A TREATMENT FOR EPILEPSY

AND TO HELP AS A MOOD STABILISER

Drugs known as anticonvulsants or mood stabilisers

DRUG:- SODIUM VALPROATE, VALPROIC ACID and VALPROATE SEMISODIUM

Sodium valproate, valproic acid, divalproex and valproate semisodium (sometimes also called divalproex) are different forms of the same drug. They are virtually the same and so, on these pages, all the information refers to just valproate, which applies exactly the same to the other forms as well. Valproate semisodium ("Depakote") may have slightly less side effects at the high doses needed when someone is manic.

What is valproate used for ?

Valproate has two main uses. Firstly as a treatment for epilepsy, to help control the fits (seizures or blackouts). Secondly, to help in mood disorders, especially if the person is suffering from mania or hypomania i.e. is "high") and as a longer-term mood stabiliser (and alternative to lithium and carbamazepine). Valproate may also be useful in some other illnesses, particularly when other treatments have not been effective.

How does valproate work ?

It is not entirely clear exactly how valproate works (both as a mood stabiliser and as an anticonvulsant) as it does several things in the brain. Firstly, there is a chemical messenger (or "neurotransmitter") in the brain called GABA, which is "inhibitory" on the brain i.e. it calms the brain down. Once it has worked there are other chemicals (or "enzymes") in the brain which are there to break GABA down so that it can no longer work. In people with normal levels of GABA this prevents there being too much GABA. In some people it is thought that there may not be enough GABA in the brain. This lack of GABA seems to "trigger" fits or over-activity/mania. Valproate helps to stop the breakdown of GABA and so leaves enough of this chemical in the brain to help prevent the fits, blackouts and over-activity. Secondly, it may inhibit "repetitive firing" of neurones. When a message is passed, there is a short "refractory" period or gap before the next message can be passed, during which time the nerve ending re-sets itself (about one thousandths of a second, if you're interested). Valproate may increase this "refractory" period or time by a small amount. Under normal circumstances, this will make no difference at all, but if the brain is overactive and lots of messages are being passed in quick succession e.g. when you are feeling high, the effect of the valproate will be to slow the number of messages back to the normal level e.g. if the next message follows along before the nerve has reset itself, the message can't be passed.

How should I take them ?

Tablets:

The tablets should be swallowed with at least half a glass of water whilst sitting or standing, so that they reach your stomach and do not stick in your throat.

It is especially important that you swallow "enteric coated" tablets or capsules (all except the 100mg Epilim) whole and do not crush or chew them. The coating helps to prevent any stomach upsets that could occur. Crushing or chewing will cause the drug to be released too soon and you may get some side-effects. Sodium valproate tablets which are not enteric coated (i.e. Epilim 100mg) may be crushed if necessary.

Taking fizzy drinks (e.g. Colas) with the 100mg tablets and syrups may lead to more stomach upsets. If this happens, it may be best not to drink too many fizzy drinks.

Liquids:

Sodium valproate is available as a syrup and as a sugar free liquid. Your pharmacist should give you a medicine spoon or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one.

If it is necessary for you to have an injection it will be given by a nurse or doctor.

When should I take my valproate ?

Take it as directed on the medicine label. It is best to take valproate after food. It is particularly important to take this regularly as directed by your doctor to make sure that you are getting the best control from your medication. Missing a dose can cause your fits to return.

How long will valproate take to work ?

Valproate should start to work soon after you start to take it. It may, however, take some time for your doctor to get the right dose for you. The aim is for the amount of medicine in your blood to be high enough to prevent or reduce fits, but low enough to give you the least amount of side-effects. Do not attempt to make any changes yourself unless specifically told to do so.

How long will I need to keep taking valproate for ?

Valproate is a "preventative medicine". It is therefore important that you keep taking valproate until your doctor tells you to stop. Do not stop taking it just because you feel better. If you stop them before you are advised to do so your fits may get worse. (See also 'What should I do if I forget to take a dose').

Is valproate addictive ?

Valproate is not addictive. For further discussion, click here.

Can I stop taking valproate suddenly ?

This is a "preventative medicine". Never stop taking this medication suddenly or without advice from your doctor as this might mean an increase in your fits or blackouts. When the time comes to stop your valproate, this will usually be by a slight reduction in your dose every few weeks.

What should I do if I forget to take a dose ?

Start again as soon as you remember unless it is almost time for your next dose, then go on as before. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet. If you are ill and vomit after taking your valproate, you should take that dose again. You should tell your doctor about either of these next time you meet. Missing a dose can cause your fits to return. The amount in your blood may drop below the level needed to control your fits.

If you have problems remembering your doses (as very many people do) ask you pharmacist, doctor or nurse about this. There are some special packs, boxes and devices which can be used to help you remember.

What sort of side-effects might occur ?

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission (www.ukppg.org.uk )

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

Will valproate make me drowsy ?

You may feel sleepy to start with so you must take care if you are allowed to drive or when operating any type of machinery. This effect should wear off after you have been taking them for a while.

Will valproate cause me to put on weight ?

Valproate can cause some people to become more hungry and they may then put on weight. A few people may put on weight even without eating more. If you start to put on weight or have problems with your weight, your doctor can arrange for you to see a dietician for advice.

