Question

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.

Questions

From your perspective as Yicheng’s psychiatric nurse practitioner, answer the following questions in a paper no longer than two double-spaced pages (not including the reference page) and in APA format. Include at least three peer-reviewed, evidence-based references.

1. Explain why Depakote ER was prescribed for Yicheng.
2. Articulate how Depakote ER is metabolized and the mechanism of action, as well as how Depakote is excreted.
3. Describe the baseline laboratory and other monitoring that should be done when a patient is prescribed Depakote ER.
4. Based on Yicheng’s current Depakote level, describe how you would adjust the Depakote dose, including what dose you would prescribe and the scheduling/time of the dose.
5. When would you order the next Depakote level? What additional laboratory tests would you order? How often should the Depakote level be ordered?
6. What side effects of Depakote should you discuss with Yicheng?

Answer 1

Solution:

1. Depakote ER is prescribed for Yicheng because he is admitted in the hospital with the case of manic episode and have bipolar disoreder. Depakote ER contain Divalproex sodium which will increase the neurotransmitter called GABA gamma aminobutyric acid which will calm the nerves thus preventing the manic episodes of the patient.

2. Metabolism:

Metabolism of Depakote ER takes place in liver. It is metabolised by Cytochrome P450 enzymes present in the liver. About 50% of the administered dose of Depakote ER is excreted through urine as glucoronide conjugate.

Mechanism of action:

The administered dose of Depakote ER is converted to valproic acid in the stomach. The valproic acid then will increase the neurotransmitter called GABA(gamma aminobutyric acid). Also it has been said that valproic acid will block the voltage gated sodium channel promoting increased GABA transmition. GABA has the property to stabilise the nerves and thus calms the manic episodes.

Excretion:

Less than 3% of orally administered dose of Depakote ER is excreted unchanged in urine. 45% of excreted products in urine is from beta oxidation and about 50 to 60 % is by glucuronidation.

3. The given are the monitering factors on depakote administration

Depakote ER can cause liver damage. VPA related liver damage can be observed by blood test. Hyperammonenemia can be seen which may cause the patient to have gastrointestenial abnormalities like nausea vomitin, diarrhoea etc. Patients may also show REYE's like syndrome which is dangerous.

Nurses should monitor the symptoms like nausea, tremours, hairloss, anorexia and diarrhoea.

4. Dosage adjustment in Depakote ER;

As DEpakote ER is administered orally it is advised to take a initial dose of 25mg/kg/day. Yicheng is about 95kg, so 2375mg of Depakote ER can be administered per day approximatly by considering his other lab values and biological factors. The maximum dose of 60mg/kg/day is recommended in patients. the dose can be increased from initial dose into lowest possible concentration to get a desired clinical effect.