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Q: Depakote Level is Low & Having Tremors
Dear Dr. Phelps,
I have Bipolar I and take 2500 mg of Depakote, 100mg of Lamictal, 300mg of
Effexor XR, 10mg of Abilfy. At my last Depakote check my level was only at 50
mgdl. Why so low? I am having tremors already and wonder if I need more Depokote
or add another type of mood stabalizer. I'm still somewhat depressed and
confused about my Depakote readings.
Thanks,
Michael
Dear Michael --
Sometimes when a person takes multiple medications the liver speeds up its
metabolism and all the medication levels fall. You're right, that's a low level
for a sizable dose. None of the other medications you're taking is famous for
doing that to Depakote levels. (Remember, Depakote is raising Lamictal levels
so be careful if you end up stopping the Depakote; your doctor knows that and
that's probably why your lamotrigine dose is only about half of where we usually
head (although one can try to get as high as 400 with that stuff, which in your
case on Depakote would be 200 mg daily -- only at your doctor's direction, of
course).
Tremor is a common problem with combinations. You're
right, that should correlate with Depakote level, not dose. It could be
coming from one of the others, primarily; or just from the combination of
things. That's a medium high Effexor dose too, and that could be a significant
contributor to tremor. You could ask your doctor if more lamotrigine might be
substituted for the Effexor, trimming the med' list by one and moving to an
agent less potentially associated with tremor (don't do this on your own, of
course). Abilify is a bit of a mystery agent: I don't think we have enough
experience with it to know just what it might be contributing here.
Dr. Phelps
Published July, 2004
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