13 hours ago

Shannon Rowland 

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Adverse Reaction to Depakote

As a nurse working in a skilled nursing facility you will frequently see patients with dementia and Alzheimer’s disease with orders for Depakote also known as valproic acid, to manage their behaviors. I had a resident that was taking Depakote for the diagnosis of dementia with behavioral disturbance. She got into an altercation with her roommate and had to be moved which intensified her behaviors and agitation. The doctor increased her Depakote due to the increased behaviors. The resident’s behaviors improved. Later the resident began to have a decline in condition and we all believed that she was having transient ischemic attacks (TIA). The resident had a history of TIAs. We placed the resident on comfort care and discontinued all of her medications. A short time after discontinuing her medication the resident became more alert and was functioning at her prior level. Her physician believed that her decline was from the Depakote because she had no other new medications or medication changes.

Pharmacokinetics & Pharmacodynamics

Depakote is typically used to treat seizure disorders but can be used as a mood stabilizer. Many providers prefer to use Depakote for behaviors with geriatric population than antipsychotics because of their side effects. Depakote is easily absorbed when taken orally. It is rapidly distributed into plasma, extracellular water, and crosses the blood-brain barrier (Deglin, Vallerand, & Sanoski, 2009, p. 1263). Depakote binds easily to protein which results in low clearance of the medication (Ghodke-Puranik, et al., 2013).  Depakote is metabolized in the liver and excreted in the urine. Depakote increases the levels of GABA, an inhibitory neurotransmitter in the CNS which is involved in controlling cortical excitability (Pravat, Krity, & Aroma, 2017).  According to Puerta & Ramirez (2015), “Significant reductions in GABA levels have been described in severe cases of AD, which could be underlying the behavioral and psychological symptoms of AD. 

Influencing Factor of Adverse Effect to Depakote

This patient may have been having an adverse reaction to Depakote due to impaired hepatic function. As we age the liver’s ability to metabolize many substances decreases (Siddoqui, 2017). The level of Depakote likely built up in this patient’s bloodstream related to impaired ability to metabolize the medication and the kidneys functions also decline as we age so execration may be impaired. What I have learned from this experience is that geriatric patients should have a hepatic function panel and comprehensive metabolic panel before starting to rule out impairment. A valproic acid level should be drawn during the course of treatment periodically to ensure that the medication is not at a toxic level.

References

Ghodke-Puranik, Y., Thorn, C. F., Lamba, J. K., Leeder, J. S., Song, W., Birnbaum, A. K., … Klein, T. E. (2013). Valproic acid pathway: pharmacokinetics and pharmacodynamics. Pharmacogenetics and genomics, 23(4), 236–241. doi:10.1097/FPC.0b013e32835ea0b2

Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2009). Daviss drug guide for nurses. Philadelphia: F.A. Davis.

Puerta, M.S.,  & Ramirez, M.J.(2015). Treatment options in Alzheimer’s disease: the gaba story. Current Pharmaceutical Design. 21(34). 4960-71. doi:  10.2174/1381612821666150914121149

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