Chronic adverse effects include subjective cognitive effects, thyroid and parathyroid dysfunction, and renal dysfunction (see Table). discontinuation of the medicine. Not all pathology laboratories use the same reference ranges, therefore noting whether the lithium concentration is consistent with the patient’s presentation and the guidelines is essential. Taking note of this is essential and helps to ensure stability of these patient-specific concentrations over time, particularly during each illness phase. Regular long-term monitoring of lithium concentrations is essential to avoid both acute and chronic toxicity. Gin Malhi has received grant or research support from the National Health and Medical Research Council, Australian Rotary Health, NSW Health, Ramsay Health, American Foundation for Suicide Prevention, Ramsay Research and Teaching Fund, Elsevier, AstraZeneca and Servier; has been a speaker for AstraZeneca, Janssen-Cilag, Lundbeck, Otsuka and Servier; and has been a consultant for AstraZeneca, Janssen Cilag, Lundbeck, Otsuka and Servier. Our information hub has important information for everyone. Caffeine might interact with serum lithium levels. An independent peer-reviewed journal providing critical commentary on drugs and therapeutics. Once stabilised, levels should be monitored at least every three months2-4. In practice, target concentrations and monitoring practices are often inconsistent. Closer monitoring is also required when these drugs are stopped. Additional monitoring should occur if signs of lithium toxicity occur, Other prescribers avoid thiazide diuretics altogether. Clinical significance Physical examinations and laboratory investigations should be performed at baseline and regular intervals after that (see Box). that affect renal function, including age, dehydration, sodium balance and They are often dependent on the serum concentration of lithium and frequently subside within days or weeks. Improved knowledge of and confidence with monitoring will contribute to better patient outcomes. Having up-to-date serum lithium concentrations at hand will assist. Typically, lithium is effective in about a third of patients – with response rates up to two-thirds in those whose relatives have achieved good responses.5 It is likely that people who commence lithium early in the course of their illness may have greater likelihood of response. To minimise the risk of relapse, it is usually necessary to maintain the lithium serum concentration between 0.6 mmol/L and 0.8 mmol/L. The The most commonly prescribed drugs that have the potential to interact with lithium are ACE inhibitors, angiotensin II receptor antagonists (sartans), diuretics, and non-steroidal anti-inflammatory drugs (NSAIDs). Drug Interactions with Lithium: An Update. Drug interactions with lithium mostly occur through the direct effect of other medicines on renal function, notably glomerular filtration rate and sodium absorption1. Lower lithium doses may be required. Medicines that interact with lithium are summarised in Table 1. Corrected 12 June 2020. of other medicines on renal function, notably glomerular filtration rate appropriate. The dose of lithium may require adjustment. Health professionals also need to stay up to date with the latest evidence as it emerges. central nervous system: muscle weakness, lack of coordination, drowsiness The most common and noteworthy drug–drug interactions with lithium are pharmacokinetic in nature. Timely, independent, evidence-based information on new drugs and medical tests, and changes to the PBS and MBS. This reduces vasodilation of the afferent arteriole which decreases blood flow to the glomerulus. assess patients for signs of toxicity during concomitant treatment anti-inflammatory drug (NSAID) was added, leading to fatal lithium toxicity. Other diuretics such as the osmotic methylxanthine (e.g. Response.redirect "/searchResults.asp?q=" & q The Centre for Adverse Reactions Monitoring (CARM) has received a total Closer monitoring of lithium concentrations is needed when people start either of these drugs and the lithium dose will probably need to be reduced until a stable therapeutic concentration has been achieved. with lithium and interacting medicines2–4. of nine case reports that identify a drug interaction with lithium. The higher the lithium concentration, the greater the risk of toxic presentations. In some cases, the concomitant data sheets)2–4. However, in some patients, stabilising their mood is not always possible with lithium alone. If NSAIDs are indicated, they should be used under medical guidance with closer monitoring of