|Systematic (IUPAC) name|
|Trade names||Convulex, Depakote, Epilim, Stavzor, Vilapro|
|Licence data||US FDA:|
|Metabolism||Hepatic—glucuronide conjugation 30–50%, mitochondrial β-oxidation over 40%|
|Biological half-life||9–16 hours|
|CAS Registry Number|
|Molecular mass||144.211 g/mol|
|(what is this?)|
Valproate (VPA, valproic acid) is an acidic organic compound that has found clinical use as an anticonvulsant and mood-stabilizing drug, primarily in the treatment of epilepsy, bipolar disorder and prevention of migraine headaches. VPA is a liquid at room temperature, but it can be reacted with a base such as sodium hydroxide to form the salt sodium valproate, which is a solid.
The acid, salt, or a mixture of the two (valproate semisodium) are marketed under a number of different brand names, including: Convulex, Depakote, Epilim, Valparin, Valpro, Vilapro and Stavzor. It is on the World Health Organization's List of Essential Medicines, a list of the most important medications needed in a basic health system.
- 1 Medical uses
- 2 Adverse effects
- 3 Mechanism of action
- 4 History
- 5 Society and culture
- 6 Formulations
- 6.1 Brand names of valproic acid
- 6.2 Brand names of sodium valproate
- 6.2.1 Portugal
- 6.2.2 United States
- 6.2.3 Australia
- 6.2.4 New Zealand
- 6.2.5 UK
- 6.2.6 Germany, Switzerland, Norway, Finland, Sweden
- 6.2.7 South Africa
- 6.2.8 Malaysia
- 6.2.9 Romania
- 6.2.10 Canada
- 6.2.11 Japan
- 6.2.12 Europe
- 6.2.13 Taiwan
- 6.2.14 Israel
- 6.2.15 India, Russia and CIS countries
- 6.3 Brand names of valproate semisodium
- 7 References
- 8 Further reading
- 9 External links
Its primary use in medicine is in the treatment of epilepsy, bipolar mania and to protect against the development of migraines. Valproate products are also used to treat manic or mixed episodes associated with bipolar disorder. Off-label uses include impulse control disorders, suggested by recent evidence of efficacy in controlling this adverse effect of Parkinson's disease medical therapy. Recently, it has been trialled in the treatment of HIV and cancer, owing to its histone deacetylase-inhibiting effects. Valproate has a broad spectrum of anticonvulsant activity, although it is primarily used as a first-line treatment for tonic-clonic seizures, absence seizures and myoclonic seizures and as a second-line treatment for partial seizures and infantile spasms. It has also been successfully given intravenously to treat status epilepticus.
The most common adverse effects of valproic acid are digestive complaints like diarrhea, nausea, vomiting and indigestion; vision problems like seeing double or lazy eye; hormonal disturbances (increased testosterone production in females and menstrual irregularities), hair loss, memory problems, weight gain, infections, low platelet count (which can make one bleed more easily), dizziness, drowsiness, tremor and headache. Less common, yet serious side effects include liver damage, brittle bones (becomes far more common with long-term use), polycystic ovaries, movement disorders (which may be irreversible like tardive dyskinesia), psychiatric/neurologic disturbances like hallucinations, anxiety and confusion; pancreatic inflammation, low body temperature and potentially life-threatening blood abnormalities.
Other possible side effects
There is evidence that valproic acid may cause premature growth plate ossification in children and adolescents, resulting in decreased height. Valproic acid can also cause mydriasis, a protracted dilation of the pupils.
Valproate causes birth defects; exposure during pregnancy is associated with about three times as many major abnormalities as usual, mainly spina bifida with the risks being related to the strength of medication used and use of more than one drug. More rarely, with several other defects, possibly including a "valproate syndrome". Characteristics of this valproate syndrome include facial features that tend to evolve with age, including a triangle shaped forehead due to earlier than normal fusion of the metopic suture, tall forehead with bifrontal narrowing, epicanthic folds, medial deficiency of eyebrows, flat nasal bridge, broad nasal root, anteverted nares, shallow philtrum, long upper lip and thin vermillion borders, thick lower lip and small downturned mouth. While developmental delay is usually associated with altered physical characteristics (dysmorphic features), this is not always the case.
A recent study showed children of mothers taking valproate during pregnancy are at risk for significantly lower IQs. Maternal valproate use during pregnancy has been associated with a significantly higher risk of autism in the offspring. A 2005 study found rates of autism among children exposed to sodium valproate before birth in the cohort studied were 8.9%. The normal incidence for autism in the general population is estimated at less than one percent. It is possible to duplicate features characteristic of autism in humans by exposing rat embryos to valproic acid at the time of neural tube closure. Valproate exposure on embryonic day 11.5 led to significant local recurrent connectivity in the juvenile rat neocortex, consistent with the underconnectivity theory of autism. A 2009 study found that the 3 year old children of pregnant women taking valproate had an IQ nine points lower than that of a well-matched control group. However, further research in older children and adults is needed.
Sodium valproate has been associated with the rare condition paroxysmal tonic upgaze of childhood, also known as Ouvrier-Billson syndrome, from childhood or fetal exposure (this condition resolved after discontinuing valproate therapy.
Women who intend to become pregnant should switch to a different medication if possible. Valproate may best be avoided in women with localisation epilepsy, where more effective and less risky alternatives, such as carbamazepine, are available. Women who become pregnant while taking valproate should be warned that it causes birth defects and cognitive impairment in the newborn, especially at high doses (although valproate is sometimes the only drug that can control seizures, and seizures in pregnancy could have even worse consequences.) They should take high-dose folic acid and be offered antenatal screening (alpha-fetoprotein and second-trimester ultrasound scans), although screening and scans do not find all birth defects. Women who are already pregnant and taking high doses of valproate should try to lower their doses.
- Pre-existing acute or chronic liver dysfunction or family history of severe liver inflammation (hepatitis), particularly medicine related.
- Known hypersensitivity to valproate or any of the excipients used in the preparation
- Urea cycle disorders
- Hepatic porphyria
- Mitochondrial disease
Valproate inhibits CYP2C9, glucuronyl transferase, and epoxide hydrolase and is highly protein bound and hence may interact with drugs that are substrates for any of these enzymes or are highly protein bound themselves. It may also potentiate the CNS depressant effects of alcohol. It should not be given in conjunction with other antiepileptics due to the potential for reduced clearance of other antiepileptics (including carbamazepine, lamotrigine, phenytoin and phenobarbitone) and itself. It may also interact with:
- Anticoagulants, due to its ability to prolong the bleeding time.
- Psychotropic agents; potential pharmacokinetic interactions.
- Benzodiazepines; may potentiate CNS depression and there are possible pharmacokinetic interactions.
- Ethosuximide; potential for ethosuximide toxicity.
- Primidone; may reduce pyrimidone's clearance leading to toxicity.
- Zidovudine; may raise its (zidovudine's) serum concentration and lead to toxicity.
- Aspirin; may displace valproate from plasma proteins, leading to increased plasma concentrations. Also interferes with valproate's metabolism.
- Felbamate; may increase plasma concentrations of valproate.
- Mefloquine; potential for increased valproate metabolism combined with the direct epileptogenic effects of mefloquine.
- Cimetidine; inhibits valproate's metabolism in the liver, hence leading to increased plasma concentrations of valproate.
- Erythromycin; inhibits valproate's metabolism in the liver, hence leading to increased plasma concentrations of valproate.
- Carbapenem antibiotics; reduces valproate levels, potentially leading to seizures.
Overdose and toxicity
|Form||Lower limit||Upper limit||Unit|
|50||125||µg/mL or mg/l|
|Free||6||22||µg/mL or mg/l|
Excessive amounts of valproic acid can result in tremor, stupor, respiratory depression, coma, metabolic acidosis, and death. In general, serum or plasma valproic acid concentrations are in a range of 20–100 mg/l during controlled therapy, but may reach 150–1500 mg/l following acute poisoning. Monitoring of the serum level is often accomplished using commercial immunoassay techniques, although some laboratories employ gas or liquid chromatography. In contrast to other antiepileptic drugs, at present there is little favorable evidence for salivary therapeutic drug monitoring. Salivary levels of valproic acid correlate poorly with serum levels, partly due to valproate's weak acid property (pKa of 4.9).
In severe intoxication, hemoperfusion or hemofiltration can be an effective means of hastening elimination of the drug from the body. Supplemental L-carnitine is indicated in patients having an acute overdose and also prophylactically in high risk patients. Acetyl-L-carnitine lowers hyperammonemia less markedly than L-carnitine.
