Lithium

Question 1

Indications

Answer 1

Mood stabiliser - mainly immediate, long-term and prophylactic control of BAD

Also: Mania, recurrent depression. aggressive behaviour

Nb. causes little interference with normal emotional reactions

Question 2

When should Li levels be checked?

Answer 2

12 hours after administration

Also check U+Es and TFTs

Question 3

What can lithium be augmented with for BAD?

Answer 3

Carbamazapine + atypical A/P (risperidone and olanzapine)

Question 4

Early SE?

Answer 4

Diabetic symptoms (polyuria, polydipsia, fatigue)
Nausea
Tremor
Drowsy

Question 5

Late SE?

Answer 5

Renal toxic (Nb. if increased Li levels suspect progressive nephrotoxicity)
Thyrotoxic –> hypothyroidism
Weight gain
Arrythmia (QTc prolongation)

Question 6

Drug interactions?

Answer 6

Diuretics and ACE-i (renal toxicity)
NSAIDS (ibuprofen)
Alcohol
SSRIs?

Question 7

Therapeutic window?

Answer 7

0.4-1 mmol/L

> 1 = toxicity
1.5 –> blurred vision, D+V, delirium, confusion
2 severe toxicity

If toxic: give fluids and stop Li –> start diuresis and check levels for 1 week

Question 8

What needs to be done before starting lithium?

Answer 8

Baseline tests:
Bloods - U+Es, TFTs, eGFR/creatinine, corrected serum calcium
Weight, BP
ECG, pulse

Question 9

Possible lithium contraindications?

Answer 9

Heart, kidney, thyroid problems and psoriasis

Do not give in first trimester, use with caution after that (only if really needed)
Do not breast-feed - risk of toxicity

Question 10

How should it be taken?

Answer 10

Start on one tablet a day - do not chew or crush the tablet
Always get the same brand from pharmacist
Do not stop taking it without consulting doctor first

If you miss a dose, can take normal dose within 3 hours - if not do not double the dose

Question 11

Warning signs to look out for?

Answer 11

Head: Drowsy, fainting, lethargy, slurred speech, tremor, blurred vision, convulsions
GI: D+V, loss of appetite, urinary retention/polyuria

Seek urgent medical help!
Carry a lithium card (available from pharmacist)

Question 12

Initial monitoring

Answer 12

Blood tests - 12 hours post dose
When starting or changing dose of lithium - measure Li levels every 5-7 days until 2 similar results are achieved at same dose

Aim for 0.6-0.8 for patients being prescribe Li for the first time

Question 13

Regular monitoring

Answer 13

Every 3 months for Li levels and U+Es
TFTs every 6 months
Calcium and creatinine every 12 months

Question 14

General advice for patient?

Answer 14

Drink plenty of fluids
Maintain usual salt intake and avoid changes to diet
Consult doctor if heavy sweating, D+V
No more than 1-2 units of alcohol a day