Lithium Guide: Side Effects Mnemonic, Toxicity, Management, Tests, Pregnancy, Contraindications

In this post, we will discuss some key features of Lithium, a drug used for Bipolar disorder. This article will guide you with a quick understanding with a summary of lithium side effects mnemonics and toxicity and management.

We will also cover tests required before commencing, tests for monitoring levels, drugs not used along with it, and finally what tests are required for lithium with pregnancy.


What is Lithium?

It is a Mood Stabilizer used for bipolar disorder. Additionally, it is also used as an adjunct in refractory depression.


Summary

Below image will help you learn lithium side effects mnemonic easily:

  1. Toxicity
    • Leucocyte Increase
    • Tremors (Coarse {Fine at therapeutic levels}, Sodium Valproate causes Fine Tremors) , Twitching
    • Hyperreflexia, Hypothyroidism
    • Increased Urine
    • Mothers- Ebstein anomaly (Teratogenic)
  2. In Pregnancy (Ebstein anomaly, Floppy baby syndrome)
    • To be Pregnant- Reduce gradually and Stop it before pregnancy is confirmed
    • Becomes Pregnant- Stop Gradually over 4 weeks
    • Pregnant and Still taking- Check plasma levels Monthly till 36 weeks of pregnancy & Weekly till birth
  3. Monitoring
    • Lithium levels: 1 week> Every 3 months (12 hours after the last dose as it has a narrow therapeutic range)
    • LFT with U&E every 6 months
  4. Drugs not used with it
    • NSAIDs (especially Ibuprofen)
    • Aspirin
    • Diuretics
    • SSRI
  5. Tests Follow Up
    • LFT
    • KFT
    • TFT,
    • Baseline ECG
    • Pregnancy test

Lithium Side Effects Mnemonic

The word itself can be used to derive the lithium side effects mnemonic. We have given the mnemonic below:

LITHIUM

  • Leucocyte
  • Increase
  • Tremors (Coarse {Fine at therapeutic levels}, Sodium Valproate causes Fine Tremors) , Twitching
  • Hyperreflexia, Hypothyroidism
  • Increased
  • Urine
  • Mothers- Ebstein anomaly (Teratogenic)

Summary of Side Effects

  • Coarse tremor (a fine tremor is seen at therapeutic levels)
  • Muscular twitching
  • Nausea and Vomiting
  • Drowsiness, confusion
  • Hyperreflexia
  • Seizure (in severe toxicity)
  • Coma (in severe toxicity)
  • Blurred vision

Management of Toxicity

There is a detailed guide on the management of lithium overdose by NHS.

  • Take serum Lithium levels
  • Mild-moderate- IV fluids (NS) and stop the drug immediately
  • Severe toxicity- Haemodialysis

Scenarios

Before Starting

There are a couple of tests that are required to be done before commencing Lithium:

  • LFT (Always first)
  • KFT (Most important)
  • TFT (Most important)
  • Baseline ECG
  • Others- Pulse, BP, Pregnancy test, PTH, FBC, U&E, Ca, Mg
  • Where
    • LFT- Liver Function Test
    • KFT- Kidney Function Test (also known as RFT- Renal Function Test)
    • TFT- Thyroid Function Test
    • PTH- Parathyroid levels
    • FBC- Full Blood Count (also known as CBC- Complete Blood Count)

Tests for Monitoring

These tests are done to ensure adequate monitoring and prevent adverse effects:

  • Lithium levels after 1 week of commencing
  • Lithium levels every 3 months (12 hours after the last lithium dose as it has a narrow therapeutic range)
  • LFT and U & E every 6 months
  • Where
    • U&E- Urea and Electrolytes

Drugs not used with Lithium

Many drugs should be considered if a patient is already on them. Some important ones include:

  • NSAIDs (especially Ibuprofen)
  • Aspirin
  • Diuretics
  • SSRI

Explanation

  • Ibuprofen- Increases renal reabsorption and decreases renal excretion of the drug, hence the risk of toxicity
  • Codeine is safe to use with lithium
  • Aspirin is not a typical painkiller for injuries
  • The addition of an Anti-depressant (SSRI) can worsen the episodes of Mania
    • It should be stopped if the mania is worsened (Antidepressants precipitate Manic episodes)
  • Diuretics used as antihypertensive and can cause hypokalemia
    • Thiazide-like diuretic (Bendroflumethiazide)
  • Remember
    • ACEi and Potassium sparing diuretics- Hyperkalemia
    • Thiazide and Thiazide like diuretics- Hypokalemia

Lithium and Pregnancy

This drug is teratogenic and has a risk of causing fetal cardiac malformations which include Ebstein anomaly, Thyroid disease, and Floppy baby syndrome.

Expected Scenarios

If a woman on lithium is planning to get pregnant

  • Reduce Gradually and Stop it before pregnancy is confirmed

If a woman on lithium becomes pregnant

  • Consider stopping it gradually over 4 weeks if she is well

If a woman takes lithium while she is pregnant

  • Check plasma levels Monthly till 36 weeks of pregnancy
  • Check plasma levels Weekly till birth

Disclaimer

Please note that this information is for educational purposes only, especially for MBBS students taking the PLAB exam for the UK license exam. We do not hold any responsibility for the usage of the information for practical purposes.

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