Depakote Level is Low & Having Tremors
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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.


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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