Lithium

Mood stabilizer (neuroprotective; restores circadian biology; inhibition of Inositol monophosphatase, adenylyl-cyclase, GMP, glycogen synthase kinase 3; serotonin increase)

Dosing

By serum level. Target: Bipolar or unipolar depression (0.6-0.8), Mania (0.8-1.1), Maintenance in bipolar I (0.8). Lower target by 30% in elderly, but same targets in children. ER better tolerated. Start 300mg and raise by 300mg/wk if tolerability is at stake, otherwise raise every 2-5 days (use ½ those doses if they are taking something that interacts with lithium). Check levels 5 days after target dose. LIQUID: Lithium citrate each 8meq/5ml = 300mg.

Management

Warn of tremor, thirst, but weight gain is rare (if only drink water), as is fatigue (1:28). Nearly all side effects treatable with antidotes or by lowering dose. Hypothyroidism (is treatable, and can give to patients with thyroid problems). Lithium works best when thyroid is optimized (tsh around 2.5). Renal impairment (explain as “the kidneys slow with age, and lithium can rarely make that worse so we check labs and stop if needed”). To prevent renal damage give NAC 1-2,000 daily and keep level < 0.8). Rare acne, psoriasis (use omega-3/inositol for psoriasis). Cardiac risks: t-wave flattening/inversion, S-A node dysfunction, bradycardia, and rare ventricular premature contractions. Baseline EKG may be needed if patient > 45 years or has a cardiac condition.

> Medical Benefits: lower risk of dementia, cancer, heart disease, stroke, anti-aging properties (prevents damage to DNA).

> Toxicity is the main risk. Avoid drug interactions, dehydration. If they are taking a medicine that can raise lithium levels, best to cut the dosing in half (by using lithium 150mg – only lithium carbonate comes in this small size) and then check leve at a lower dose (e.g. 450mg/d instead of 900mg/d).

> Drug interactions are unpredictable; their potency varies widely by patient. Warn of OTC interaction with NSAIDs (ibuprofen, naproxen), but aspirin/Tylenol are OK, and the prescription NSAID clinoril is usually OK. Fear the thiazide and loop diuretics (the “-ides”, eg hydrochlorothiazide), ACE inhibitors (the “-prils”, eg lisinopril), and angiotensin II antagonists (the “-sartans”, eg losartan), and some antibiotics (metronidazole, tetracycline). Best for ‘Classic bipolar’ with clean separation of mania/depression, low rates of comorbidity (except panic), low rapid cycling/mixity. Only drug besides clozapine that reduces suicide risk. Good for childhood bipolar

EMR Text