What are the steps to initiate lithium carbonate in an adult with bipolar disorder via telehealth, including screening for contraindications, ordering baseline labs (serum creatinine, estimated glomerular filtration rate, thyroid‑stimulating hormone, electrolytes, pregnancy test), initial dosing, patient counseling, and follow‑up monitoring?

Initiating Lithium via Telehealth for Bipolar Disorder

Pre-Initiation Screening and Contraindications

Before prescribing lithium via telehealth, you must verify the patient has no significant renal or cardiovascular disease, severe debilitation, dehydration, sodium depletion, or concurrent diuretic use—these are absolute contraindications where lithium toxicity risk is extremely high. 1

Critical History Elements to Obtain

• Document current kidney function status by asking about history of kidney disease, frequent urination, or previous abnormal kidney tests 1
• Screen for cardiovascular disease including heart failure, arrhythmias, or significant cardiac history 1
• Assess hydration status and sodium intake by asking about fluid intake, dietary salt restriction, or recent illness with vomiting/diarrhea 1
• Review all current medications with specific attention to diuretics, ACE inhibitors, NSAIDs, or other drugs affecting renal function 1
• Obtain pregnancy status for all females of childbearing potential, as lithium requires careful risk-benefit assessment in pregnancy 2, 1

Baseline Laboratory Orders

Order the following labs before the first lithium dose—treatment can begin once results confirm safety, typically within 24-48 hours for urgent cases: 2, 3, 1

• Complete blood count (CBC) 2, 3
• Comprehensive metabolic panel including creatinine, BUN, and electrolytes 2, 3
• Thyroid-stimulating hormone (TSH) and free T4 2, 3, 4
• Urinalysis 2, 3
• Serum calcium 2, 3
• Pregnancy test (urine or serum β-hCG) for females of childbearing potential 2, 3
• Baseline ECG if patient is over 40 years or has cardiac risk factors 1

Initial Dosing Protocol

For acute mania, start lithium carbonate 300 mg three times daily (900 mg/day total) in adults, which typically achieves therapeutic levels of 1.0-1.5 mEq/L needed for acute treatment. 1

Weight-Based Dosing Considerations

• Adults ≥50 kg: Start 300 mg TID (900 mg/day) 1
• Elderly patients or those <50 kg: Start 300 mg BID (600 mg/day), as they often require lower doses and exhibit toxicity at levels tolerated by younger adults 1
• Patients with any renal impairment: Start 300 mg BID maximum, with more frequent monitoring 1

Dosing Instructions for Telehealth

• Instruct patients to take lithium with food or milk to minimize gastrointestinal upset 1
• Emphasize taking doses at consistent times (e.g., 8 AM, 2 PM, 8 PM) to maintain stable levels 1
• Advise maintaining consistent fluid intake of 8-10 glasses of water daily and avoiding sudden changes in salt intake 3, 1

Patient Counseling and Education

Provide written and verbal education covering these critical safety points during the telehealth visit: 2, 3

Expected Benefits and Timeline

• Response rates for acute mania range from 38-62%, meaning some patients respond excellently while others may not respond at all 2
• Therapeutic effects become apparent after 1-2 weeks at therapeutic levels 2
• Lithium reduces suicide attempts 8.6-fold and completed suicides 9-fold, an effect independent of mood stabilization 2

Common Side Effects

• Early side effects (first 2 weeks): Fine hand tremor, nausea, increased thirst, increased urination, mild diarrhea 3, 1
• These typically improve with continued treatment or dose adjustment 2
• Weight gain occurs in many patients and requires proactive dietary counseling 2

Warning Signs of Toxicity

Instruct patients to stop lithium immediately and contact you or go to the emergency department if they develop: 3, 1

• Coarse tremor (shaking that affects whole hand/arm, not just fingers) 3
• Confusion, slurred speech, or difficulty walking 3
• Severe nausea, vomiting, or diarrhea 3, 1
• Muscle twitching or weakness 1
• Blurred vision or ringing in ears 1

