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Lithium
Lithium Monitoring:
Baseline: TSH, Calcium, CBC diff, electrolytes, BUN/SCr, ECG (if >45 or CVD)
Follow-up:
Q6mo: TSH, CBC diff, electrolytes, BUN/SCr, Lithium level
Q2yr: Calcium
Q5yr: ECG (if >45 or CVD)
Drug Levels (bipolar disorder):
5 days after starting then weekly for 2 weeks then every 6 months or when new drug initiated
Most important interactions:
ACE-Inhibitors –Increases lithium levels by 35% causing possible toxicity.
NSAID – Increases lithium levels (>100% with some NSAIDs) causing possible toxicity.
Caffeine – Decreases lithium levels. May worsen tremor.
Thiazides/K sparing diuretics – Increases lithium levels.
B-blockers – Increases lithium levels. May improve tremors.
Lithium Monitoring:
| System | Monitoring | ADE | Incidence | Recommendation | |
| Baseline | Follow-up | ||||
| CNS | Physical Exam | PRN for signs &
symptoms |
Tremors, incoordination, weakness | 30-60% | Check level, reduce dose, eliminate caffeine, consider BB |
| Cardiac | ECG (if >45 or CVD) | Every 5 years (if >45 or CVD) | QRS widening, benign T wave changes, bradycardia | 20-30% | Clinical Judgement |
| Renal | Electrolytes | Every 6 months | Polyuria polydypsia diabetes insipidus | Up to 60% | Usually reversible, consider d/c |
| BUN SCr | Every 6 months | Renal Failure | Consider d/c | ||
| GI | Physical Exam | PRN for signs &
symptoms |
Nausea, vomiting, diarrhea | 20-50% | Administer with food, consider slow release formulation |
| Endocrine | TSH | Every 6 months | Hypothyroidism | Up to 30% | Initiate levothyroxine |
| Calcium | Every 2 years | Hyperparathyroidism Hypercalcemia | 10-40% | Clinical judgment | |
| Physical Exam | PRN for signs & symptoms | Irregular or prolonged menstrual cycles | 15% | Clinical judgement | |
| Hematologic | CBC diff | Every 6 months | Leucopenia leukocytosis | 2-10% | Generally transient, use clinical judgement |
References:
Yatham LN, Kennedy SH, O'Donovan C, Parikh S, MacQueen G, McIntyre R et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disorders. 2005;7(Suppl 3):5-69
Therapeutic Choices (5th Ed). Bipolar disorder. 78-96
Clinical Handbook of psychotropic drugs (17th Ed). 2007;173-181