Valproate in Females of Childbearing Age: Items to Consider
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As psychiatric mental health nurse practitioners (PMHNPs), the responsibility to ensure the safety and well-being of our patients is paramount. One need-to-know topic revolves around the use of valproate (Depakote) in females of childbearing age, especially given the risks associated with pregnancy. Let's dive into the considerations that should guide our decision-making process.
As a brief aside… remember Depakote, while a great treatment option in the prevention and reduction of mania, does come with a variety of side effects. Relatively common side effects include: hair loss, weight gain, nausea, drowsiness, and dizziness. Less common side effects can include: hepatotoxicity, low platelets, pancreatitis, memory impairment, hyperammonemia, encelopathy, & PCOS. Not to mention need for frequent blood level monitoring. To review some of presenting signs of Depakote toxicity see here. All of this to say… while Depakote is a great treatment option, there are a variety of potential drawbacks. Once you add in the risks associated with it’s use in pregnancy, it becomes outright difficult to justify. This will be the focus of the post today.
Risks of Valproate During Pregnancy
Neural Tube Defects: Exposure to Depakote in the first trimester significantly increases the risk of neural tube defects, like spina bifida.
Cognitive Impact: Studies suggest children exposed to valproate in utero may exhibit lower IQ scores compared to those exposed to other antiseizure medications.
Congenital Malformations: Risks of other congenital malformations, such as cleft palate, heart defects, and urogenital disorders, are heightened with valproate use.
Because of these risks, the use of valproate is contraindicated in pregnancy.
Weighing the Risks for Females of Childbearing Age
For females of childbearing age, the decision to prescribe valproate necessitates a thorough risk-benefit analysis:
Alternative Treatments: With the availability of antipsychotics like seroquel which are functionally similar to mood stabilizers & have a more favorable safety profile during pregnancy, the question arises: Why opt for Depakote? In the absence of an obvious answer, Depakote is likely a poor choice.
Efficacy and Patient Response: In few case, patients might have tried multiple mood stabilizers with limited success and found Depakote particularly effective. In cases of rapid cycling or mixed episodes, Depakote might offer superior control. The choice then leans on weighing the proven therapeutic efficacy for a particular patient against the potential risks.
Contraception: If Depakote is deemed essential for the patient's management and the patient isn't planning for pregnancy, effective contraception becomes crucial. A common recommendation is the utilization of two forms of birth control. Collaborate with the patient's gynecologist.
Patient Education & Autonomy: Ensure that patients are fully educated about the risks, allowing them to make informed decisions. It’s essential to respect patient autonomy, but this autonomy is meaningful only when backed by comprehensive knowledge.
if the patient is unwilling to utilize various forms of birth control & has a history of sexual promiscuity then Depakote is likely a poor treatment option as the risks of an unplanned pregnancy & subsequent birth defects becomes too high
The Case for Depakote Over Safer Alternatives
While other agents like Seroquel or other atypical antipsychotics are generally considered safer during pregnancy, there may be scenarios where continuing Depakote remains the preferable choice:
Prior Efficacy: For patients who have already achieved long-standing stability on Depakote, there might be hesitancy to switch medications. A change in medication could risk destabilizing their mood or reintroducing symptoms, especially if they have a history of being treatment-resistant.
Patient's Choice: Some patients, informed of the risks, may still choose the known stability of Depakote over the unpredictability of how they might respond to a new medication. Their autonomy and informed choice are paramount, especially if they have faced challenges with medication changes in the past.
Challenges of Medication Transition: Transitioning to a new medication isn't always straightforward. It can involve a period of tapering off Depakote while introducing and titrating the dose of the new drug. This transition period could pose risks of mood destabilization or the emergence of side effects.
Conclusion
While considering safer alternatives for pregnant patients or those planning for pregnancy is vital, it's equally essential to factor in the potential risks of switching medications, especially if the patient has historically responded well to Depakote. Collaboration, close monitoring, and open communication with the patient remain the pillars of such clinical decisions.