Lifestyle and Safety Instructions

• Maintain consistent hydration with 8-10 glasses of water daily 3
• Avoid sudden changes in salt intake—both low-salt diets and excessive salt can affect lithium levels 3, 1
• Notify prescriber before starting any new medications, especially NSAIDs, diuretics, or blood pressure medications 1
• Avoid dehydration from excessive sweating, fever, vomiting, or diarrhea—contact prescriber if these occur 1
• Secure medication storage is essential, especially in patients with suicide history, as lithium overdoses can be lethal 2

Follow-Up Monitoring Schedule

Acute Phase (First 4-8 Weeks)

Check serum lithium level twice weekly until both the level and clinical symptoms stabilize, typically requiring 2-4 weeks. 1

• First lithium level: Draw 5-7 days after starting, exactly 12 hours after the previous evening dose 1
• Target level for acute mania: 1.0-1.5 mEq/L 1
• Subsequent levels: Twice weekly until stable, then weekly 1
• Clinical assessment: Weekly telehealth visits to assess mood symptoms, side effects, and adherence 2

Dose Adjustments

• If level <1.0 mEq/L and inadequate response: Increase by 300 mg/day 1
• If level >1.5 mEq/L or significant side effects: Decrease by 300 mg/day 1
• Recheck level 5-7 days after any dose change 1

Maintenance Phase (After Stabilization)

Once stable on lithium, transition to maintenance dosing of 300 mg TID or QID (typically 900-1200 mg/day) targeting levels of 0.6-1.2 mEq/L. 1

• Lithium levels: Every 2 months minimum in stable patients 1
• Creatinine and BUN: Every 3-6 months 2, 3
• TSH: Every 3-6 months 2, 3
• Calcium: Every 6-12 months 2, 3
• Urinalysis: Every 6-12 months 2, 3
• Clinical assessment: Monthly telehealth visits initially, then every 2-3 months once fully stable 2

Duration of Treatment

Continue lithium for at least 12-24 months after achieving mood stabilization; many patients require lifelong treatment. 2, 3

• Withdrawal of lithium dramatically increases relapse risk, with over 90% of noncompliant patients relapsing versus 37.5% of compliant patients 2
• The highest relapse risk occurs within 6 months of discontinuation 2, 3
• If discontinuation is planned, taper gradually over 2-4 weeks minimum under close supervision 2

Telehealth-Specific Considerations

Laboratory Coordination

• Send electronic lab orders immediately after the telehealth visit to a convenient lab location for the patient 3
• Arrange for results to be sent directly to you with clear instructions for the lab to call you with critical values 3
• Schedule follow-up telehealth visit within 7-10 days to review labs and adjust dosing 2

Ensuring Medication Access

• Send prescription electronically to patient's preferred pharmacy immediately after confirming baseline labs are acceptable 1
• Prescribe 30-day supply initially with no refills, requiring follow-up visit and lab check before continuation 2
• Verify patient has picked up medication within 24-48 hours via pharmacy or patient contact 2

Safety Monitoring via Telehealth

• Provide written handout with warning signs of toxicity and emergency contact numbers 3
• Schedule weekly check-in calls or secure messages during the first month to assess adherence and side effects 2
• Use standardized mood rating scales (e.g., Young Mania Rating Scale) at each visit to objectively track response 2

Common Pitfalls to Avoid

• Never start lithium without baseline renal function—this is the most critical safety measure 1
• Never rely solely on serum levels—clinical assessment is equally important for dose optimization 1
• Never prescribe lithium to patients on diuretics without extreme caution and daily monitoring, as toxicity risk is very high 1
• Never allow patients to adjust their own dose—all changes must be prescribed and monitored 1
• Never discontinue lithium abruptly—this precipitates rebound mania in >90% of patients 2
• Never forget to counsel on hydration and salt intake—dehydration is the most common precipitant of toxicity 1

When Telehealth Is Insufficient

If the psychiatric indication is life-threatening and the patient has significant renal disease, cardiovascular disease, or is on diuretics, hospitalization is mandatory for lithium initiation with daily level monitoring. 1