Mechanism of action
Although the mechanism of action of valproate is not fully understood, it has recently been shown to protect against a seizure-induced reduction in phosphatidylinositol (3,4,5)-trisphosphate (PIP3) as a potential therapeutic mechanism. In addition, its anticonvulsant effect has been attributed to the blockade of voltage-dependent sodium channels and increased brain levels of gamma-aminobutyric acid (GABA). The GABAergic effect is also believed to contribute towards the anti-manic properties of valproate. In animals, sodium valproate raises cerebral and cerebellar levels of the inhibitory synaptic neurotransmitter, GABA, possibly by inhibiting GABA degradative enzymes, such as GABA transaminase, succinate-semialdehyde dehydrogenase and by inhibiting the re-uptake of GABA by neuronal cells. It also possesses histone deacetylase-inhibiting effects. The inhibition of histone deacetylase, by promoting more transcriptionally active chromatin structures, likely presents the epigenetic mechanism for regulation of many of the neuroprotective effects attributed to valproic acid. Intermediate molecules mediating these effects include VEGF, BDNF, and GDNF.
Valproic acid was first synthesized in 1882 by B.S. Burton as an analogue of valeric acid, found naturally in valerian. Valproic acid is a carboxylic acid, a clear liquid at room temperature. For many decades, its only use was in laboratories as a "metabolically inert" solvent for organic compounds. In 1962, the French researcher Pierre Eymard serendipitously discovered the anticonvulsant properties of valproic acid while using it as a vehicle for a number of other compounds that were being screened for antiseizure activity. He found it prevented pentylenetetrazol-induced convulsions in laboratory rats. It was approved as an antiepileptic drug in 1967 in France and has become the most widely prescribed antiepileptic drug worldwide. Valproic acid has also been used for migraine prophylaxis and bipolar disorder.
Society and culture
|Epilepsy||Yes||Yes||Yes||Limited (depends on the seizure type; it can help with certain kinds of seizures: drug-resistant epilepsy, partial and absence seizures, can be used against glioblastoma and other tumors both to improve survival and treat seizures, and against tonic-clonic seizures and status epilepticus).|
|Acute migraine management||No||No||No||Only negative results.|
|Schizophrenia||No||No||No||Weak and mostly negative evidence.|
|Agitation in dementia||No||No||No||Weak and mostly negative evidence.|
|Fragile X syndrome||Yes (orphan)||No||No||Limited.|
|Familial adenomatous polyposis||Yes (orphan)||No||No||Limited.|
|Chronic pain & fibromyalgia||No||No||No||Limited.|
|Alcohol hallucinosis||No||No||No||One randomised double-blind placebo-controlled trial.|
|Intractable hiccups||No||No||No||Limited, five case reports support its efficacy, however.|
|Non-epileptic myoclonus||No||No||No||Limited, three case reports support its efficacy, however.|
|Cluster headaches||No||No||No||Limited, two case reports support its efficacy.|
|West syndrome||No||No||No||A prospective clinical trial supported its efficacy in treating infantile spasms.|
|HIV infection eradication||No||No||No||Double-blind placebo-controlled trials have been negative.|
|Myelodysplastic syndrome||No||No||No||Several clinical trials have confirmed its efficacy as a monotherapy, as an adjunct to tretinoin and as an adjunct to hydralazine.|
|Acute myeloid leukaemia||No||No||No||Two clinical trials have confirmed its efficacy in this indication as both a monotherapy and as an adjunct to tretinoin.|
|Cervical cancer||No||No||No||One clinical trial supports its use here.|
|Malignant melanoma||No||No||No||One phase II study has seemed to discount its efficacy.|
|Breast cancer||No||No||No||A phase II study has supported its efficacy.|
|Impulse control disorder||No||No||No||Limited.|
|Systematic (IUPAC) name|
|CAS Registry Number|
|Molecular mass||166.20 g·mol−1|
|(what is this?)|
Valproate exists in two main molecular variants: sodium valproate and valproic acid without sodium (often implied by simply valproate). A mixture between these two is termed semisodium valproate. It is unclear whether there is any difference in efficacy between these variants, except from the fact that about 10% more of sodium vaproate is needed than valproic acid without sodium to compensate for the sodium itself.
Brand names of valproic acid
Branded products include:
- Absenor (Orion Corporation Finland)
- Convulex (G.L. Pharma GmbH Austria)
- Depakene (Abbott Laboratories in US and Canada)
- Depakine (Sanofi Aventis France)
- Depakine (Sanofi Synthelabo Romania)
- Depalept (Sanofi Aventis Israel)
- Deprakine (Sanofi Aventis Finland)
- Encorate (Sun Pharmaceuticals India)
- Epival (Abbott Laboratories US and Canada)
- Epilim (Sanofi Synthelabo Australia)
- Stavzor (Noven Pharmaceuticals Inc.)
