What are the special population considerations for lithium (lithium carbonate) therapy?

From the Guidelines

Lithium requires special population considerations, particularly in patients with renal impairment, where reduced dosing and more frequent monitoring of lithium levels and kidney function are necessary, as noted in the 2014 study 1.

Special Population Considerations

When prescribing lithium, it is crucial to consider the patient's renal function, as lithium is primarily excreted through the kidneys.

• Patients with renal impairment, especially those with a GFR < 30 ml/min/1.73 m2, require reduced dosing and close monitoring of lithium levels and kidney function to avoid toxicity.
• The 2014 study 1 provides guidance on dosing adjustments for various medications in patients with chronic kidney disease, emphasizing the need for careful consideration of renal function when prescribing lithium.

Monitoring and Dosing

Regular monitoring of serum lithium levels, thyroid function, renal function, and electrolytes is essential in all populations, with the frequency of monitoring adjusted based on individual risk factors.

• The target serum lithium level is 0.6-1.2 mEq/L, and doses should be adjusted accordingly to minimize the risk of toxicity.
• Patients with cardiovascular disease require careful assessment, as lithium can cause ECG changes.

Pregnancy and Pediatric Considerations

Pregnant women should use lithium only when benefits outweigh risks, with dose reductions near delivery to prevent neonatal toxicity, as noted in the example answer.

• Children and adolescents require weight-based dosing, typically starting at 300-600 mg/day divided into 2-3 doses, with more frequent monitoring of levels due to their faster metabolism.

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From the FDA Drug Label

Previously existing underlying thyroid disorders do not necessarily constitute a contraindication to lithium treatment; where hypothyroidism exists, careful monitoring of thyroid function during lithium stabilization and maintenance allows for correction of changing thyroid parameters, if any Lithium is excreted in human milk. Nursing should not be undertaken during lithium therapy except in rare and unusual circumstances where, in the view of the physician, the potential benefits to the mother outweigh possible hazards to the child Usage in Children: Since information regarding the safety and effectiveness of lithium in children under 12 years of age is not available, its use in such patients is not recommended at this time.

The special population considerations for lithium include:

• Pregnancy: Lithium is classified as Pregnancy Category D, and its use should be avoided due to potential teratogenic effects 2.
• Nursing mothers: Lithium is excreted in human milk, and nursing should not be undertaken during lithium therapy except in rare circumstances where benefits outweigh potential hazards to the child 2.
• Children: The use of lithium is not recommended in children under 12 years of age due to lack of safety and effectiveness information 2.
• Patients with thyroid disorders: Lithium treatment may be undertaken with careful monitoring of thyroid function in patients with pre-existing thyroid disorders 2.
• Patients with significant renal or cardiovascular disease: Lithium should generally not be given to patients with significant renal or cardiovascular disease, and if used, it should be with extreme caution, including daily serum lithium determinations and adjustment to low doses 2.

From the Research

Special Population Consideration for Lithium

• Children and adolescents have higher volumes of body water and more active renal glomerular filtration rates than adults, making their central nervous system vulnerable to the impact of lithium 3.
• Elderly patients have less body water, slower metabolism, and often comorbid illnesses, requiring close evaluation and monitoring when prescribed lithium 3, 4.
• The use of lithium in older adults with bipolar disorder is generally well tolerated, but there are methods to minimize adverse effects, such as striving for the lowest possible dose without losing efficacy 5, 4.
• Special considerations for lithium use in older adults include monitoring of renal function, thyroid function, and parathyroid function, as well as management of side effects such as weight gain, cognitive impairment, and tremor 6, 5, 4.
• Lithium is effective in the management of manic, depressive, and maintenance phases of bipolar disorder treatment in older adults, but further research is needed to strengthen the evidence base for lithium therapy in this population 4.