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GENERIC NAME: lithium
BRAND NAME: Eskalith; Lithobid
DRUG CLASS AND MECHANISM: Lithium is used for the treatment of manic/depressive (bipolar) and depressive disorders. Lithium is a positively charged element or particle that is similar to sodium and potassium. It interferes at several places inside cells and on the cell surface with other positively charged atoms such as sodium, potassium, calcium, and magnesium which are important in many cellular functions.
Lithium interferes with the synthesis and reuptake of chemical messengers by which nerves communicate with each other (neurotransmitters). Lithium also affects the concentrations of tryptophan and serotonin in the brain. In addition, lithium increases the production of white blood cells in the bone marrow. Lithium's effects usually begin within one week of starting treatment, and the full effect is seen by 2 to 3 weeks.
Lithium has been used since the 1950's. The currently most frequently used preparation, lithium carbonate, was not approved by the FDA until 1970.
PREPARATIONS: Tablets: 450mg. Capsules: 300mg.
STORAGE: Tablets and capsules should be kept at room temperature, 15-30°C (59-86°F).
PRESCRIBED FOR: Lithium is used most frequently for bipolar affective disorder (manic-depressive illness) and has also been used for unipolar depression.
DOSING: Lithium is generally taken with food, although its absorption is not markedly affected by the presence of food. (See section on side effects below.) Doses vary widely and are adjusted based on measurements of the levels of lithium in the blood. Early in therapy, dose adjustments are made as often as every 5 to 7 days to establish the correct dose. Patients with kidney diseases excrete less lithium from the body and, therefore, require lower doses.
DRUG INTERACTIONS: NSAIDs, e.g. ibuprofen (Motrin, Advil), naproxen Naprosyn, Aleve), indomethacin (Indocin), nabumetone (Relafen), diclofenac (Voltaren, Cataflam, Arthrotec), ketorolac (Toradol), reduce the kidney's ability to eliminate lithium and lead to elevated levels of lithium in the blood. This can lead to side effects. Blood concentrations of lithium may need to be measured for 4 to 7 days after an NSAID is either added or stopped during lithium therapy. Aspirin and sulindac (Clinoril) do not appear to affect lithium concentrations in the blood.
Diuretics (water pills) should be used cautiously in patients receiving lithium. Diuretics that act at distal tubule, e.g., hydrochlorothiazide, spironolactone (Aldactone), triamterene (Dyrenium; Dyazide, Maxzide), can increase blood concentrations of lithium. Diuretics that act at the proximal tubule, e.g. acetazolamide (Diamox), are more likely to reduce blood concentrations of lithium. Diuretics such as furosemide (Lasix) and bumetanide (Bumex) may have no affect on lithium concentrations in blood.
ACE inhibitors, e.g. enalapril (Vasotec), lisinopril (Zestril, Prinivil), benazepril (Lotensin), quinapril (Accupril), moexipril (Univasc), captopril (Capoten), ramipril (Altace), may increase the risk of developing lithium toxicity, by increasing the amount of lithium that is reabsorbed in the tubules of the kidney and thereby reducing the excretion of lithium. When carbamazepine (Tegretol) and lithium are used together, some patients may experience side effects, including dizziness, lethargy, and tremor. Central nervous system side effects also may occur when lithium is used with antidepressants, for example, fluoxetine (Prozac) sertraline (Zoloft), and paroxetine (Paxil), fluvoxamine (Luvox), amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin).
Medications which cause the urine to become alkaline (the opposite of acidic) can increase the amount of lithium that is lost into the urine. This results in lower blood concentrations of lithium and reduces the effects of lithium. Such drugs include potassium acetate, potassium citrate, sodium bicarbonate, and sodium citrate.
Caffeine appears to reduce serum lithium concentrations, and side effects of lithium have increased in frequency when caffeine is consumed.
Both diltiazem (Cardizem-CD, Tiazac, Dilacor-XR) and verapamil (Calan-SR, Isoptin-SR, Verelan, Covera-HS) have been reported to have variable effects on lithium levels in blood. In some patients there may be decreased lithium blood levels and in others lithium toxicity.
Methyldopa (Aldomet) may increase the likelihood lithium toxicity.
Various reactions have resulted when lithium is administered with phenothiazines, for example, chlorpromazine (Thorazine), thioridazine (Mellaril), trifluoperazine (Stelazine) or with haloperidol (Haldol). Such reactions have included delirium, seizures, encephalopathy, high fever or certain neurologic reactions that affect movement of muscles, called extrapyramidal symptoms.
Lithium can cause goiter or hypothyroidism. The use of lithium with potassium iodide can increase the likelihood of this adverse reaction.
The use of the beta-blocker, propranolol (Inderal), with lithium can lead to a slow heart rate and dizziness. Other beta-blockers, for example, metoprolol (Lopressor), atenolol (Tenormin) also may interact with lithium and be associated with a slow heart rate.
PREGNANCY: Lithium crosses the placenta and has been associated with toxicity in the fetus. Children born to women taking lithium during pregnancy have an increased risk of goiter and cardiac anomalies. If possible, lithium should be withheld during the first trimester. Women of childbearing age who may require lithium should be counseled about becoming pregnant.
NURSING MOTHERS: Lithium is secreted into breast milk. Symptoms of lithium toxicity, including changes in the electrocardiogram, have been seen in some breast-fed infants, whose mothers were taking lithium. If possible, women taking lithium should not breast-feed their infants.
SIDE EFFECTS: The most common side effects that can occur in persons taking lithium are fine hand tremor, dry mouth, altered taste perception, weight gain, increased thirst, increased frequency of urination, mild nausea or vomiting, impotence, decreased libido, diarrhea, and kidney abnormalities. Many of the gastrointestinal side effects (nausea, taste alterations, diarrhea) often disappear with continued therapy. Additionally, they may be less common if lithium is taken in divided doses with meals. If diarrhea or excessive urination lead to dehydration, lithium toxicity is possible. Lithium can also cause changes in the electrocardiogram, low blood pressure, and decreased heart rate.
The following side effects suggest that lithium blood levels may be too high, and that the dose of lithium may need to be reduced (after confirmation by measurement of lithium levels in blood): loss of appetite; visual impairment; tiredness; muscle weakness; muscle fasciculations (twitches); tremor; unsteady gait; confusion, seizure; arrhythmias; slurred speech; coma.
About 1 in every 25 persons who receives lithium develops a goiter (an enlarged thyroid gland). Hypothyroidism (low thyroid hormone levels) has been reported. Signs of hypothyroidism may include dry rough skin, hair loss, hoarseness, mania, mental depression, increased sensitivity to cold, and swelling of the feet, lower legs, and neck. | |
