Is lithium contraindicated in 14-year-olds?

Is Lithium Contraindicated in 14-Year-Olds?

No, lithium is not contraindicated in 14-year-olds and is in fact FDA-approved for bipolar disorder in patients age 12 and older. 1

FDA Approval and Age Considerations

• Lithium is the only FDA-approved medication specifically indicated for bipolar disorder in adolescents aged 12 years and older 1
• The American Academy of Child and Adolescent Psychiatry recognizes lithium as a first-line treatment option for both acute mania and maintenance therapy in this age group 2, 1
• There are no age-related restrictions that would prohibit lithium use in a 14-year-old patient 2

Clinical Evidence Supporting Use in Adolescents

• Lithium has demonstrated efficacy in reducing both suicides and suicide attempts in adults with bipolar disorder, with discontinuation associated with increased suicide morbidity and mortality 2
• Open-label studies in adolescents (ages 12-18) with bipolar depression showed significant improvement, with mean depression scores decreasing substantially (effect size of 1.7) and response rates of 48% 3
• A retrospective study of 143 children and adolescents (ages 9-18) found lithium to be generally safe and tolerable for both bipolar and non-bipolar conditions 4
• Lithium has shown effectiveness for managing aggression in conduct disorder, with 48.3% of patients aged 8-17 years classified as responders 5

Required Monitoring for Safe Use

Baseline assessment must include: complete blood count, thyroid function tests (TSH), urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females 1

Ongoing monitoring every 3-6 months must include: lithium serum levels (target 0.6-1.2 mEq/L), renal function, thyroid function, and urinalysis 2, 1, 4

Safety Profile in Adolescents

• Common adverse effects are generally mild to moderate and include headache (74%), nausea/vomiting (67%), stomachache (30%), and abdominal cramps (19%) 3
• Thyroid dysfunction occurs in approximately 28.6% of pediatric patients, with 14.68% requiring thyroxine replacement 4
• Patients with higher baseline TSH levels and longer duration of lithium treatment are at increased risk for thyroid complications and require closer monitoring 4
• White blood cell counts may increase during treatment (exceeded 13,000 in 9.8% of patients), but this is generally not clinically significant 4
• Renal function changes are typically minimal, with no patients in one large study exceeding normal creatinine reference values 4

Important Clinical Caveats

• Lithium should be avoided or used with extreme caution during concurrent electroconvulsive therapy (ECT) due to reports of acute brain syndrome 2
• Renal insufficiency is considered a contraindication to lithium use, especially if sodium restriction is required 6
• Lithium has significant overdose risk and requires careful third-party supervision in patients with suicidal history, as overdoses can be lethal 1
• Abrupt discontinuation dramatically increases relapse risk, with more than 90% of noncompliant adolescents experiencing relapse compared to 37.5% of compliant patients 1

Dosing Considerations for Adolescents

• Initial dosing typically starts at 30 mg/kg/day in divided doses, adjusted to achieve therapeutic serum levels of 1.0-1.2 mEq/L 3
• Adolescents may require different dosing than adults due to age-related differences in renal clearance 6
• Therapeutic drug monitoring is essential, with serum concentrations drawn 12 hours after the last dose 6

2, 1, 3, 4, 5