- Valcote (Abbott Laboratories Argentina)
- Valpakine (Sanofi Aventis Brazil)
Brand names of sodium valproate
- Tablets – Diplexil-R by Bial.
- Intravenous injection – Depacon by Abbott Laboratories.
- Syrup – Depakene by Abbott Laboratories. (Note Depakene capsules are valproic acid).
- Depakote tablets are a mixture of sodium valproate and valproic acid.
- Tablets – Eliaxim by Bial.
- Epilim Crushable Tablets Sanofi
- Epilim Sugar Free Liquid Sanofi
- Epilim Syrup Sanofi
- Epilim Tablets Sanofi
- Sodium Valproate Sandoz Tablets Sanofi
- Valpro Tablets Alphapharm
- Valproate Winthrop Tablets Sanofi
- Valprease tablets Sigma
- Epilim by Sanofi-Aventis
- Depakote Tablets (as in USA)
- Tablets – Orlept by Wockhardt and Epilim by Sanofi
- Oral solution – Orlept Sugar Free by Wockhardt and Epilim by Sanofi
- Syrup – Epilim by Sanofi-Aventis
- Intravenous injection – Epilim Intravenous by Sanofi
- Extended release tablets – Epilim Chrono by Sanofi is a combination of sodium valproate and valproic acid in a 2.3:1 ratio.
- Enteric-coated tablets – Epilim EC200 by Sanofi is a 200-mg sodium valproate enteric-coated tablet.
- Capsules – Episenta prolonged release by Beacon
- Sachets – Episenta prolonged release by Beacon
- Intravenous solution for injection – Episenta solution for injection by Beacon
Germany, Switzerland, Norway, Finland, Sweden
- Tablets – Orfiril by Desitin Pharmaceuticals
- Intravenous injection – Orfiril IV by Desitin Pharmaceuticals
- Syrup – Convulex by Byk Madaus
- Tablets – Epilim by Sanofi-synthelabo
- Tablets – Epilim by Sanofi-Aventis
- Companies are SANOFI-AVENTIS FRANCE, GEROT PHARMAZEUTIKA GMBH and DESITIN ARZNEIMITTEL GMBH
- Types are Syrup, Extended release mini tablets, Gastric resistant coated tablets, Gastric resistant soft capsules, Extended release capsules, Extended release tablets and Extended release coated tablets
- Intravenous injection – Epival or Epiject by Abbott Laboratories.
- Syrup – Depakene by Abbott Laboratories its generic formulations include Apo-Valproic and ratio-Valproic.
- Tablets – Depakene by Kyowa Hakko Kirin
- Extended release tablets – Depakene-R by Kyowa Hakko Kogyo and Selenica-R by Kowa
- Syrup – Depakene by Kyowa Hakko Kogyo
In much of Europe, Depakine and Depakine Chrono (tablets) are equivalent to Epilim and Epilim Chrono above.
- Tablets (white round tablet) – Depakine (Chinese: 帝拔癲; pinyin: di-ba-dian) by Sanofi Winthrop Industrie (France)
Depalept and Depalept Chrono (extended release tablets) are equivalent to Epilim and Epilim Chrono above. Manufactured and distributed by Sanofi-Aventis.
- Valprol CR by Intas Pharmaceutical (India)
- Encorate Chrono by Sun Pharmaceutical (India)
- Serven Chrono by Leeven APL Biotech (India)
Brand names of valproate semisodium
- Brazil – Depakote by Abbott Laboratories
- Canada – Epival by Abbott Laboratories
- Mexico – Epival and Epival ER (extended release) by Abbott Laboratories
- United Kingdom – Depakote (for psychiatric conditions) and Epilim (for epilepsy) by Sanofi-Aventis and generics
- United States – Depakote and Depakote ER (extended release) by Abbott Laboratories and generics
- India – Valance and Valance OD by Abbott Healthcare Pvt Ltd,Divalid ER by Linux laboratories Pvt Ltd,Valex ER by Sigmund Promedica, Dicorate by Sun Pharma
- Germany – Ergenyl Chrono by Sanofi-Aventis and generics
- Chile – Valcote and Valcote ER by Abbott Laboratories
- France and other European countries — Depakote
- Peru – Divalprax by AC Farma Laboratories
- China – Diprate OD
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- PsychEducation: Valproate/divalproex (divalproex)
- The Comparative Toxicogenomics Database:Valproic Acid
- Chemical Land21: Valproic Acid
- RXList.com: Depakene (Valproic Acid) (U.S.)
- South African Electronic Package Inserts: Convulex
- Med Broadcast.com: Valproic Acid (Canadian)