From the Guidelines
Valproic acid is not recommended as a first-line treatment for agitation in hospice patients, as there is limited evidence supporting its use in this context, and other medications such as antipsychotics or benzodiazepines may be more effective. The available evidence suggests that antipsychotics, such as risperidone or haloperidol, may be more effective in managing agitation in hospice patients, particularly when the agitation is related to delirium or perceptual disturbances 1. Benzodiazepines, such as lorazepam or midazolam, may also be useful in managing severe agitation and distress, but their use should be limited to the shortest period possible due to the risk of increased patient agitation and delirium 1.
When considering the use of valproic acid in hospice patients, it is essential to weigh the potential benefits against the risks, including sedation, gastrointestinal upset, tremor, and potential liver toxicity. The medication requires monitoring for side effects, and blood level monitoring may be necessary to ensure therapeutic ranges are maintained. However, in the absence of strong evidence supporting its use in agitation, other medications may be more appropriate.
In terms of dosing, if valproic acid were to be considered, typical dosing starts at 125-250mg twice daily, with gradual titration as needed up to 500-1000mg daily in divided doses, though lower doses are often sufficient in frail or elderly hospice patients. The medication is available in multiple formulations, including oral solution, sprinkles, and syrup, which can be advantageous for patients with swallowing difficulties. Ultimately, the choice of medication should be based on a comprehensive approach that includes non-pharmacological interventions and assessment of underlying causes of agitation.
Key considerations in managing agitation in hospice patients include:
- Assessing the underlying cause of agitation
- Using non-pharmacological interventions whenever possible
- Selecting medications based on the specific cause and presentation of agitation
- Monitoring for side effects and adjusting medications as needed
- Considering the use of antipsychotics or benzodiazepines as first-line treatments for agitation in hospice patients, rather than valproic acid.
From the Research
Valproic Acid for Agitation in Hospice Patients
- Valproic acid may be effective in treating agitation in hospice patients, as suggested by a retrospective study published in The American journal of hospice & palliative care 2.
- The study found that valproic acid was used as monotherapy in 10 patients, with no additional antipsychotic or benzodiazepines needed, and may be a useful alternative to traditional treatments for agitation in palliative care.
Effectiveness and Safety of Valproic Acid
- A systematic review published in Psychopharmacology found that intravenous valproate seems efficacious in reducing agitation in psychiatric patients, and generally appears safe compared to other neuroleptics or antiepileptics 3.
- Another study published in Clinical therapeutics found that valproic acid may be an alternative option to assist in the management of agitation and delirium in the ICU, with a downward trend in the prevalence of agitation and delirium observed during valproic acid therapy 4.
- A retrospective cohort study published in The Annals of pharmacotherapy found that valproic acid is frequently prescribed in agitated, delirious patients and may have a role in the management of ICU delirium, with delirium resolution occurring in 55% of patients 5.
Use of Valproic Acid in Critically Ill Patients
- A retrospective cohort study published in Journal of intensive care medicine found that valproic acid is safe and can assist in the prevention of polypharmacy and overall workload in critically ill patients admitted primarily for cardiogenic shock and respiratory failure requiring mechanical ventilation 6.
- The study also found that valproic acid decreased the need for sedatives, and a 10 mg/kg loading dose decreased the risk for initiating additional psychoactive medications by day 3 of therapy.
Key Findings
- Valproic acid may be a useful alternative to traditional treatments for agitation in hospice patients 2.
- Valproic acid seems efficacious in reducing agitation in psychiatric patients, and generally appears safe compared to other neuroleptics or antiepileptics 3.
- Valproic acid may be an alternative option to assist in the management of agitation and delirium in the ICU 4, 5.
- Valproic acid is safe and can assist in the prevention of polypharmacy and overall workload in critically ill patients 6.