1. Valproate usually requires two weeks to take full effect, but a trial of four to six weeks should be completed before evaluating efficacy.
2. Serum levels, along with a CBC, platelet count, and PT/PTT should be obtained weekly during the first month of treatment and steady state levels are approximated in 2-3 days.
3. Divalproex (Depakote) is the best tolerated form of valproate and is often begun at a dosage of 20 • g/kg for rapid stabilization of mania. This roughly corresponds to 500 mg tid or 750 bid with titration up to a serum level of 50-125 mg/mL. The average dose is between 1500-3000 mg/day. Depakote ER (extended release) tablets (500 mg) allow for once a day dosing. Depakote ER has 80-90% bioavailability compared to Depakote.
4. Elderly patients require doses approximately half that of younger adults.
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