Is it safe to prescribe 90 days of lithium for a patient with a history of bipolar disorder?

Can You Order 90 Days of Lithium for a Patient?

Yes, you can order a 90-day supply of lithium for a stable patient with bipolar disorder, but this requires careful risk stratification, confirmed therapeutic stability, reliable monitoring adherence, and absence of suicide risk or factors predisposing to toxicity.

Critical Safety Requirements Before Extended Prescribing

Lithium has a narrow therapeutic index and requires ongoing monitoring to prevent potentially lethal toxicity 1, 2. Before prescribing 90 days of lithium, you must verify:

Patient Stability Criteria

• Mood stability for at least 12-24 months on current lithium regimen, as maintenance therapy should continue for this minimum duration after stabilization 3
• Therapeutic lithium levels consistently maintained at 0.8-1.2 mEq/L for acute treatment or 0.6-1.0 mEq/L for maintenance, with some patients responding at lower concentrations 4, 3
• Demonstrated medication adherence, as >90% of noncompliant adolescents relapsed versus 37.5% of compliant patients 3

Monitoring Compliance History

• Patient has reliably attended appointments for lithium level monitoring every 3-6 months 3, 5
• Regular renal function monitoring (BUN, creatinine, urinalysis) and thyroid function tests have been completed every 3-6 months 3, 5
• No missed monitoring appointments in the past 6-12 months, as regular monitoring is essential to prevent toxicity 5

Absolute Contraindications to Extended Supply

• Active suicidal ideation or history of suicide attempts, as lithium carries significant overdose risk and can be lethal 3, 1
• Significant renal or cardiovascular disease, severe debilitation, dehydration, or sodium depletion, as the risk of lithium toxicity is very high in such patients 1
• Concurrent diuretic use, which dramatically increases lithium toxicity risk 1
• Unstable medical conditions that could precipitate toxicity, such as dehydration, medication interactions, or renal impairment 5

Risk Mitigation Strategies for 90-Day Prescriptions

Implement Third-Party Supervision When Indicated

• For patients with any suicide risk history, engage family members to help restrict access to lethal quantities of medication and implement third-party medication supervision for lithium dispensing 3
• Prescribe limited quantities with frequent refills to minimize stockpiling risk in high-risk patients 3

Patient and Caregiver Education Requirements

• Educate patients and caregivers about early signs of lithium toxicity: tremor, nausea, diarrhea, polyuria-polydipsia 5
• Instruct patients to temporarily suspend lithium during intercurrent illness, planned IV radiocontrast administration, bowel preparation, or prior to major surgery 5
• Warn patients to avoid concomitant NSAIDs, which can increase lithium levels, and maintain adequate hydration, especially during illness 5

Mandatory Monitoring Schedule

• Schedule follow-up appointments at 30-day intervals during the 90-day period to assess mood symptoms, suicidal ideation, medication adherence, and adverse effects 3
• Order lithium levels, renal function (BUN, creatinine), and thyroid function tests at the 45-day mark (mid-supply) to detect early toxicity 3, 5
• Verify patient understanding that they must present for monitoring or the prescription will not be renewed 5

Common Pitfalls to Avoid

• Never prescribe 90 days of lithium to a newly initiated patient or one with recent dose adjustments, as lithium levels should be measured twice per week until stabilized 5
• Do not provide extended supplies to patients with poor adherence history, as withdrawal of maintenance lithium therapy is associated with increased relapse risk, especially within 6 months following discontinuation 3
• Avoid extended prescriptions in patients with unstable renal function or those at risk for dehydration, as these factors precipitate toxicity 5, 1
• Never ignore clinical signs of lithium toxicity even when serum levels are in the normal range, as toxicity can occur with therapeutic levels, particularly in chronic toxicity 6
• Do not prescribe 90-day supplies without confirming the patient has a reliable pharmacy that will dispense in 30-day increments, allowing for intervention if monitoring is missed 3

Alternative Approach for Higher-Risk Patients

For patients who do not meet all stability criteria but require extended prescriptions for access reasons, prescribe 30-day supplies with two refills, requiring check-in (phone or in-person) at 30 and 60 days before each refill is released 3. This maintains access while preserving safety checkpoints.