Lithium Counseling and Travel Advice

Lithium Counseling for a Patient Traveling

Initial Patient Assessment

  • Patient is a 48-year-old male diagnosed with bipolar mood disorder six months ago and is currently on lithium.
  • He is planning to travel next week.
  • The goal is to take further history and arrange necessary investigations.

Lithium Monitoring and Side Effects

  • Plasma Concentration Level: Aim for a lithium plasma concentration level of 0.6 to 0.8 mmol/L.
  • Short-term Side Effects:
    • Tremor
    • Fatigue
    • Diarrhea
    • Thirst
    • Polyuria
    • Vomiting
  • Regular Follow-ups:
    • Kidney function (urea, electrolytes, creatinine): Every 3-6 months
    • Thyroid function (TSH): Every 6 months
    • Parathyroid function and calcium level: Annually
    • Plasma lithium level: Every 3-6 months
    • Weight and waist circumference to check BMI

Lithium Toxicity

  • Causes:
    • Interaction with drugs like NSAIDs.
    • Reduced fluid intake.
    • Severe reduction in sodium chloride intake.
    • Fluid loss (e.g., due to diarrhea or vomiting).

Patient History Taking

  • Open-ended Questions:
    • Start by ensuring confidentiality.
    • "Where are you going?"
    • "How long will you be staying there?"
    • "Are you staying in an urban or rural area?"
    • "Are you traveling alone or with someone?"
    • "Any special plans?"
    • "Are you planning to get tattoos or any medical procedures?"
    • "Any sexual activities overseas?"
  • Bipolar Mood Disorder:
    • "How’s your mood been lately?"
    • "How’s your sleep been lately?"
    • "How’s your appetite been lately?"
    • "Any suicidal ideas?"
    • "Any mania symptoms?"
    • "Have you had any recent gambling or shopping sprees? Spending a lot of money?"
    • "Any sexual history? How are things going?"
  • Treatment Adherence and Side Effects:
    • "Are you compliant with your medication?"
    • "Any side effects? Diarrhea? Headaches? Vomiting?"
    • "Any tiredness? Weight gain?"
    • "Do you have any shakiness of the hands?"
    • "Are you having regular follow-ups with your GP and specialist?"
    • "Have you checked your lithium test lately? If yes, when was the last time?"
    • "Any other medications you are on?"

Investigations

  • Blood Tests:
    • Serum lithium level (to check target range).
    • Thyroid Stimulating Hormone (TSH) for thyroid function.
    • Kidney function test: urea, electrolytes, and creatinine.
    • eGFR (estimated Glomerular Filtration Rate) for kidney function.
    • Serum calcium level.

Patient Education and Advice

  • Medication Safety:
    • Inform the pharmacist about lithium use before taking any new medication.
    • Be cautious about inflammatory painkillers and blood pressure medications.
  • Hydration and Diet:
    • Dehydration increases the risk of lithium toxicity.
    • Drink plenty of fluids.
    • Maintain a normal salt intake.
  • Travel Documentation:
    • Provide a letter explaining the patient’s condition and medication history for use in case of sickness or admission to a healthcare facility overseas.
  • Medication Management:
    • Divide medication, keep some in a handbag to avoid loss.
    • Avoid alcohol overseas.
  • Inform Traveling Companion:
    • If traveling with someone, notify them about the condition and ask them to monitor for relapse symptoms.
    • Signs of relapse: decreased mood, increased mood, needing less sleep, risky behavior (out-of-control sexual activity, gambling, spending a lot of money).
  • Emergency Plan:
    • Advise to go to the emergency department if relapse symptoms occur.
  • Travel Advice:
    • Avoid street food.
    • Drink bottled water.
    • Practice safe sex.
    • If traveling to areas with high risk of mosquito bites, use mosquito repellents, avoid bright colors, and avoid wearing perfumes.
    • Check the smart traveler website for destination-specific advice.
    • Discuss and decide on necessary vaccines or malaria prophylaxis.