What is the information about Lithium (lithium carbonate) medication?

From the Guidelines

Lithium is a medication primarily used to treat bipolar disorder, particularly for managing manic episodes and preventing mood swings, with a recommended therapeutic blood level range of 0.6-1.2 mEq/L 1.

Key Points

• Lithium is available as lithium carbonate (Lithobid, Eskalith) or lithium citrate, typically starting at 300mg twice daily and gradually increasing to a therapeutic dose of 900-1200mg daily, divided into multiple doses.
• Patients must maintain consistent salt and water intake as changes can affect lithium levels, and regular blood monitoring is necessary to ensure effectiveness while avoiding toxicity 1.
• Common side effects include tremor, increased thirst, frequent urination, nausea, and diarrhea, and long-term use requires monitoring of thyroid and kidney function 1.
• Lithium works by stabilizing neurotransmitter systems in the brain, particularly affecting sodium transport and modulating second messenger systems like inositol and glycogen synthase kinase-3.
• It's contraindicated during pregnancy (first trimester), with certain heart or kidney conditions, and interacts with NSAIDs, diuretics, and ACE inhibitors which can increase lithium levels 1.

Monitoring and Maintenance

• Baseline laboratory assessment should include complete blood cell counts, thyroid function tests, urinalysis, blood urea nitrogen, creatinine, and serum calcium levels, and a pregnancy test in female adolescents 1.
• Once a stable lithium dose is obtained, lithium levels, renal and thyroid function, and urinalyses should be monitored regularly (every 3-6 months) 1.
• Treatment is typically long-term for bipolar disorder, often continuing for years to prevent relapse, with some individuals needing lifelong therapy when the benefits of continued treatment outweigh the risks 1.

From the FDA Drug Label

Previously existing underlying thyroid disorders do not necessarily constitute a contraindication to lithium treatment; where hypothyroidism exists, careful monitoring of thyroid function during lithium stabilization and maintenance allows for correction of changing thyroid parameters, if any Where hypothyroidism occurs during lithium stabilization and maintenance, supplemental thyroid treatment may be used. Information for the patients: Outpatients and their families should be warned that the patient must discontinue lithium therapy and contact his physician if such clinical signs of lithium toxicity as diarrhea, vomiting, tremor, mild ataxia, drowsiness, or muscular weakness occur Lithium may impair mental and/or physical abilities. Caution patients about activities requiring alertness (e.g., operating vehicles or machinery). Drug interactions: Combined use of haloperidol and lithium. An encephalopathic syndrome (characterized by weakness, lethargy, fever, tremulousness and confusion, extrapyramidal symptoms, leucocytosis, elevated serum enzymes, BUN and FBS) followed by irreversible brain damage has occurred in a few patients treated with lithium plus haloperidol A causal relationship between these events and the concomitant administration of lithium and haloperidol has not been established; however, patients receiving such combined therapy should be monitored closely for early evidence of neurological toxicity and treatment discontinued promptly if such signs appear The possibility of similar adverse interactions with other antipsychotic medication exists. Lithium may prolong the effects of neuromuscular blocking agents. Therefore, neuromuscular blocking agents should be given with caution to patients receiving lithium Caution should be used when lithium and diuretics or angiotensin converting enzyme (ACE) inhibitors are used concomitantly because sodium loss may reduce the renal clearance of lithium and increase serum lithium levels with risk of lithium toxicity. When such combinations are used, the lithium dosage may need to be decreased, and more frequent monitoring of lithium plasma levels is recommended 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. In a study conducted in healthy subjects, mean steady-state lithium plasma levels increased approximately 17% in subjects receiving lithium 450 mg BID with celecoxib 200 mg BID as compared to subjects receiving lithium alone Pregnancy Teratogenic Effects - Pregnancy Category D: See WARNINGS section Nursing mothers: Lithium is excreted in human milk. Nursing should not be undertaken during lithium therapy except in rare and unusual circumstances where, in the view of the physician, the potential benefits to the mother outweigh possible hazards to the child Usage in Children: Since information regarding the safety and effectiveness of lithium in children under 12 years of age is not available, its use in such patients is not recommended at this time. There has been a report of a transient syndrome of acute dystonia and hyperreflexia occurring in a 15 kg child who ingested 300 mg of lithium carbonate. DESCRIPTION Each capsule for oral administration contains: Lithium Carbonate USP . . . . . . . . 150 mg, 300 mg or 600 mg Inactive Ingredients: The capsules contain colloidal silicon dioxide, gelatin, sodium lauryl sulfate, talc, titanium dioxide, FD&C Blue No. 1, FD&C Red No. 40, D&C Yellow No 10 and the imprinting ink contains shellac, isopropyl alcohol, dehydrated alcohol, butyl alcohol, propylene glycol, strong ammonia solution, potassium hydroxide and black iron oxide. Lithium is an element of the alkali-metal group with atomic number 3, atomic weight 6. 94, and an emission line at 671 nm on the flame photometer. The empirical formula for Lithium Citrate is C6H5Li3O7; molecular weight 209.92. Lithium acts as an antimanic. Lithium carbonate USP is a white, light, alkaline powder with molecular formula Li2CO3 and molecular weight 73.89.

The key points about Lithium (lithium carbonate) medication are:

• Contraindications: Previously existing underlying thyroid disorders do not necessarily constitute a contraindication to lithium treatment.
• Warnings: Lithium may impair mental and/or physical abilities, and caution patients about activities requiring alertness.
• Drug interactions:
  • Combined use of haloperidol and lithium may cause encephalopathic syndrome.
  • Lithium may prolong the effects of neuromuscular blocking agents.
  • Caution should be used when lithium and diuretics or angiotensin converting enzyme (ACE) inhibitors are used concomitantly.
  • Non-steroidal anti-inflammatory drugs (NSAIDS) may increase lithium levels.
• Pregnancy and lactation: Pregnancy Category D, and nursing should not be undertaken during lithium therapy.
• Pediatric use: Not recommended for children under 12 years of age.
• Mechanism of action: Lithium acts as an antimanic.
• Composition: Lithium carbonate USP is a white, light, alkaline powder with molecular formula Li2CO3 and molecular weight 73.89 2, 2.

From the Research

Overview of Lithium Medication

• Lithium, also known as lithium carbonate, is a mood stabilizer commonly prescribed for bipolar disorder and treatment-resistant depression 3, 4, 5.
• It has a narrow therapeutic index, which increases the risk of toxicity in patients taking this medication 3, 4, 5, 6.

Risk of Toxicity

• Lithium toxicity can occur due to various factors, including overdose, impaired kidney function, and intercurrent illnesses 5, 6.
• Patients aged 65 and older are at a higher risk of lithium toxicity due to decreased kidney function and other comorbidities 5.
• Lithium toxicity can manifest as neurological symptoms, such as tremors, ataxia, confusion, and seizures, and can also affect other organs 3, 4, 6.

Clinical Manifestations

• The clinical manifestations of lithium toxicity can vary widely, making diagnosis challenging 3, 4.
• Symptoms can include altered mental status, tremors, generalized weakness, dysarthria, and cognitive decline 3, 4.
• In severe cases, lithium toxicity can lead to life-threatening complications, such as acute respiratory distress syndrome (ARDS) 7.

Management and Treatment

• Swift identification and management of lithium toxicity are crucial to prevent long-term neurological damage and other complications 3, 4.
• Treatment may involve fluid diuresis, hemodialysis, and supportive care, depending on the severity of the toxicity 3, 6, 7.
• Careful monitoring of serum lithium levels and kidney function is essential to prevent lithium toxicity, especially in high-risk patients 5, 6.