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Lithium carbonate
Lithium carbonate (Lithobid, Lithonate)
Lithium
(LITH-ee-um)
Pregnancy Category: D Carbolith Duralith Eskalith Eskalith CR Lithane Lithobid Lithonate Lithotabs PMS-Lithium Carbonate (Rx)
Lithium citrate
Lithium citrate
Lithium
(LITH-ee-um)
Pregnancy Category: D PMS-Lithium Citrate

Classification: Antipsychotic agent, miscellaneous

Action/Kinetics: Mechanism for the antimanic effect of lithium is unknown. Various hypotheses include: (a) a decrease in catecholamine neurotransmitter levels caused by lithium's effect on Na ⁺-K ⁺ ATPase to improve transneuronal membrane transport of sodium ion; (b) a decrease in cyclic AMP levels caused by lithium which decreases sensitivity of hormonal-sensitive adenyl cyclase receptors; or (c) interference by lithium with lipid inositol metabolism ultimately leading to insensitivity of cells in the CNS to stimulation by inositol.
Affects the distribution of calcium, magnesium, and sodium ions and affects glucose metabolism. Peak serum levels (regular release): 1-4 hr; (slow-release): 4-6 hr. Onset: 5-14 days. Therapeutic serum levels: 0.4-1.0 mEq/L (must be carefully monitored because toxic effects may occur at these levels and significant toxic reactions occur at serum lithium levels of 2 mEq/L). t1/2 (plasma): 24 hr (longer in presence of renal impairment and in the elderly). Lithium and sodium are excreted by the same mechanism in the proximal tubule. Thus, to reduce the danger of lithium intoxication, sodium intake must remain at normal levels.

Uses: Control of mania in manic-depressive clients. Investigational: To reverse neutropenia induced by cancer chemotherapy, in children with chronic neutropenia, and in AIDs clients receiving AZT. Prophylaxis of cluster headaches. Also for premenstrual tension, alcoholism accompanied by depression, tardive dyskinesia, bulimia, hyperthyroidism, excess ADH secretion, postpartum affective psychosis, corticosteroid-induced psychosis. Lithium succinate, in a topical form, has been used for the treatment of genital herpes and seborrheic dermatitis.

Contraindications: Cardiovascular or renal disease. Brain damage. Dehydration, sodium depletion, clients receiving diuretics. Lactation.

Special Concerns: Safety and efficacy have not been established for children less than 12 years of age. Use with caution in geriatric clients because lithium is more toxic to the CNS in these clients; also, geriatric clients are more likely to develop lithium-induced goiter and clinical hypothyroidism and are more likely to manifest excessive thirst and larger volumes of urine.

Side Effects: Due to initial therapy: Fine hand tremor, polyuria, thirst, transient and mild nausea, general discomfort. The following side effects are dependent on the serum level of lithium. CV: Arrhythmia, hypotension, peripheral circulatory collapse bradycardia, sinus node dysfunction with severe bradycardia causing syncope; reversible flattening, isoelectricity, or inversion of T waves. CNS: Blackout spells, epileptiform seizures, slurred speech, dizziness, vertigo, somnolence, psychomotor retardation, restlessness, sleepiness, confusion, stupor, coma, acute dystonia, startled response, hypertonicity, slowed intellectual functioning, hallucinations, poor memory, tics, cog wheel rigidity, tongue movements. Pseudotumor cerebri leading to increased intracranial pressure and papilledema; if undetected may cause enlargement of the blind spot, constriction of visual fields, and eventual blindness. Diffuse slowing of EEG; widening of frequency spectrum of EEG; disorganization of background rhythm of EEG. GI: Anorexia, N&V;, diarrhea, dry mouth, gastritis, salivary gland swelling, abdominal pain, excessive salivation, flatulence, indigestion, incontinence of urine or feces, dysgeusia/taste distortion, salty taste, swollen lips, denal caries. Dermatologic: Drying and thinning of hair, anesthesia of skin, chronic folliculitis, xerosis cutis, alopecia, exacerbation of psoriasis, acne, angioedema. Neuromuscular: Tremor, muscle hyperirritability (fasciculations, twitching, clonic movements), ataxia, choreo-athetotic movements, hyperactive DTRs, polyarthralgia. GU: Albuminuria, oliguria, polyuria, glycosuria, decreased C_CR, symptoms of nephrogenic diabetes, impotence/sexual dysfunction. Thyroid: Euthyroid goiter or hypothyroidism, including myxedema, accompanied by lower T₃ and T₄. Miscellaneous: Fatigue, lethargy, dehydration, weight loss, transient scotomata, tightness in chest, hypercalcemia, hyperparathyroidism, thirst, swollen painful joints, fever.
The following symptoms are unrelated to lithium dosage. Transient EEG and ECG changes, leukocytosis, headache, diffuse nontoxic goiter with or without hypothyroidism, transient hyperglycemia, generalized pruritus with or without rash, cutaneous ulcers, albuminuria, worsening of organic brain syndrome, excessive weight gain, edematous swelling of ankles or wrists, thirst or polyuria (may resemble diabetes mellitus), metallic taste, symptoms similar to Raynaud's phenomenon.

