From the Guidelines
When taking lithium, it is recommended to use acetaminophen (Tylenol) as the first-choice pain reliever, as it does not interact significantly with lithium 1. For mild to moderate pain, the standard adult dose is 325-650 mg every 4-6 hours, not exceeding 3,000 mg per day. You should avoid or use with extreme caution NSAIDs like ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin, as these can increase lithium levels in your blood, potentially leading to lithium toxicity 1. This interaction occurs because NSAIDs affect kidney function, reducing lithium clearance from your body. If you absolutely need an NSAID for a specific condition, consult your psychiatrist first, as they may need to monitor your lithium levels more closely or adjust your lithium dose. For severe pain requiring prescription medications, always inform all your healthcare providers about your lithium therapy to avoid potential drug interactions. Some alternative options for pain management while on lithium include:
- Antidepressants, such as selective serotonin norepinephrine reuptake inhibitors (SSNRIs) like duloxetine and venlafaxine, which have shown efficacy in treating neuropathic pain 1
- Anticonvulsants, such as gabapentin and pregabalin, which are considered first-line treatments for neuropathic pain 1
- Topical analgesics, such as lidocaine, which can be used to treat localized areas of pain 1 Signs of lithium toxicity include tremor, confusion, vomiting, diarrhea, and unsteady gait - seek immediate medical attention if these develop after taking any pain medication. It's essential to consult with your healthcare provider before taking any new medications, especially when taking lithium, to ensure safe and effective pain management. In terms of specific medications, gabapentin and pregabalin are considered safe options for patients with neuropathic pain who are taking lithium, as they have few drug interactions 1. However, it's crucial to monitor kidney function and adjust dosages accordingly, as these medications require dosage reduction in patients with renal insufficiency 1. Ultimately, the best course of treatment will depend on individual circumstances and should be determined in consultation with a healthcare provider.
From the FDA Drug Label
Non-steroidal anti-inflammatory drugs (NSAIDS): Lithium levels should be closely monitored when patients initiate or discontinue NSAID use. In some cases, lithium toxicity has resulted from interactions between an NSAID and lithium. Indomethacin and piroxicam have been reported to increase significantly steady-state plasma lithium concentrations There is also evidence that other nonsteroidal anti-inflammatory agents, including the selective cyclooxygenase-2 (COX-2) inhibitors, have the same effect.
The FDA drug label advises caution with the use of NSAIDs with lithium, as they can increase lithium levels and lead to toxicity. It does not specify which pain medications are safe to take with lithium. Therefore, it is recommended to avoid NSAIDs and consult a physician for alternative pain management options while on lithium therapy 2.
From the Research
Pain Medications with Lithium Therapy
When taking lithium (lithium carbonate) therapy, it's crucial to be cautious with pain medications to avoid potential interactions. The following points outline some considerations:
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs):
- Some NSAIDs can increase serum lithium levels, potentially leading to lithium toxicity 3, 4.
- Indomethacin seems to have the most potent effect on increasing serum lithium levels 3.
- Ibuprofen and naproxen can also significantly increase serum lithium levels, but with marked interindividual variation 3.
- Aspirin and sulindac do not appear to affect serum lithium levels to a clinically significant degree 3, 4.
- Acetaminophen:
- There is no direct evidence of an interaction between acetaminophen and lithium in the provided studies.
- However, acetaminophen is mentioned as a potential first-line treatment for pain, including in patients with conditions like hidradenitis suppurativa 5.
- Gabapentin and Pregabalin:
- These medications are used for treating various types of pain, including neuropathic pain and, in the case of gabapentin, potentially sciatica 5, 6.
- There is no direct evidence of interactions between gabapentin, pregabalin, and lithium in the provided studies.
- Pregabalin has been studied in patients using NSAIDs for other pain conditions, showing some efficacy in reducing pain and improving sleep, although results are mixed 7.
- Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs):
- Duloxetine and venlafaxine are mentioned as potential treatments for pain, especially in conditions like hidradenitis suppurativa, and can also address associated depression 5.
- There is no direct evidence of interactions between SNRIs and lithium in the provided studies.
Key Considerations
- Patients on lithium therapy should have their serum lithium levels monitored closely when starting or stopping any NSAID due to the potential for significant interactions 3, 4.
- The choice of pain medication should be made under the guidance of a healthcare provider, considering the potential risks and benefits, especially in patients with complex medical regimens like those on lithium therapy.