All About Lithium

AMI/FAMI does not endorse particular drugs. However, many of our relatives are on Lithium. If you have questions, discuss it with your doctor. This report was written by Jean K. Bouricus for the National Allilance for the Mentally Ill (1 800 950 NAMI)

Background

Lithium carbonate is the drug most commonly used to treat bipolar (manic/depressive) illness. Valproic acid and Tegretol are also frequently used, sometimes in combination with lithium. There are different brands of lithium in tablets, capsule, & liquid form: Lithotabs, Lithane, Lithonate, Eskalith, Cibalith, & Lithobid. Lithobid is a slow release version that helps diminish side effects. Lithobid may cause diarrhea. Lithium is usually effective in the treatment of the manic phase & in acute bipolar depression. It serves as a mood stabilizer and is helpful in 70-80% of bipolar patients.

Lithium in the treatment of mania & depression.

Since it may require 2 to 3 weeks for lithium to control manic symptoms, the doctor will often prescribe an antipsychotic like Haldol during this time. There have been a few reports of what appeared to be a toxic reaction to the combo of Haldol & lithium. This might be due to the fact that lithium blood levels in these cases were found to be somewhat high. Physicians using combinations of lithium & antipsychotics, should closely monitor patients.

When the manic symptoms disappear, the antipsychotic usually will be discontinued, but the lithium continued. Some patients on lithium occasionally have "breakthrough depressions". They may respond to an increase in the dosage (up to 1.2 milliequivalents per liter (mEq/L)) or the addition of an antidepressant. When depressions occur in patients who have been taking lithium, & whom are able to tolerate a higher dose, it is possible that the dosage has been inadequate..

Even depressed patients who have never had a manic episode sometimes respond well to lithium. Some patients who have not responded to (tricyclic) antidepressants, even after several weeks of treatment, have been given lithium along with their antidepressant & have shown significant improvement.

Lithium in the treatment of schizophrenia.

Lithium is also useful in treating schizoaffective disorders where there is schizophrenic thought disorder accompanied by a change in mood (either excitement or depression). Some think lithium plus an antipsychotic may be the best treatment for this illness. However, it is questionable whether schizophrenics who have no affective disorder (strong emotions not related to what is happening in the environment) will respond to this combo.

Poor response to lithium is sometimes due to a failure to follow the prescribed schedule. 25 to 50% of patients on lithium fail to take it as prescribed.

Cautions

A patient should have a physical exam before lithium is started. Kidney function, thyroid, blood salts, & blood cell count should be checked & an ECG considered.

There are some patients who probably should not be given lithium, such as patients with kidney or heart disease, those who are taking thiazide diuretics for high blood pressure, those who are severely debilitated, & those who require low sodium diets. Low sodium intake can result in toxic lithium blood levels.

Lithium Dosages

Supervision of the lithium blood level is extremely important. If the level is too low, the symptoms will not be controlled. If it is too high, the resulting toxic condition can be very dangerous.

The correct dosage of lithium is partly determined by the weight of the patient. An average beginning dose is about 300 milligrams 2 to 4 times a day. Blood measuring should be done twice weekly for the first 2 weeks, once a week for the next 3 or 4 weeks, at 2 week intervals for the next 2 months, then monthly. The best time to draw the blood is 12 hours after the patient has taken his last dose.

The desired blood level is usually between .6 & 1.2mEQ/L. A level higher than 1.5 mEq/L may be unsafe. Levels below .5 to .6 mEq/L should be considered adequate only for some elderly persons or those who can't tolerate more. For patients who object to having blood drawn, there is a way of checking the lithium via saliva.
If a patient who has been taking lithium stops, they may experience anxiety, tension, palpitation, nausea, diarrhea, restlessness, & headaches.

Side Effects of Lithium

Among the side effects may be nausea, loss of appetite, & mild diarrhea. They are common during the early weeks, but usually diminish with time. Patients may also experience dizziness & a fine tremor of the hands. Tremors are less likely if the dose is increased slowly, rather than rapidly. They may be diminished if the patient takes smaller doses several times a day. The use of Lithobid, may also reduce the severity of tremors. 40 to 80 mg. per day of Inderal (propranolol) can control tremors. However, Inderol will also lower blood pressure & reduce the heart rate. Sudden discontinuation of Inderol may result in anxiety & tremulousness.

Patients with kidney disease should not be given lithium. Increased production of urine & excessive thirst are two side-effects which are usually not problems. Midamor, twice a day, can reduce the urine problem. To prevent kidney damage, patients should be maintained on the lowest effective dose. It was found that taking all the lithium in one daily dose at bedtime diminished the urine problem.

Other potential side effects include weight gain, hypothyroidism, increased white blood cell count, skin rashes, & birth defects.

If the concentration of lithium becomes too great, more serious problems will appear. Nausea may become more severe & there may be vomiting, diarrhea, sluggishness, dizziness, muscle twitchings, & an irregular heartbeat. Any of these signs are likely to be present for several days & should send a patient promptly to a doctor to have his blood level of lithium measured.

Drug Interactions.

Lithium can interact with many different drugs including Ibuprophin (Advil, etc.), Acetazolamide, Antihypertensives, Anti inflammatory drugs, Calcium channel blockers, Carbamazepine, diuretics, hydroxyzine, ibuprofen, inderal, procardia, marijuana, muscle relaxants, neuroleptics, table salt, baking powder, tetracycline, tricyclic antidepressants, MAO inhibitors, caffeine, an other drugs. If you or your relative use any of these, you should discuss the possible side effects with your doctor.