Lithium and Considerations

Psych Management
Psych Team

Don’t Avoid It

If you work in psych or healthcare, lithium can be a blessing or a nightmare. This post is about the nightmares and how to deal with them. Most medical references give some general information, and basically, if something goes wrong the patient needs to go to the ER.

However, I think the one problem is how the management of lithium is overwhelming or simply not addressed, thus many providers avoid it all together. I’m not crapping on anyone against using it because there are many other great alternatives that are not so risky….but lithium is too good of a medication to just ignore.

I have several patients on it when nothing else has worked, the person is constantly hospitalized, persistent depressive symptoms or aggression, and symptoms have successfully resolved. I also don’t want to spend time reinventing wheels, if something helps, let’s manage it so nobody ends up on the news.

First, I’ll discuss what lithium is treating, typical doses, and levels…then a summary about the considerations. I would also like to mention Stahl’s Prescriber Guide 7th ed. is a great reference for management but there are some things I don’t agree with but that’s okay because providers are faced with a ton of stuff that doesn’t fit into a guidebook. I also want to note that I work with a collaborative physician so I’m not just winging it completely solo. I always recommend having support and backup.

Prior to Prescribing: before even riding off into the lithium valley, the patient needs an EKG, CBC, electrolytes, thyroid and kidney function, and urine (lithium is metabolized by the kidneys and dosing adjustments may be required), and lastly a PREG test. These things could contraindicate starting lithium and so the provider may rightfully want to consider using other great alternatives….

The Basics

  • Treatment: lithium is the first line to treat mania, manic and depressive episodes in bipolar, schizoaffective disorder, and prophylaxis for mood disorders. Also commonly prescribed for vascular headache and MDD.
  • Class/Mechanism of Action: lithium is a mood stabilizer and works on the sodium ion channels but its MOA is primarily unknown

-Stahl

Blood level monitoring is required and correlates with clinical efficacy:

  • Acute Stabilization: 0.8-1.5 mEq/L
  • Prophylaxis/Maintenance 0.6-1.2 mEq/L

The Real World

A short case study. I inherit a patient doing well on lithium and over the summer the lithium level became toxic per PCP and now the family is on the phone panicking. They took the kid to the doctor because of increased thirst and headaches and the doctor referred them back to me. I asked them to go to the ER but the mother said she had to go to work and couldn’t take the child till the end of the week. I asked if they can call an ambulance, take an emergency day off work, take the kid to the hospital and I will talk to the staff but they declined all options… How to manage and why ME!?? 

Step 1: I assumed that maybe the level isn’t too bad or a false positive if the PCP didn’t send them directly to the ER (eventually they went to the ER and it was very high>1.2). But at the time, I asked the family to stop all sports, drink extra fluids, and d/c the dose. Therefore, step one is educating and DOCUMENTING. I told the family to seek immediate assistance but I can’t force them. Even if they were in my office, you can’t force people to do things they don’t want to do. I wasn’t judgmental or angry, I just kept letting them know the risks and the urgency. The purpose of documenting is self-explanatory but definitely in critical situations or when the patient/family refuses.

Step 2: More education/compliance. So this is for anyone prescribing or dealing with lithium. WE NEED COMPLIANCE. I inherit this patient but I probably wouldn’t have started the kid on lithium. This is actually a nice family but they sort of do what they want to do and usually don’t follow up so again reiterate the importance of getting levels to check and being more engaged. Also, providers have to be more mindful. I don’t watch sports so when the family said something about varsity, I’m quite sure it went over my head plus with the kid having (recent) headaches, he could’ve been using ibuprofen plus the summer months ALL equal lithium levels easily getting high. You have to let the family and patient know these risks; LOW NA+ equals HIGH LI+ so be mindful if the patient starts landscaping, mowing the lawn, drinking more coffee or other changes in fluids, playing sports, heat waves…etc. but this is why FOLLOW-UPS are IMPORTANT.

Factors that Increase Lithium

  • ASA (but not always)
  • Dehydration (N/V/D)
  • Impaired Renal Function
  • NSAIDS
  • Salt deprivation
  • Sweating (salt loss)
  • Thiazide diuretics

Step 3: Restart the med. The patient was in the ED for >10 hours for hydration but the organs were good so I let the family know, we can restart the medication. I reassured the family prior to them going to the hospital because it was the only thing that truly helped. I usually start low (so 150mg BID) then increase based on parameters, and work my way up (depending on mood and blood levels aka COMPLIANCE). Another thing that’s good about 150mg, is how I can double the dose without refilling to see if it’s tolerated, in other words, you can easily increase to like 2 tablets BID but remember, you’re increasing at least >1-week increments and consider the weight for ranges. Continue to educate and encourage the blood draws and follow-ups!

Side-Effects 

  • Initial: GI (N/V/D), hand tremors, sedating, polyuria, polydipsia, metallic taste
  • Long-Term: weight gain, dermatological, leukocytosis, hypothyroidism goiter, diabetes insipidus, acne, rash, hair loss

Toxicity 

  • Levels >1.5: coarse tremor, NVD, confusion, ataxia, slurred speech, lethargy (hold lithium for one day and reevaluate)
  • Levels >2.0 mEq/L: profound CNS depression, arrhythmia (T-wave flattening and inversion), seizures, coma, DEATH

EXTRA

I have another young patient who had an elevated lithium level but it wasn’t too high so we half the dose and he did well. Use the table to know your limits and parameters. Sometimes I’ll trial an increase to target the mood, but my increases are within the limits and only increase at least >1 week. The provider doesn’t have to completely stop lithium, it’s safer to taper off the medication if you want to discontinue.

Clinical Summary  

  • Make sure the patient qualifies to be on a lithium regimen, including minimal issues with COMPLIANCE.
  • Lithium is the DOC for rapid cycling and the only mood stabilizer shown to decrease suicidality. The biggest concern is the narrow therapeutic index (0.6-1.2). Lithium is not recommended in severe kidney or heart disease. Increased Epstein’s anomaly risks with pregnant women.
  • Educated to watch for signs of THIRST and the factors/activities that may increase the risk of high lithium levels. Stahl suggests tapering over 3 months but I just half the dose each week so instead of twice a day, I’ll do once a day for 1-2 weeks depending on tolerance. Stahl’s version is to avoid relapses of mania and SI but I have patients that will cold turkey stop with no issues.
  • If levels are high 1.2-1.5, you can trial tapering down or withholding the dose for a day but recheck <5-7 days, check kidney and thyroid function (lithium can induce hypothyroidism). If levels are >1.5 or if there are signs of toxicity, the dose should be stopped immediately and the patient should go to the urgent care/ER for hydration, seizure precautions, and possibly dialysis.
  • Restart the lithium at a lower dose and stay within parameters. Divide doses or use sustained-release to limit side effects. Monitor weight, BMI, fasting glucose, lipids, electrolytes, CBC, EKG at least yearly. Lithium side effects are typically dose-related but usually resolve after discontinuing.
  • And again, did I forget to mention DOCUMENT 

References and Additional Info

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