Psych · Psychopharmacology — lithium
Lithium
Also known as Lithium carbonate · Lithium citrate · Li+ mood stabiliser · Lithium monitoring · Lithium TDM
Exam-exhaustive fellowship monograph on lithium — initiation and 12-hour trough levels, acute mania and bipolar maintenance evidence (BALANCE, Geddes, Severus), anti-suicide efficacy (Cipriani), renal/thyroid/parathyroid monitoring (McKnight, Shine, Kessing), toxicity and EXTRIP, interaction ladder, pregnancy (Patorno, Munk-Olsen), special populations. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Coarse tremor, ataxia, dysarthria, confusion, seizures or reduced consciousness on lithium — stop drug, serial levels, treat as toxicity until proven otherwise
- Dehydration, gastroenteritis, or new NSAID / ACE inhibitor / ARB / thiazide without a level plan — chronic accumulation risk
- Fever with neurological change is not 'viral until proven psychiatric' — check lithium level and renal panel
- First-trimester unplanned pregnancy on lithium — urgent perinatal psychiatry and obstetric risk–benefit, not panic-stop without a plan
- Rapid eGFR fall, severe polyuria with rising levels, or symptomatic hypercalcaemia — escalate monitoring and specialist review
- High suicide risk bipolar illness — do not casually abandon lithium without a replacement safety plan
Meet the patient
A 58-year-old woman, twelve stable years on lithium, is brought to ED by her son. Four days of vomiting and diarrhoea after a family barbecue. She has been taking ibuprofen for the aches, and her GP started ramipril last month. She is drowsy, dysarthric, and her hands have a coarse, flapping tremor that was not there last week.[6][11][12]
Nobody changed her lithium dose. Nothing about her prescription is wrong on paper. Three ordinary events — dehydration, an over-the-counter anti-inflammatory, and a new antihypertensive — quietly raised her lithium while everyone watched the psychiatry.[11][12]
That is the exam question in one patient: lithium harms people through clearance, not through prescribing errors. Everything below exists to catch that.[6][11][12]
References16ShowHide
- [1]Geddes JR, Burgess S, Hawton K, et al. Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials Am J Psychiatry, 2004.PMID 14754766
- [2]Geddes JR, Goodwin GM, Rendell J, et al. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial Lancet, 2010.PMID 20092882
- [3]Severus E, Taylor MJ, Sauer C, et al. Lithium for prevention of mood episodes in bipolar disorders: systematic review and meta-analysis Int J Bipolar Disord, 2014.PMID 25530932
- [4]Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis Lancet, 2011.PMID 21851976
- [5]Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
- [6]McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699
- [7]Shine B, McKnight RF, Leaver L, et al. Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data Lancet, 2015.PMID 26003379
- [8]Kessing LV, Gerds TA, Feldt-Rasmussen B, et al. Use of Lithium and Anticonvulsants and the Rate of Chronic Kidney Disease: A Nationwide Population-Based Study JAMA Psychiatry, 2015.PMID 26535805
- [9]Patorno E, Huybrechts KF, Bateman BT, et al. Lithium Use in Pregnancy and the Risk of Cardiac Malformations N Engl J Med, 2017.PMID 28591541
- [10]Munk-Olsen T, Liu X, Viktorin A, et al. Maternal and infant outcomes associated with lithium use in pregnancy: an international collaborative meta-analysis of six cohort studies Lancet Psychiatry, 2018.PMID 29929874
- [11]Decker BS, Goldfarb DS, Dargan PI, et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup Clin J Am Soc Nephrol, 2015.PMID 25583292
- [12]Gitlin M Lithium side effects and toxicity: prevalence and management strategies Int J Bipolar Disord, 2016.PMID 27900734
- [13]Hiemke C, Bergemann N, Clement HW, et al. Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017 Pharmacopsychiatry, 2018.PMID 29390205
- [14]Malhi GS, Gessler D, Outhred T The use of lithium for the treatment of bipolar disorder: recommendations from clinical practice guidelines J Affect Disord, 2017.PMID 28437764
- [15]Forlenza OV, Diniz BS, Radanovic M, et al. Disease-modifying properties of long-term lithium treatment for amnestic mild cognitive impairment: randomised controlled trial Br J Psychiatry, 2011.PMID 21525519
- [16]Shulman KI, Almeida OP, Herrmann N, et al. Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report Bipolar Disord, 2019.PMID 30375703