Lithium

Lithium in general
Indications: Tx of acute mania (can take 6-10d take effect; use valproate/antipsychotic in the meantime) Bipolar disorder: prevention of manic and depressive episodes Chronic schizophrenia Precautions: Hyponatraemia (dehydration, Addisons, diet) Thiazide diuretics: [Li+] effect via reduced renal clearance Elderly Psoriasis Surgery (pre- and perioperative periods) Other drugs that increase serotonin levels Antidepressants, opioids, stimulants, illicit drugs Pregnancy o Teratogenic neural tube defects, patent ductus arteriosus, Ebsteins abnormality Dosing Normal range in plasma: 0.4-1mmol/L prophylaxis, 0.5-1.2 acute mania Must be titred regularly; Pts on Li should always have blood measurements done when presenting to emergency. Before starting Tx, pts should undertake urinalysis and have T4 levels checked. MOA unconfirmed, likely Na+/K+ ATPase alterations + altered NT release + adenylate cyclase activity reduction. Li+ actions: Serotonin release Dopamine release intracellular 2nd messengers No psychotropic effect in normal individuals

Mx of OD
OD is generally chronic and accidental, rather than acute (eg suicide) non-intentional OD makes up ~98-99% of overdoses with lithium and has a much better prognosis. Normally cant stop Li+ abruptly (withdrawal reaction). Haemodialysis first line Often indicated to remove several drugs (Li+, gentamicin, aspirin overdose) that are causing renal failure. Forced dialysis Used in pts without renal failure where haemodialysis not available (some rural locations). Either increased salt intake or (preferably) isotonic saline infusion: If pt presents within 1h of ingestion, can use activated charcoal

Pores in internal structure of charcoal take up substances from the gut and carry them to the other end of the GIT and the wonderful world beyond.

Possible future Rx for Li toxicity might be amiloride.

Adverse affects and toxicity

Adverse effects: Common: Metallic taste, nausea, diarrhoea, epigastic discomfort, weight gain, fatigue, headache, vertigo, tremor, acne, psoriasis, leucocytosis, polyuria, hypothyroidism, benign ECG T wave changes Infrequent: Nephrogenic diabetes insipidus ( polyuria polydipsia), hair loss, hyperparathyroidism, memory impairment Rare: Arrhythmias, hyperthyroid Signs of toxicity: Mild-moderate: Li+>1.5mmol/L altered vision, nausea, vomiting, diarrhoea, muscle weakness, drowsiness Severe: Li+>2.0mmol/L increased muscle tone, coma, Szs, arrhythmias, renal failure, dysarthria (severe speech slurring), disorientation, psychosis, coarse tremor