to treat mania in the cases of bipolar disorder. Its normal therapeutic range is estimated at 50 to 125 mcg/mL of the value of the total serum concentration figure. The VPA has a high efficacy to albumin which further constitutes free drug concentrations that are directly responsible for the derived therapeutic effect. This paper analyses Yicheng’s case study to establish how his VPA levels can be increased to a normal range.
Before starting Depakote, serum liver tests or blood tests should be administered to ensure that the Depakote levels fall within the normal range. Notably, low levels will make Depakote ineffective while too much will be considered as toxic. The normal reference range for Depakote level monitoring is 50-100 mcg/Ml. A value greater than 100mcg/mL is considered toxic (Bentley & Staros, 2019). Yicheng’s Depakote level is below the minimum required range since its current value is recorded as 45 mcg/mL. In this case, it is necessary to adjust the equation to normalize the VPA serum concentrations.
In this case, the patient’s Depakote ER dosage will be increased from 1500 mg to 4000 mg a day to maintain the normal VPA levels (Jackson, McCollum, Ognibene, Diaz & De Leone, 2015). After the changes in the dosage, VPA serum levels will be assessed 2 to 4 days later (Vickery & Vickery, 2017). Additionally, specific goal of the intended clinical effect when adjusting the VPA dose will be considered. The test will be administered one to four hours after the patient takes the last dosage. Taking the test at this point is recommended since the VPA levels will be at its peak values. Alternatively, the test can also be accomplished immediately before the next dose is administered to the patient as this is considered to be more useful in comparison to peak value times (Labcorp, 2020).
Bentley, S. & Staros, B. (2019). Valproic Acid Level. Medscape. Retrieved from https://emedicine.medscape.com/article/2090462-overview
Jackson, J., McCollum, B., Ognibene, J., Diaz, F. & De Leone, J. (2015). Three Patients Needing High Doses of Valproic Acid to Get Therapeutic Concentrations. Case Reports in Psychiatry. https://doi.org/10.1155/2015/542862
Labcorp, (2020). Valproic Acid, Serum or Plasma. Retrieved on 24th June, 2020 from https://www.labcorp.com/tests/007260/valproic-acid-serum-or-plasma
Vickery, B. & Vickery, S. (2017). Is your patient’s valproic acid dosage too low or high? Adjust it with this equation. Current Psychiatry, 16(4), e1-e2