lithium concentrations. of treatment. IMPACT – the Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Vic. Michael Berk is supported by a National Health and Medical Research Council Senior Principal Research Fellowship (1059660 and APP1156072). Ongoing education for Aboriginal and Torres Strait Islander health workers and practitioners on quality use of medicines and medical tests, Practical information, tools and resources for health professionals and staff to help improve the quality of health care and safety for patients. Regular use is more problematic than episodic use. ► Prescriber Update See 'Serotonin syndrome' and 'Monoamine-oxidase inhibitor' under Antidepressant drugs in BNF for more information and for specific advice on avoiding monoamine-oxidase inhibitors during and after administration of other serotonergic drugs. Lithium clearance is easily influenced by drugs that alter renal function such as ACE inhibitors, angiotensin receptor antagonists, diuretics, and non-steroidal anti-inflammatory drugs. (see below) should be performed for patients requiring concomitant treatment As a part of optimising lithium dosing, clinicians may notice that a specific concentration achieves the most therapeutic benefit during euthymic periods and during manic and depressive episodes. Lithium is not metabolised and is almost entirely eliminated by the kidneys1. A trial with other mood stabilisers, such as adjunctive sodium valproate or an atypical antipsychotic, is often necessary. and sodium absorption1. spironolactone) diuretics may also alter lithium concentrations. May lead to dizziness, somnolence, confusion, cerebellar symptoms. detection and management of renal impairment. inhibitors. During the COVID-19 pandemic, you need to continue to take your usual medicines and stay as healthy as possible. or lethargy (these may progress to dizziness, ataxia, tinnitus, blurred products, Other: psyllium or ispaghula husk, urea, mannitol, Prescribers should contact the treating psychiatrist or consult a medicines information pharmacist if they are unsure how to manage a patient. lithium immediately and seek medical attention2-4. Devices Safety Authority, www.medsafe.govt.nz/profs/PUArticles/RenalDanagersSept10.htm, medsafe.govt.nz/profs/Datasheet/l/LithicarbFCtab.pdf, medsafe.govt.nz/profs/Datasheet/l/Lithiumcarbonatecap.pdf, medsafe.govt.nz/profs/Datasheet/p/priadeltab.pdf, Medicines Adverse Reactions As a result, serum lithium levels are sensitive to physiological factors Amiloride is recommended as a diuretic because it blocks entry of lithium through the epithelial sodium channel in the collecting duct. Too much lithium increases the risk of both acute and chronic toxicity. travelling to the tropics and/or experiencing gastroenteritis are at particular Siponimod (Mayzent) for multiple sclerosis, Two hepatitis C medicines delisted from the PBS, Episode 19: Opioids special #1: Tapering opioids in partnership with patients with chronic non-cancer pain, Episode 18: Dementia and changed behaviours: a person-centred approach, Thyroid disease: challenges in primary care, A new Working Together agreement between CHF and NPS MedicineWise, Lithium therapy and its interactions [Correction], Gin S Malhi, Erica Bell, Tim Outhred, Michael Berk, during the early maintenance phase (e.g. May lead to ataxia, confusion and somnolence, reversible after About risk and should be appropriately advised. Asthma in adults and adolescents: what’s new for mild asthma management? Combinations of these are frequently used, so prescribers should be aware of their additive effects for a patient taking lithium. Prescribers are advised to regularly monitor serum lithium and ► Lithium Interactions, Prescriber Update 38(3): 36-38 Asthma and children: diagnosis and treatment, Medicinal cannabis: what you need to know, Aboriginal and Torres Strait Islander health professionals, Active ingredient prescribing: all you need to know. Site Map, 0 Then intake or fluid balance2-4. Close monitoring and dose adjustments are therefore often needed as patients get older. %>, New Zealand Medicines and Medical 20 years of helping Australians make better decisions about medicines, medical tests and other health technologies, Please help us to improve our services by answering the following question. vision, dysarthria, coarse tremor, and muscle twitching). Aids are available to assist prescribers with lithium management, including an Australian tool called the ‘Lithiumeter’.4. Information for consumers on prescription, over-the-counter and complementary medicines. 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