Bipolar Treatments- Lithium

Question 1

Which stages of BPD don’t respond well to Li?

Answer 1

Rapid cyclers and mixed states

Question 2

Li metabolism

Answer 2

It’s not metabolized, it’s 100% excreted unchanged in the urine

Question 3

Li is best in what stage of BPD?

Answer 3

Euphoric mania

(Onset of mania is 6-10 days, full effects in ~3 weeks, >4 weeks for AD effects)

Question 4

Li works best in what kinds of BPD patients?

Answer 4

People with fewer prior episodes and less complicated features

Question 5

Li is first-line treatment in what phases of BPD?

Answer 5

Acute mania, acute bipolar depression, and maintenance in BP-I and BP-II

Used alone or in combination with other drugs (VPA, CBZ, APS) for the acute treatment of mania and for maintenance treatment

Question 6

Li can unmask what disease?

Answer 6

Brugada Syndrome

Question 7

Li is CI’ed in what diseases?

Answer 7

Severe renal or cardiac disease (or with dehydration or Na depletion)

Also CI’ed in breastfeeding

Question 8

Li is known to decrease risk of…

Answer 8

…suicide

Question 9

Li dosing

Answer 9

900-2,400mg/day in 2-4 divided doses, take with food

Question 10

Long-term effects of Li on the kidneys

Answer 10

Polydipsia and polyuria with or without NDI could occur

AKI most common effect, CKD also reported

Question 11

Li’s effect on renal function

Answer 11

may experience morphological changes; STAY HYDRATED and avoid use in patients with preexisting renal disease and concomitant use with drugs that affect renal function

Question 12

Li’s effect on GI and CNS effects

Answer 12

Dose-related and worst at the peak

Maintain at lowest effective dose, try QD (XL) dosing HS, take with food, change to liquid formulation if diarrhea present

Question 13

Li’s effect on muscle weakness and lethargy

Answer 13

Tremor will develop in about 50% of patients but will subside with continued use

Reduce tremor with switch to long-acting preparations, lower dose if possible, or add a beta-blocker (propranolol)

Question 14

Li and cardiac effects

Answer 14

Baseline cardiology consult recommended because the results could be benign and reversible to AV block and bradycardia

Question 15

Li’s effects on the thyroid gland

Answer 15

Li concentrates in the thyroid gland and interferes with thyroid synthesis –> induces formation of thyroid antibodies

Some patients will develop goiter or clinical hypothyroidism but is NOT DOSE-RELATED

MONITOR TSH, may be reversible, may use supplementation

Question 16

Examples of meds to avoid in Li therapy that affect renal function

Answer 16

NSAIDs, ACEIs, ARBs

Question 17

LI ADE considerations

Answer 17

Li isn’t good for non adherent patients; must maintain good hydration, avoid meds that affect renal function

Question 18

Li monitoring: labs

Answer 18

SCr, BUN, baseline PE, general chemistry, CBC with diff, FG, lipids, weight, waist circumference, thyroid function tests, serum electrolytes, dermatologic (it can cause acne)

Question 19

Li monitoring: serum concentration

Answer 19

0.6-1.2 mEq/L!! Anything >1.5 is toxic

Question 20

Li therapeutic response and serum concentration

Answer 20

Not directly related to serum concentration

Question 21

When to take a serum concentration of Li

Answer 21

Best at TROUGH level 8-12 hours after last dose- 5 days after stable dose is achieved to determine “steady state” or sooner if you suspect toxicity or non-adherence

Question 22

Meds that can increase Li levels

Answer 22

ACEis, ARBs, NSAIDs, thiazides

Question 23

Meds that can DECREASE Li levels

Answer 23

mannitol and methyl-xanthines (CAFFEINE)