Bipolar Manic-Depressive Medication - Medtick
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Bipolar Manic-Depressive Medication

What is it?

  • Lithium toxicity/overdose can happen when this level reaches 1.5 mEq/L or higher.
  • Severe lithium toxicity happens at:
    • Levels of 2.0 mEq/L and above, which can be life-threatening in rare cases.
    • Levels of 3.0 mEq/L and higher are considered a medical emergency.

Healthline 

  • Lithium (Priadel, Camcolit, Lithobid, Eskalith, Lithonate, Lithotabs, Eskalith-CR )

Tests

  • Lithium levels should be checked seven days after initiation, seven days after dose change and then every seven days until the desired serum level is achieved and remains stable.
  • Blood samples for lithium levels are taken 12 hours post dose; if a patient is prescribed a twice-daily liquid preparation, the blood sample should be taken just prior to the next dose.
  • Once stable, lithium levels are checked every three months for the first year and every six months thereafter.
  • Patients with risk factors for toxicity should have their lithium level checked every three months for as long as the risk factor remains present. Risk factors include being aged over 65 years, impaired renal or thyroid function, raised calcium levels, taking interacting medicines, poor symptom control, poor adherence or where the last level was >0.8mmol/L
  • Additional monitoring is recommended if a patient becomes acutely unwell, there are significant changes to fluid or sodium intake, or an interacting medicine is started.
Lithium carbonate. British National Formulary. 2023. https://bnf.nice.org.uk/drugs/lithium-carbonate/ (accessed February 2024)
Lithium citrate. British National Formulary. 2023.
 https://bnf.nice.org.uk/drugs/lithium-citrate/ (accessed February 2024)
  • Weight, eGFR (kidney test) , U&Es (blood test for electrolytes) , TFTs (thyroid test) and calcium levels should be monitored every six months.

Lithium monitoring. Specialist Pharmacy Service. 2023. 

https://www.sps.nhs.uk/monitorings/
lithium-monitoring/
(accessed February 2024)

Target levels 

  • Target lithium levels are 0.4–1.0mmol/L​[2,3]​. A lower level (0.4–0.6mmol/L) may be indicated for older patients, those on longer-term maintenance therapy for bipolar disorder or patients being treated for depression.
Lithium carbonate. British National Formulary. 2023. 
https://bnf.nice.org.uk/drugs/lithium-carbonate/
(accessed February 2024)
Lithium citrate. British National Formulary. 2023. 
https://bnf.nice.org.uk/drugs/lithium-citrate/
(accessed February 2024)
Depression in adults: treatment and management. National Institute for Health and Care . 2022. 
https://www.nice.org.uk/guidance/ng222 
(accessed February 2024)
  • Levels of 0.6–0.8mmol/L are recommended for patients being prescribed lithium for the first time for acute mania.

Bipolar disorder: assessment and management. National Institute for Health and Care Excellence . 2014. 
https://www.nice.org.uk/guidance/cg185 
(accessed February 2024)

  • Higher lithium levels of 0.8–1.0mmol/L may be considered for harder to treat mania.

Taylor DM, Barnes TR, Young AH. The Maudsley Prescribing Guidelines in Psychiatry. 14th ed. Wiley-Blackwell 2021. https://www.wiley.com/en-gb/The+Maudsley+Prescribing
+Guidelines+in+Psychiatry%2C+
14th+Edition-p-9781119772224 
(accessed February 2024)

Side effects

  • The most common side effects at initiation (usually resolve within a few days):
    • Nausea
    • Diarrhoea
    • Vertigo
  • Other side effects (may persist) such as:
    • Fine hand tremors
    • Polyuria (heavy urination)
    • Polydipsia (thirst)
  • Other symptoms reported are:
    • Ankle oedema
    • Aggravation of psoriasis
    • Metallic taste in the mouth
    • Weight gain
  • Longer term, lithium can be associated with:

Complications /Information to beware of/General tips:

Non-steroidal anti-inflammatory drugs (NSAIDs; e.g. diclofenac, ibuprofen, naproxen) should be avoided by patients without professional medical advice
  • Lithium is primarily excreted via the kidneys and should not be used in severe renal impairment, Caution is required in mild or moderate renal impairment, with close monitoring of lithium levels.
  • Lithium can cause thyroid disturbances, such as hypothyroidism and thyrotoxicosis, and it it should not be prescribed in untreated hypothyroidism.
  • Lithium can aggravate Brugada syndrome and/or if one has a family history of this condition.
  • Lithium should be avoided in cardiac disease associated with rhythm disorders.
  • Lithium should be avoided in Addison disease.
  • Lithium should be avoided in with low sodium levels, including dehydration or low-sodium diets.

​Bipolar disorder: Lithium. National Institute for Health and Care Excellence . 2023. https://cks.nice.org.uk/topics/bipolar-disorder/prescribing-information/lithium/ (accessed February 2024)

  • Lithium must be used with extreme caution, and only under specialist supervision, in pregnancy and breastfeeding.
Treating bipolar disorder during breastfeeding. Specialist Pharmacy Service. 2023. https://www.sps.nhs.uk/articles/
treating-bipolar-disorder-during-breastfeeding/
(accessed February 2024)
Antenatal and postnatal mental health: clinical management and service guidance. National Institute for Health and Care Excellence . 2020. https://www.nice.org.uk/guidance/
cg192 
(accessed February 2024)

Lithium toxicity can be confused with and/or mistaken for:

Detailed Information

Please copy and paste any key words from the title: Bipolar Manic-Depressive Medication in the following respective 'Medtick References and/or Sources' to find out more about the disease (this also may include diagnosis tests and generic medical treatments).

References

The Pharmaceutical Journal, PJ, February 2024, Vol 312, No 7982;312(7982)::DOI:10.1211/PJ.2024.1.217950

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