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Lithium, a natural salt, is
perhaps the oldest psychiatric medication.
It has been used for bipolar disorder since 1950, and its
non-medical use dates back to the second century a.d. when spring water containing lithium was known to calm
overactive and manic states.
Lithium treats manic symptoms of
racing thoughts, sleeplessness, excitation and irritability. Lithium can also be used to treat
depression. Since lithium has been
around so long, we know a lot about this medicine. We know that lithium not only treats but helps prevent depression, mania and
suicide and can protect nerve cells from damage. On the other hand, we know that there can
be side effects to lithium and that it needs to be dosed carefully to avoid
these.
There is a lot to know about lithium,
so it is important to read everything below and ask questions. Lithium is a safe medicine when both the
doctor and the patient are carefully monitoring it.
How does it work?
Lithium helps stabilize nerve
cell firing, but it is not clear exactly how it does this. It also helps regulate serotonin, which
can play a role in depression, anger and suicide.
What types are available and how is it taken?
Lithium is available in two
forms: regular and slow release, which differ in
how fast the lithium enters the blood stream. Regular release lithium may be better for
your kidneys, while slow release lithium is less likely to upset your
stomach. Lithium can also be taken
with food if stomach upset occurs.
Lithium is usually taken twice a day, but if the dose is low enough
(usually less than 900mg) it can be taken all at night, which reduces
daytime side effects.
The right dose for you will
depend on your blood level of lithium, which is described below.
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Name
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Brands and Strengths
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Description
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Lithium Carbonate
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Generic (300mg), Eskalith
(300mg capsules), Liquid.
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Regular lithium.
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Slow Release Lithium
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Lithobid SR (300mg), Eskalith CR (450mg tabs).
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Slowly releases lithium over 9-12 hours; these tablets
should not be broken.
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More about blood levels
Lithium levels need to be
checked a few times in the beginning to determine your dose. The best time
to have your level checked is 12 hours after your last dose or just before
your next dose. If you take it all at night, have it checked in the
morning. If you take lithium in the morning, go to the lab before your
morning dose and then take that dose after your blood is drawn.
A good blood level of lithium
ranges from 0.5 – 1.2, with levels in the higher range needed if
there are active symptoms. Levels below 0.5 rarely help, and levels above
1.2 or 1.5 can cause toxic effects. After a change in your dose, it takes
5-7 days for the level to settle, so we will wait this long before it is
redrawn.
Once your dose is established,
your level should remain steady and can be checked every 6 months. We will
also check your thyroid and kidney function at these times to make sure
lithium is not affecting them (see Side Effects). Some things can change
your level, and these should be avoided or done under supervision with
close checking of the level:
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Dehydration
(e.g. from excessive exercise,
body heat, alcohol or caffeine without fluid replacement; or from fever,
infection, or diarrhea).
·
Going on a
low-salt diet.
·
Changing your
medicines, whether prescribed or over-the-counter.
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Changes in your
medical condition (e.g. heart, liver or kidney failure; edema, diarrhea,
fever or infection, low sodium levels, hyponatremia).
How long will I need to take it for?
After your
symptoms have resolved, lithium continues to work to prevent future
episodes of bipolar disorder. Going without lithium can lead to more
bipolar episodes, and after too many episodes your brain can get in a habit
(called “kindling”) of mood swings that is harder to
treat. Stopping and starting lithium
too much can also increase the episodes.
Therefore, it is best to take lithium regularly as long as side
effects are not a problem. If lithium is ever stopped, it should be done
slowly to prevent a sudden return of symptoms.
What side effects can I expect?
The most common reason that
people stop lithium is side effects. Lithium also has physical benefits: it
can reduce menstrual cramping and relieve cluster headaches.
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SIDE EFFECT
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DESCRIPTION
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TREATMENT
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Thirst, increased urine, dry mouth.
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Thirst is increased as lithium causes more water to go out of the
kidneys (increased peeing); this side effect is not dangerous and occurs
in at least 50% of people.
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Keep hydrated by drinking water.
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Tremor
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A fine tremor, usually of the hands.
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Lower the dose or use a tremor medicine like propranolol.
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Weight Gain
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Weight gain can be due increased calories from drinking beverages,
and changes in appetite and metabolism.
Half of people who take lithium have weight gain.
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Drink water rather than sodas or high-calorie beverages. Exercise
(walk 30 minutes a day). Diet.
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Stomach discomfort
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This is more common in the first months of treatment, occurring in
30% of people, and may go away.
“Bloated” feelings can sometimes be due to a full
bladder.
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Take with food; use an extended release form of lithium.
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Tiredness
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When lithium helps depression it usually relieves tiredness,
however, sometimes it can make people tired as a side effect.
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Concentration
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Some people report trouble with concentration and memory on
lithium. Although these
differences are not detectable on cognitive tests of memory, they may
still be real. Lithium will
sometimes help concentration and memory when it treats depression.
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Skin changes
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Acne, rash, irritated skin.
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Antibiotic treatment usually clears the acne.
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Increased saliva
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Although lithium can cause dry mouth, it can also increase saliva
production.
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Headaches
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Lithium improves cluster headaches,
but headaches can also occur as a side effect.
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Tylenol or aspirin; avoid other pain medicines (see Drug
Interactions).
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Diarrhea
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Loose stools are common in the beginning of treatment and may
continue throughout treatment.
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Antidiarrheals such as Imodium are safe to take.
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Hair loss
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This rare (5% of people) effect often improves over time.