Will valproate affect my sex life?

Drugs can affect desire (libido), arousal (erection) and orgasmic ability. Valproate has not been reported to have a major adverse effect on these three stages. However, if this does seem to happen, you should discuss this with your doctor, as a change in dose may help minimise any problem.

Can I drink alcohol while I am taking valproate ?

There is not a complete ban on drinking alcohol if valproate is taken, but make sure you do not take more than one or two drinks a day as it may make you feel more sleepy. This is particularly important if you are allowed to drive or operate machinery and you must seek advice on this.

Are there any foods or drinks that I should avoid ?

Fizzy drinks (e.g. Colas) can produce stomach upsets if taken with the uncoated Epilim tablets (100mg) or syrup. This does not happen with the other tablets or capsules. Other than this you should have no problems with any food or drink other than alcohol (see above).

Will valproate affect my other medication ?

If you are taking enteric coated tablets or capsules, do not take indigestion remedies at the same time of day. This is because indigestion remedies contain alkalis, substances which can break down the coating of the tablet before it reaches the stomach. You may then get more side effects. If you need to take something for indigestion wait for at least 2 hours after taking your sodium valproate EC tablets or capsules.

Antidepressants and antipsychotic drugs can decrease the effect of this drug. Make sure your doctor knows if you are on either of these, or any other medication as he or she will be able to adjust your medication accordingly. If you have a headache it is best to take paracetamol rather than aspirin while you are taking valproate. This does not necessarily mean that some of these drugs can not be used together, just that you may need to follow your doctors instructions very carefully.

If I am taking a contraceptive pill, will this be affected ?

It is not thought that the contraceptive pill is affected by valproate.

What if I want to start a family or discover I'm pregnant?

It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Federal Drug Administration) classifies medicines in pregnancy in five groups:

Valproate is classified as "D". There is some evidence of problems e.g. a 1 in 100 chance of spina bifida and a "valproate syndrome". You will need to seek personal advice from an expert, as counselling and screening at a specialist centre is recommended. Taking folic acid supplements throughout pregnancy (and possibly before) may reduce this risk. You will of course also need to consider the risk of relapse if you stop your valproate. One study suggested that there might be a slightly higher chance of a child having higher educational needs if the mother took valproate throughout pregnancy, but this has not been proven yet. If you are taking valproate for epilepsy, then you will need to also consider the risk of seizures as well, if the medication is stopped.

Will I need blood tests ?

For the first 6 months of treatment you will need a regular blood test (e.g. every month) to check that the drug is not affecting your liver.

You may also then need to have blood tests from time to time to make sure that the dose of valproate is enough and not too much or too little for you.

Can I drive whilst taking valproate ?

If you have epilepsy, it is essential that you report this, as well as sudden disabling attacks of loss or partial loss of consciousness, to the 'Driver and Vehicle Licensing Centre' (DVLC). The DVLC will then make a medical assessment of your condition consulting with your doctor(s) where necessary. For more information see leaflet 'D100' ('What you need to know about driving licensing') which is available from most post offices, or contact the Driver Enquiry Unit, DVLC, SWANSEA SA6 7JL. (Telephone: 01792 772151 between 8.15 am. to 4.30 pm. on Monday to Friday). You will need to quote your Driver Number whether you write or telephone. If you are taking valproate to help stabilise your moods, it is not necessary to do this. Your doctor will be able to advise you, and may wish to access the UK Driver and Vehicle Licensing Agency (DVLA) guidelines website, which has the current DVLA guidelines on anxiety/depression, psychotic disorders, mania and other conditions or for epilepsy. If your doctor advises you not to drive, and you continue to do so, the doctor can inform the DVLA directly, as he or she would be lawfully responsible were you to have an accident. Once told, the DVLA may wish to carry out an enquiry, but you are entitled to drive until there a decision is made.

If you are allowed to drive remember that valproate can make you drowsy when you first start taking it, so care should be taken when driving or operating any type of machinery.

Email your comments or feedback.
Several developments have been as a result of feedback from visitors.

No site can be entirely bias-free. No matter how hard someone tries, training and background will always influence your outlook. We have, however, tried to eliminate bias, and we hope you take these pages in the spirit in which they are provided i.e. a genuine attempt to inform, educate and support.

Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.  

Email your comments or feedback.
Many developments have been as a result of feedback from visitors.

No site can be entirely bias-free. No matter how hard someone tries, training and background will always influence your outlook. We have, however, tried to eliminate bias, and we hope you take these pages in the spirit in which they are provided i.e. a genuine attempt to inform, educate and support.

Information here is based on published data. References include the UK British National Formulary (BNF, published by the British Medical Association and Royal Pharmaceutical Society of Great Britain), Martindale (the extra pharmacopoea, published by RPSGB Pharmaceutical Press), Psychotropic Drug Directory (latest edition), Data Sheet Compendium (UK Manufacturers Data Sheets, published by the Association of British Pharmaceutical Industry), MicroMedex (an independent and extensive CD-ROM based drug information source), UK Psychiatric Pharmacy Group leaflets, Royal College of Psychiatrists advice and guidelines and the current medical literature. Thanks also to all those people who left e-mail comments, suggestions and requests, who have helped shape the site.