1. Lithium Practical Prescribing
Flavio Guzman, MD

2. Overview Monitoring Dosing Measurement of lithium levels
Therapeutic range
Drug interactions

3. Monitoring

4. Before starting lithium
Explain and discuss
Discuss with the patient risks of adverse effects
Women of childbearing age: uncertainty about risk of congenital malformations
Baseline blood tests
Physical exam
Waist circumference and BMI
McKnight, R. F et al (2012). Lithium toxicity profile: a systematic review and meta-analysis. The Lancet, 379(9817),

5. Blood tests before starting lithium
Urea
Creatinine
Electrolytes
Renal
Thyroid: TSH
Parathyroid: Serum Ca++
Endocrine
Malhi, Get al (2012). The science and practice of lithium therapy. Australian and New Zealand journal of psychiatry,46(3),

6. During lithium therapy
After 6 months
Renal
Urea
Creatinine
Thyroid: TSH
Every 12 months
Renal:
Electrolytes
Endocrine
Serum Ca++ (every 12 months)
Measure waist circumference and BMI
Malhi, Get al (2012). The science and practice of lithium therapy. Australian and New Zealand journal of psychiatry,46(3),

7. Prescribing information

8. Dosage forms Lithium preparations:
Lithium carbonate capsules: 150, 300, 600 mg
Lithium carbonate tablets: 300 mg
Lithium carbonate controlled-release tablets: 450 mg
Lithium carbonate slow-release tablets: 300 mg
Lithium citrate syrup 8 mEq/5 mL

9. Acute Maintenance Dosage range Lithium carbonate: 1200 - 1800 mg/day
Antimanic concentration of mEq/L
Maintenance
Lithium carbonate: mg/day
Maintenance levels of mEq/L
Eskalith (Lithium) [Prescribing Information] Research Triangle Park, NC: GSK, Inc. Accessed November 2014

10. How to start 300 mg/day 300 mg/day two or three times daily
Malhi, Get al (2012). The science and practice of lithium therapy. Australian and New Zealand journal of psychiatry,46(3),

11. How to start Increase 300 mg every 3 to 7 days as tolerated
Single dose at night reduces fatigue and sedation
Malhi, Get al (2012). The science and practice of lithium therapy. Australian and New Zealand journal of psychiatry,46(3),

12. When to measure lithium? Steady-state
Steady-state is reached after 4-5 half lives
Drug concentration
Half-lives

13. The 12-hour sampling interval
12-hour interval since last dose and the drawing of blood
Blood should be drawn in the morning
Drug should be in steady state
Janicak, P. Bipolar disorder in adults and lithium: Pharmacology, administration, and side effects.In: UpToDate, Keck, P , UpToDate, Waltham, MA Accessed November 2014

14. Measuring lithium levels
Therapeutic range:
mEq/L
PI: Mania
1.5 mEq/l
Malhi, Get al (2012). The science and practice of lithium therapy. Australian and New Zealand journal of psychiatry,46(3),

15. Measuring Low Mid-range High < 0.6 mEq/l 0.6-0.8 mEq/l
Malhi, Get al (2012). The science and practice of lithium therapy. Australian and New Zealand journal of psychiatry,46(3),

16. Initiation: mid-range
Measuring
Initiation: mid-range
mEq/l
Severus, W. E et at. (2008). What is the optimal serum lithium level in the long‐term treatment of bipolar disorder–a review?. Bipolar disorders, 10(2),

17. Drug Interactions

18. Lithium + other psychiatric drugs
Antipsychotics:
Lithium + AP: case reports of encephalopathy
Most frequently reported with haloperidol
May increase the risk of EPS and NMS
Anticonvulsants:
Shared adverse effects may be more pronounced
Tremor and weight gain with divalproex
Antidepressants:
Safe and effective
Janicak, P. Bipolar disorder in adults and lithium: Pharmacology, administration, and side effects.In: UpToDate, Keck, P , UpToDate, Waltham, MA Accessed November 2014

19. NSAIDs (Non-steroidal anti-inflammatory drugs)
Lithium + other drugs
NSAIDs (Non-steroidal anti-inflammatory drugs)
Most NSAIDs
Reduce lithium clearance
Aspirin and possibly sulindac appear to be exceptions
Thiazide diuretics
Increase serum concentrations
Eskalith (Lithium) [Prescribing Information] Research Triangle Park, NC: GSK, Inc. Accessed November 2014

20. Lithium + other drugs Less well established
May also cause lithium retention
Potassium-sparing diuretics:
Do not decrease lithium clearance
Other diuretics
Reported to cause lithium retention and toxicity in some patients
Angiotensin converting enzyme inhibitors and AT II antagonists
Eskalith (Lithium) [Prescribing Information] Research Triangle Park, NC: GSK, Inc. Accessed November 2014

21. Summary
Monitor renal function, thyroid, parathyroid and weight before and during treatment
Importance of 12-hour interval after the last dose
Lithium starting level: mEq/l
NSAIDs and thiazide diuretics can increase lithium levels

22. End of presentation