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Sexual function
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Little is known about this with lithium; it does not seem to affect
sexual function like other medications can.
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Taste changes
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A decrease in taste for food.
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Discoordination
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Occasional periods of feeling faint, weak or discoordinated.
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Medical Changes with Lithium
The following are medical changes that can occur with lithium.
In order to prevent these, we may need to stop lithium if early signs of
these appear in your labs. Unlike
most of the above side effects, these changes are more likely to happen the
longer lithium is taken, and they may persist after stopping lithium.
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MEDICAL CHANGE
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DESCRIPTION
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Low thyroid
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Symptoms of decreased thyroid hormone (hypothyroidism) include
lethargy, weight gain, dry skin, depression, and sensitivity to
cold. This effect is common, occurring
in 15-25% of people on long-term lithium treatment, and is easily
treatable with hormone replacement.
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Kidney changes
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Rare impairment of kidney function, usually caused by an overdose
of lithium. Symptoms include
increased urination, especially at night.
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Heart problems
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Changes in heart rhythms can occur, especially in people with
pre-existing heart disease. Cardiac exams (EKG) should be followed if you
are at risk.
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Elevated calcium
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Rarely, calcium levels can increase due to overactive
parathyroid. Symptoms of high
calcium include nausea, loss of appetite, and increased urination.
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Changes in white blood cells.
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Lithium can cause increases in white blood cells; this change is
not a problem and may help fight infection.
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Lithium Overdose
The following are signs that
your lithium level is too high:
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Confusion,
imbalance while walking, slurred speech, nausea and vomiting, diarrhea,
tremor.
A high
level can be dangerous to the kidneys and the brain. Refer to “More
About Blood Levels” above to understand what can raise levels. If you
think your level is too high, do the following:
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Stop lithium and
drink fluids (especially Gatorade or normal saline, which can be made by
dissolving ¼ teaspoon of salt in 1 cup of warm water).
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Call your doctor or go to the emergency room.
Precautions
Since lithium may cause drowsiness or discoordination, Make sure you know how you react to
it before you drive, use machines, or do anything else that could be
dangerous if you are not alert, well-coordinated, or able to see well.
Pregnancy:
There is a small risk (approximately 5 in 10,000) of heart
defects in the child, especially if lithium is taken during the first
trimester. Lithium should also be avoided latter in the pregnancy, since
changes in body water can cause toxic levels in the mother and child.
Lithium poses no known risks to the ovaries when it is taken before
pregnancy.
Breast-feeding: Although children who are exposed to
lithium during breast-feeding appear to develop normally, it is probably
best to avoid this exposure. You can also minimize the exposure by
breastfeeding when lithium levels are low, such as in the morning or at
least 4-6 hours after your dose. Breast milk can also be pumped and stored
during these safer times.
Children: Lithium has not been adequately
studied in children under 12.
Older adults: Lithium
is often removed from the body more slowly in people after age 65, so lower
dosages may be needed.
Medical problems that can worsen with
lithium:
- Heart
disease
- Kidney
disease
- Certain
neurologic diseases
- Ulcerative
colitis or irritable bowel syndrome
- Psoriasis,
acne, hair loss
- Lupus
(Systemic lupus erythematosus)
- Cataracts
- Thyroid
illness
Drug Interactions
Many medicines can raise lithium levels, including
over-the-counter remedies, so consult your physician before trying new
medicines. Sometimes these medicines can be taken with careful monitoring
of lithium levels.
Pain
Medicines
Many pain medications, including
Motrin (ibuprofen), Vioxx (rofecoxib), Celebrex (celecoxib) and Naprosyn (naproxen), can increase lithium levels.
Tylenol (acetaminophen) and aspirin are safe and should be taken for
general pain.
Diuretics,
Heart and Blood Pressure Medicine
Diuretics (e.g. lasix,
hydrochlorothiazide), which are often used to treat high blood pressure or
edema/swelling, can increase lithium levels, as can ACE (angiotensin-converting enzymes) inhibitors (e.g. enalapril, captopril), and
calcium-channel blockers (e.g. verapamil, diltiazem, nifedipine). These
medicines should be taken only under close medical supervision.
Caffeine,
Alcohol, Drugs
Caffeine, tea and coffee can lower
lithium levels, so be careful if you are a regular user of these and then
stop (that could raise your level). Lithium may reduce the effects that
alcohol or street drugs have on the brain.
Other
Psychiatric Medicines
Lithium may slightly increase the
risk of two very rare conditions that can occur with psychiatric medicines.
One is Serotonin Syndrome, which can happen with antidepressants that
affect serotonin (e.g. Prozac and other SSRIs, Effexor). The other is Neuroleptic
Malignant Syndrome, which can occur with antipsychotics
(e.g. Zyprexa, Haldol, Risperdal).
Other
medicines that can raise lithium levels:
Tetracycline, doxycycline, metronidazole,
eplerenone.
Anti-parkinson medicines can interact with
lithium.
Medicines
that can lower lithium levels:
Antacids, caffeine, coffee, tea, acetazolamide, urea, and theophylline.
Important: if you regularly take
these and then stop, it could raise your lithium level.
Storage
- Keep
out of the reach of children.
- Store
away from heat and direct light.
- Do
not store in the bathroom, near the kitchen sink, or in other damp
places. Heat or moisture may cause the medicine to break down.
- Do
not keep outdated medicine or medicine no longer needed. Be sure that
any discarded medicine is out of the reach of children.
Updated 4/1/4 by Chris Aiken,
M.D.
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