Lithium

Pregnancy and breastfeeding

avoid in breast feeding as present in milk

avoid especially 1st trimester risk teratogenicity

dose requirements increase 2nd and third trimester but returns normal after delivery

ensure effective contraception

Monitoring serum level concentrations

take levels 12 hours after dose aiming for 0.4-1mmol and lower dose in elderly

0.8-1mmol/l for acute episodes and previous relapses

monitor weekly after initiation and after each dose change until stable

monitor 3 monthly for a year then 6 months thereafter

Monitoring other parameters

Before initiaition

-cardiac - thyroid -renal functiion

-ECG - weight - FBC - U+E

during treatment

weight

U+E

EGFR

thyroid function

discontinuing lithium

avoid abrupt withdrawal high tisk relapse

reduce gradually over 4 weeks - 3 months (ideal)

monitor for relapse

if stopped abruptly consider atypical antipsychotic or valproate

patient/carer advice

report signs lithium toxicity:

-hypothyroidism weight gain

-renal dysfunction

-benign intracranial hypertension

maintain adequate fluid - hyponatraemia cause lithium toxicity

avoid diet change

maintain same brand and have treatment pack

interarctions increase lithium conc. (DAMNT)

diuretics

ACE/ARB

metronidazole

NSAIDS

Tetracyclines

Interactions decrease lithium conc.

antacids

urine alkaliniser

theophylline

osmotic and carbonic anhydrase inhibitor

interactions increase neurotoxicity

Carbamazepine

antipsychotics

SSRI

triptans

calcium channel blockers

interactions increase risk serotonin syndrome

SSRI

tramodol

st johns wort

sumatriptan