Guidelines for Discontinuing Lithium
Lithium discontinuation should be done gradually over several weeks to months rather than abruptly, as abrupt discontinuation is associated with a 7-fold increase in suicide attempts and a 9-fold increase in completed suicides in bipolar patients. 1
Risk Assessment Before Discontinuation
Before considering lithium discontinuation, evaluate:
- Current clinical stability
- History of previous episodes and their severity
- Risk of suicide
- Patient's preference after thorough education about risks
- Availability of alternative treatment options
Specific Discontinuation Protocol
When to Consider Discontinuation
- After at least 2-3 years of stability in bipolar disorder 1
- When significant adverse effects persist despite dose adjustments
- When renal function deteriorates (GFR < 30 ml/min/1.73 m²) 1
- During pregnancy (with careful risk-benefit analysis)
Common Reasons for Discontinuation
The most common reasons patients discontinue lithium include 2:
- Adverse effects (62% of discontinuations)
- Psychiatric reasons (44%)
- Physical health reasons (12%)
The five most common adverse effects leading to discontinuation are:
- Diarrhea (13%)
- Tremor (11%)
- Polyuria/polydipsia/diabetes insipidus (9%)
- Creatinine increase (9%)
- Weight gain (7%)
Tapering Schedule
- Slow tapering is essential - abrupt discontinuation significantly increases relapse risk 3, 4
- Recommended schedule:
- Reduce by 300mg (or 25-30% of dose) every 2-4 weeks
- Monitor for emergence of symptoms at each step
- Total discontinuation period should span at least 1-3 months
Monitoring During Discontinuation
- Weekly clinical assessments for the first month
- Biweekly assessments for the second month
- Monthly assessments for 6-12 months after complete discontinuation
- Monitor for early signs of relapse (sleep disturbances, mood changes)
- Serum lithium levels during tapering to confirm adherence to tapering schedule
Special Considerations
Risk of Relapse
Patients should be informed that:
- Median time to relapse after lithium discontinuation is approximately 1.33 years compared to 7.33 years for those who continue lithium 4
- The risk of manic recurrence is particularly high in the first weeks after discontinuation 3
- Some patients may experience lithium-discontinuation-induced refractoriness, where lithium is no longer effective if restarted after discontinuation 5
High-Risk Patients
Extra caution and slower tapering is needed for:
- Patients with history of severe manic episodes
- Patients with history of suicide attempts
- Patients with rapid cycling
- Patients with type 1 bipolar disorder (more likely to discontinue lithium and refuse medication) 2
Temporary Discontinuation
For temporary discontinuation (e.g., during surgery, contrast imaging):
- Resume lithium as soon as medically appropriate
- Consider using alternative mood stabilizers during the interruption period
- Monitor more frequently during this period
Alternative Treatments
If lithium must be discontinued permanently:
- Consider valproate as an alternative mood stabilizer 1
- Atypical antipsychotics may be considered based on individual patient factors 1
- Combination therapy may be necessary in some cases
Patient Education
Patients and families should be educated about:
- Early warning signs of relapse
- The importance of regular follow-up
- The need to contact healthcare providers immediately if symptoms emerge
- The risks of self-discontinuation without medical supervision 6
Remember that lithium discontinuation carries significant risks, particularly for patients with bipolar disorder, and should be approached with caution and close monitoring.