Interactions
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:
Aspirin: may increase valproate concentrations. May also interfere with valproates metabolism. Benzodiazepines: may cause CNS depression and there are possible pharmacokinetic interactions. Carbapenem antibiotics: reduce valproate levels, potentially leading to seizures. Cimetidine: inhibits valproates metabolism in the liver, leading to increased valproate concentrations. Erythromycin: inhibits valproates metabolism in the liver, leading to increased valproate concentrations. Ethosuximide: valproate may increase ethosuximide concentrations and lead to toxicity. Felbamate: may increase plasma concentrations of valproate. Mefloquine: may increase valproate metabolism combined with the direct epileptogenic effects of mefloquine. Oral contraceptives: may reduce plasma concentrations of valproate. Primidone: may accelerate metabolism of valproate, leading to a decline of serum levels and potential breakthrough seizure. Rifampicin: increases the clearance of valproate, leading to decreased valproate concentrations
Warfarin: valproate may increase free warfarin concentration and prolong bleeding time. Zidovudine: valproate may increase zidovudine serum concentration and lead to toxicity. Pharmacology
Pharmacodynamics
Although the mechanism of action of valproate is not fully understood, traditionally, its anticonvulsant effect has been attributed to the blockade of voltage-gated sodium channels and increased brain levels of gamma-aminobutyric acid (GABA).
While developmental delay is usually associated with altered physical characteristics (dysmorphic features), this is not always the case.Children of mothers taking valproate during pregnancy are at risk for lower IQs. Maternal valproate use during pregnancy increased the probability of autism in the offspring compared to mothers not taking valproate from 1.5% to 4.4%. 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 1 in 44 (2.3%). 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 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 or decrease their dose of valproate. 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 worse outcomes for the fetus than exposure to valproate). Studies have shown that taking folic acid supplements can reduce the risk of congenital neural tube defects.