What advice should be given to a patient before initiating lithium (lithium carbonate) therapy?

From the Guidelines

Before initiating lithium therapy, patients should be advised to undergo baseline laboratory assessments, including complete blood cell counts, thyroid function tests, and renal function tests, and to maintain regular monitoring of lithium levels and renal function to minimize the risk of toxicity and ensure optimal treatment outcomes. When considering lithium therapy, it is essential to inform patients about the potential risks and benefits, as well as the importance of regular monitoring to prevent adverse effects 1. Some key points to discuss with patients include:

• The need for regular blood tests to monitor lithium levels, as the therapeutic window is narrow and toxicity can occur
• Maintaining consistent salt and fluid intake, as changes can affect lithium levels
• Understanding that lithium takes 1-3 weeks for full effect and should continue their medication even when feeling better
• Recognizing signs of toxicity such as tremor, confusion, diarrhea, vomiting, or drowsiness and reporting them immediately
• Informing all healthcare providers about lithium use and avoiding NSAIDs, which can increase lithium levels
• Discussing pregnancy plans, as lithium carries risks during pregnancy
• Limiting alcohol consumption, as it can affect hydration and medication effectiveness
• Carrying medical identification indicating lithium use, as this can be crucial in emergency situations. Regular monitoring of lithium levels, renal function, and thyroid function is crucial, and patients should be advised to follow up with their healthcare provider every 3-6 months 1.

From the FDA Drug Label

WARNING Lithium toxicity is closely related to serum lithium levels, and can occur at doses close to therapeutic levels. Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy (see DOSAGE AND ADMINISTRATION). CONTRAINDICATIONS Lithium should generally not be given to patients with significant renal or cardiovascular disease, severe debilitation or dehydration, or sodium depletion, and to patients receiving diuretics, since the risk of lithium toxicity is very high in such patients. OVERDOSAGE The toxic levels for lithium are close to the therapeutic levels. It is therefore important that patients and their families be cautioned to watch for early symptoms and to discontinue the drug and inform the physician should they occur.

The patient should be advised of the following before initiating lithium therapy:

• The risk of lithium toxicity and its close relationship to serum lithium levels
• The importance of monitoring serum lithium levels and having facilities available for prompt and accurate determinations
• The need to watch for early symptoms of lithium toxicity and to discontinue the drug and inform the physician if they occur
• The potential for severe interactions with certain medical conditions, such as significant renal or cardiovascular disease, and with certain medications, such as diuretics 2, 2, 2

From the Research

Pre-Lithium Therapy Advice

Before initiating lithium (lithium carbonate) therapy, patients should be informed of the following:

• The importance of regular monitoring of lithium serum levels, renal function, and thyroid function 3, 4, 5
• The need for screening prior to initiating lithium therapy, including assessment of drug-drug interactions and somatic comorbidity 4, 6
• The risks associated with compromised renal function, particularly in older patients with cardiovascular diseases 6
• The potential for dose-dependent adverse effects and the narrow therapeutic range of lithium 3, 4
• The importance of verbal and written information to patients and their families to prevent adverse effects 3

Monitoring and Follow-up

Patients should be aware that:

• Regular monitoring of lithium serum levels, renal function, and thyroid function will be necessary during treatment 3, 4, 5
• Blood samples for lithium monitoring should be obtained 12 hours after the evening dose 4
• Monitoring of physical and laboratory parameters, such as urinary frequency and lipid profile, may also be necessary 5, 7
• A once-daily dosing schedule may be a viable method to reduce the side effects of lithium and improve patient compliance 7