Overcoming our Therapeutic Neglect of Lithium

A patient in his mid 30s was brought to the hospital by police for increased aggression towards his family members. On evaluation he reported a decline in his sleep over the previous four days.  He was speaking rapidly, with a lot to talk about a huge investment that he had made online.  He admitted to having high energy and a racing mind. It was immediately evident that he was highly distractible,  with increased aggressive and  hypersexual gestures. 

He was diagnosed with bipolar disorder 8 years ago but had poor response to trials of divalproex, carbamazepine, aripiprazole and risperidone. I expected him to have had a trial of Lithium at some point, but to my surprise none of his previous psychiatrists have considered that option at all. 

Why do we shun highly effective drugs like Lithium for bipolar disorder and Clozapine for schizophrenia?

Lithium’s therapeutic neglect is rather a sad story. It is the gold standard treatment for bipolar disorder and some argue that it is the only drug with an effect that fits the term Mood Stabilizer (1).  But it continues to be underutilized by physicians due to our concerns over its side effect profile. 

Interestingly, physicians are deterred by lithium’s side effects more than patients who are on it! (2)

At PEF, we believe that it is critical to periodically remind oneself of how to tackle the common as well as serious side effects of lithium. For example, fine tremor is one of the most common side effects of lithium, seen in approximately one quarter of patients. On the other hand, severe tremors that are often coarse may be a sign of lithium toxicity. 

When it comes to side effects, we have seen among our colleagues, knowing what to look for and how to tackle each side effect, imparts a great deal of confidence that enables effective use of Lithium.

Let’s Answer this Question first:

Which of the following feature is more consistent with tremors due to lithium toxicity?

How can you differentiate lithium tremors from lithium toxicity tremors?

Lithium toxicity tremors are: 

  • coarser 
  • more irregular 
  • more widespread (affecting other body parts) 
  • more severe 
  • associated with the other symptoms of toxicity.

We bring to you detailed, but easily accessible knowledge on lithium’s adverse events in following six chapters:

(1) Lithium and Acute Kidney Injury:
  • Evaluation
(2) Lithium induced Polyuria/polydipsia (Nephrogenic Diabetes Insipidus):
  • Mechanism of action.
  • Risk factors for polyuria/polydipsia.
  • Is this effect on kidneys reversible after lithium discontinuation.
  • Pharmacological treatment for lithium-induced NDI (nephrogenic diabetes insipidus).
  • Guidelines to minimize risk of renal damage.
(3) Lithium and Risk of Hypercalcemia & Hyperparathyroidism:
  • Mechanism of action.
  • Differentiate Lithium associated hypercalcemia/hyperparathyroidism from primary hyperparathyroidism.
  • Symptoms of hypercalcemia.
  • Monitoring guideline.
  • Management.
(4) Lithium induced Tremors:
  • Clinical features of lithium induced tremors.
  • Onset & course of lithium tremors.
  • Risk factors.
  • Differentiating lithium tremors Vs Lithium toxicity tremors.
  • Management of lithium tremors.
  • Treatment options if beta blockers are not effective/not tolerated.
(5) Lithium induced Hypothyroidism:
  • Underlying mechanism of action.
  • Risk factors for lithium induced hypothyroidism.
  • Monitoring recommendations.
  • Management recommendations.
(6) Lithium induced Neuropathy:
  • Underlying mechanism.
  • Clinical Presentation: onset, localization, recovery and prognosis.
  • Evaluation.
  • Management.
  • Summary of published case reports.

SUBSCRIBE TO: 

PHYSICIAN’S GUIDE FOR CLINICAL PSYCHIATRY COURSE

  • Total chapters: 250+ Chapters.
  • Chapters and Sections are frequently updated.
  • Triweekly Email Clinical Summary: subscribers receive 3 emails/week.
  • Journal Club: we will post most recently published psychiatry articles relevant to your daily clinical practice.
  • Coffee Club: contain short discussions with clinical experts in the field of psychiatry
  • Goal: is to have all important clinically relevant topics in one course.
  • Annual Subscription of $65/year: for continued access to course on an annual basis.

 

References:
  1. Post RM. The new news about lithium: an underutilized treatment in the United States. Neuropsychopharmacology. 2018 Apr;43(5):1174-9.
  2. Gitlin M. Lithium side effects and toxicity: prevalence and management strategies. International journal of bipolar disorders. 2016 Dec;4(1):1-0.

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