Recommended Protocol for Lithium Titration
The optimal protocol for lithium titration involves starting with lower doses (typically 300 mg 2-3 times daily for adults) and gradually adjusting based on serum levels, with target therapeutic ranges of 0.6-1.2 mEq/L for maintenance therapy and 1.0-1.5 mEq/L for acute mania. 1
Initial Dosing
- For standard adult patients, begin with 600 mg total daily dose (typically 300 mg twice daily) of lithium carbonate 1, 2
- For elderly patients, use lower starting doses (150 mg/day) due to increased sensitivity and reduced clearance 3
- Initial recommended dose is usually 12-24 mmol (450-900 mg) per day, depending on age and body weight 2
Titration Schedule
- Increase dose gradually based on serum lithium levels and clinical response 1
- During acute phase treatment, monitor serum levels twice weekly until the serum level and clinical condition have stabilized 1
- Draw blood samples for serum lithium determination 8-12 hours after the previous dose (typically in the morning before the first dose) when lithium concentrations are relatively stable 1, 2
- Adjust dosage in weekly increments until therapeutic levels are achieved 1
Target Serum Levels
- For acute mania: 1.0-1.5 mEq/L 1
- For long-term maintenance: 0.6-1.2 mEq/L 1
- With sustained-release preparations, aim for the upper range (0.8-1.0 mEq/L) rather than 0.6-0.8 mEq/L for standard formulations 2
Maintenance Dosing
- Typical maintenance doses vary by age 2:
- <40 years: 25-35 mmol (925-1300 mg) daily
- 40-60 years: 20-25 mmol (740-925 mg) daily
60 years: 15-20 mmol (550-740 mg) daily
- Most patients can be maintained on 300 mg of lithium carbonate three or four times daily 1
Monitoring Schedule
- During initial titration: Check serum levels twice weekly 1
- During maintenance phase: Monitor serum lithium levels at least every two months 1
- For patients with renal impairment: More frequent monitoring is required 3
Special Considerations
- For patients with GFR < 60 ml/min/1.73 m², consider lower doses and more frequent monitoring 3
- For patients with GFR < 30 ml/min/1.73 m², reduce dose by 50% 3
- Avoid concomitant use of NSAIDs as they can increase lithium levels and risk of toxicity 3
- Maintain adequate hydration, especially during intercurrent illness 3
- During pregnancy, lithium clearance increases by 30-50%, potentially requiring dosage adjustments 2
Discontinuation Protocol
- If discontinuation is necessary, decrease by approximately 10% of the original dose per week 4
- For patients on long-term lithium treatment, consider slower tapering (10% per month rather than per week) 4
- Avoid concurrent medication changes during lithium tapering 4
Common Pitfalls to Avoid
- Relying solely on serum levels without clinical assessment can lead to inadequate treatment 1
- Failure to account for age-related changes in lithium clearance can increase toxicity risk in elderly patients 3, 2
- Not monitoring for dehydration, which can rapidly increase lithium levels and lead to toxicity 3
- Inconsistent timing of blood draws for lithium levels can lead to misinterpretation of results 2
- Changing lithium brands during treatment may alter bioavailability and serum levels 5