When should a patient stop taking Depakote (valproate) prior to Coronary Artery Bypass Grafting (CABG)?

Depakote (Valproate) Does Not Require Discontinuation Before CABG

Depakote (valproate) does not need to be stopped prior to CABG surgery, as it is not included in any guideline recommendations for preoperative medication discontinuation. The major cardiology guidelines specifically address antiplatelet agents, anticoagulants, and GP IIb/IIIa inhibitors, but make no mention of antiepileptic drugs like valproate requiring discontinuation 1, 2.

Medications That DO Require Discontinuation Before CABG

The following medications have specific discontinuation timelines that should not be confused with valproate:

Antiplatelet Agents (Class I Recommendations)

• Clopidogrel and ticagrelor: Discontinue at least 5 days before elective CABG 1, 2
• Prasugrel: Discontinue at least 7 days before elective CABG 1, 2
• Aspirin: Continue perioperatively (100-325 mg daily) 1, 2

Anticoagulants

• Enoxaparin: Discontinue 12-24 hours before CABG, transition to unfractionated heparin 1, 2
• Fondaparinux: Discontinue 24 hours before CABG, transition to unfractionated heparin 1, 2
• Bivalirudin: Discontinue 3 hours before CABG, transition to unfractionated heparin 1, 2
• Unfractionated heparin: Continue until surgery 1, 3, 2

GP IIb/IIIa Inhibitors

• Eptifibatide or tirofiban: Discontinue 2-4 hours before surgery 1, 2
• Abciximab: Discontinue at least 12 hours before surgery 1, 2

Valproate-Specific Considerations for Surgery

While valproate does not require discontinuation, the FDA label highlights important perioperative monitoring considerations:

Bleeding Risk Monitoring

• Check platelet counts and coagulation parameters before surgery due to valproate's effects on platelet function and coagulation 4
• Valproate can cause thrombocytopenia, inhibit secondary phase of platelet aggregation, and cause abnormal coagulation parameters (e.g., low fibrinogen) 4
• In clinical trials, 27% of patients receiving ~50 mg/kg/day had platelet counts ≤75 × 10⁹/L 4

Key Distinction

The guidelines explicitly state not to confuse medications like duloxetine with antiplatelet or anticoagulant medications requiring preoperative discontinuation 2. The same principle applies to valproate—it is not an antiplatelet or anticoagulant agent requiring routine discontinuation.

Common Pitfalls to Avoid

• Do not discontinue valproate unnecessarily, as this could precipitate breakthrough seizures in patients with epilepsy 5
• Do not confuse valproate with antiplatelet agents that have specific discontinuation requirements 2
• Do ensure preoperative laboratory monitoring of platelets and coagulation parameters given valproate's known hematologic effects 4
• Communicate valproate use to the surgical team so they can monitor for potential bleeding complications 3

Postoperative Management

• Resume valproate as soon as feasible postoperatively to maintain seizure control, as there are no guidelines recommending prolonged discontinuation after CABG 5
• Continue monitoring platelet counts and coagulation parameters in the immediate postoperative period 4