Laboratory Test Alterations: False + urinary glucose test (Benedict's), serum glucose, creatinine kinase. False - or serum PBI, uric acid; TSH, I¹³¹ uptake; T₃, T4

Overdose Management: Symptoms: Symptoms dependent on serum lithium levels. Levels less than 2 mEq/L: N&V;, diarrhea, muscle weakness, drowsiness, loss of coordination.
Levels of 2-3 mEq/L: Agitation, ataxia, blackouts, blurred vision, choreoathetoid movements, confusion, dysarthria, fasciculations, giddiness, hyperreflexia, hypertonia, agitation or manic-like behavior, myoclonic twitching or movement of entire limbs, slurred speech, tinnitus, urinary or fecal incontinence, vertigo.
Levels over 3 mEq/L: Complex clinical picture involving multiple organs and organ systems. Arrhythmias, coma hypotension, peripheral vascular collapse, seizures (focal and generalized) spasticity, stupor, twitching of muscle groups.
Treatment: Early symptoms are treated by decreasing the dose or stopping treatment for 24-48 hr: Use gastric lavage. Restore fluid and electrolyte balance (can use saline) and maintain kidney function. Increase lithium excretion by giving aminophylline, mannitol, or urea. Prevent infection. Maintain adequate respiration. Monitor thyroid function. Institute hemodialysis.

Drug Interactions: Acetazolamide / Lithium effect by renal excretion Bumetanide / Lithium toxicity R/T renal clearance Carbamazepine / Risk of lithium toxicity Diazepam / Risk of hypothermia Ethacrynic acid / Lithium toxicity R/T renal clearance Fluoxetine / Serum lithium levels Furosemide / Lithium toxicity R/T renal clearance Haloperidol / Risk of neurologic toxicity Iodide salts / Additive effect to cause hypothyroidism Mannitol / Lithium effect by renal excretion Mazindol / Chance of lithium toxicity R/T serum levels Methyldopa / Chance of neurotoxic effects with or without lithium serum levels Neuromuscular blocking agents / Lithium neuromuscular blockade severe respiratory depression and apnea NSAIDs / Lithium renal clearance, possibly R/T inhibition of renal prostaglandin synthesis Phenothiazines / Phenothiazine levels or lithium levels Phenytoin / Risk of lithium toxicity Probenecid / Risk of lithium toxicity R/T serum levels Sodium chloride / Excretion of lithium is proportional to amount of sodium chloride ingested; if client is on salt-free diet, may develop lithium toxicity since less lithium excreted Sympathomimetics / Drug pressor effects Theophyllines, including Aminophylline / Lithium effect R/T renal excretion Thiazide diuretics, triamterene / Risk of lithium toxicity R/T renal clearance Tricyclic antidepressants / TCA effects Urea / Lithium effect by renal excretion Urinary alkalinizers / Lithium effect by renal excretion Verapamil / Lithium levels and toxicity

How Supplied: Lithium carbonate: Capsule: 150 mg, 300 mg, 600 mg; Tablet: 300 mg; Tablet, Extended Release: 300 mg, 450 mg; Lithium citrate: Syrup: 300 mg/5 mL

Dosage
•Capsules, Tablets, Extended-Release Tablets, Syrup Acute mania.
Adults: Individualized and according to lithium serum level (not to exceed 1.4 mEq/L) and clinical response. Usual initial: 300-600 mg t.i.d. or 600-900 mg b.i.d. of slow-release form; elderly and debilitated clients: 0.6-1.2 g/day in three doses. Maintenance: 300 mg t.i.d.-q.i.d.
Administration of drug is discontinued when lithium serum level exceeds 1.2 mEq/L and resumed 24 hr after it has fallen below that level.
To reverse neutropenia.
300-1,000 mg/day (to achieve serum levels of 0.5-1.0 mEq/L) for 7-10 days.
Prophylaxis of cluster headaches.
600-900 mg/day.