From the Guidelines
When taking lithium, acetaminophen (Tylenol) is generally the safest pain medication option. This is because NSAIDs, such as ibuprofen (Advil, Motrin), naproxen (Aleve), and aspirin, can increase lithium levels in the blood, potentially leading to lithium toxicity, as they can reduce kidney clearance of lithium 1. For mild to moderate pain, acetaminophen should be your first choice, and it can be taken at standard doses (typically 325-650 mg every 4-6 hours, not exceeding 3,000 mg daily) without significant interaction concerns with lithium. Some key points to consider when taking pain medications with lithium include:
- Avoiding concomitant NSAIDs to prevent increased lithium levels and potential toxicity 1
- Maintaining hydration during intercurrent illness to minimize the risk of lithium toxicity
- Monitoring GFR, electrolytes, and lithium levels regularly (at least 6 monthly or more frequently if the dose changes or the patient is acutely unwell) to ensure safe use of lithium 1 For more severe pain requiring opioids, medications like codeine, tramadol, or hydrocodone may be used cautiously under medical supervision, as they don't directly interact with lithium but can have additive central nervous system effects. It is essential to inform all healthcare providers about your lithium therapy before taking any new medication, even over-the-counter options, and report any unusual symptoms promptly.
From the FDA Drug Label
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. The FDA drug label does not answer the question.
From the Research
Pain Medications Safe to Use with Lithium
When considering pain management for patients taking lithium, it is essential to choose medications that do not interact adversely with lithium. The following options can be considered:
- Acetaminophen: This is a safe choice for patients taking lithium, as there is no significant interaction between the two medications 2, 3.
- Topical NSAIDs: These can be used for non-low back, musculoskeletal injuries, but it is crucial to exercise caution and monitor serum lithium levels closely 2, 4.
- Selective cyclooxygenase-2 NSAIDs: Although these are a more expensive treatment alternative, they can be used to avoid the gastrointestinal adverse effects of nonselective NSAIDs. However, their interaction with lithium should be carefully monitored 2, 4.
Medications to Use with Caution
Certain medications should be used with caution in patients taking lithium:
- Nonsteroidal anti-inflammatory drugs (NSAIDs): These can increase serum lithium levels and diminish renal lithium clearance, potentially leading to lithium toxicity. Indomethacin, ibuprofen, and naproxen are known to have this effect, while sulindac and aspirin may not have a clinically significant impact 3, 4, 5.
- Opioids: While opioids can be used for severe or refractory acute pain, their use should be carefully monitored, especially in patients on medication-assisted therapy for opioid use disorder 2.
Monitoring and Precautions
When using any pain medication with lithium, it is crucial to: