Table 1 Recommendations for patients treated with lithium and their prescribers

Background Lithium salts (carbonate, citrate, or sulphate) have been widely used for about 70 years to treat illnesses characterized by periods of depression and elevated or excited mood (bipolar disorder) or with depression only (major depressive disorder). Lithium and other mood-stabilizing treatments do not cure mood disorders but can reduce the frequency, severity, and duration of relapses and improve long-term stability

Indications Lithium is especially effective in preventing recurrences of excited (manic) mood and can also reduce the risk of depressive recurrences. It is the only medicine with evidence of reducing risk of suicidal behavior associated with mood disorders. It may also reduce risk of cognitive decline in the elderly

Dosing Lithium should be taken regularly, exactly as prescribed. If a dose is missed, do not double the next dose. A single daily dose is sometimes used and more convenient than divided doses. Changing the brand or type of lithium salt used may require dosage re-adjustment with supervision by your doctor

Blood concentrations of lithium Measuring the blood level of lithium is very important. It should be done about 1 week after the first dose, then weekly in the first month, at least once a month in the next 3–6 months, and every 3–6 months thereafter. Blood sampling should be done reliably at a consistent interval (optimally about 12 h after the last dose of the day) and about a week after any dose change. Prescribed dosing is guided by blood concentrations of lithium decided by your doctor, usually at 0.50–0.80 mEq/L

Factors that can alter blood levels Talk with your doctor about lowering your daily dose of lithium or to discontinue temporarily with: fever above 38 °C (100.4 °F), dehydration or diarrhea, or when a low sodium diet is required (not recommended during lithium therapy). Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) is not recommended with lithium (acetaminophen/paracetamol is preferred for pain). ACE-inhibitors, some cardiac antiarrhythmics, and thiazide-diuretics should not be used with lithium

Other blood tests Blood levels of creatinine (for kidney function), sodium, potassium, calcium, thyroid and parathyroid hormones should be measured before starting the treatment and at least, once or twice a year thereafter

Adverse effects Nausea, thirst, tremor, fatigue, decreased cognitive functions, increased appetite, increased frequency of urination. These are most often encountered early in treatment and usually improve with time, but may require additional treatments

Use in medical conditions Lithium should not be used by patients who have or have had: acute myocardial infarction (heart attack), acute kidney failure, or certain rare disorders of heart rhythm. It can be used cautiously and with close medical monitoring with: cardiac arrhythmia, reduced kidney function, psoriasis, myeloid leukemia, Addison’s disease, hypothyroidism, and certain neurological disorders, including abnormalities of posture and movement, tremors, myasthenia gravis, and epilepsy. Lithium should be stopped 48–72 h before surgery requiring general anesthesia, and during periods of low fluid intake. Ask your doctor before taking new medicines

Use in the elderly At ages over 60 years, doses and blood levels of lithium are at the low end of the therapeutic range (e.g., 0.4–0.6 mEq/L). Undesirable effects in the elderly in addition to those already described can include: confusion or worsening of cognitive functions, unsteady balance (ataxia), restless movements (akathisia), declining kidney function, hypothyroidism, possible worsening of diabetes, and leg-swelling (peripheral edema)

Pregnancy Lithium is used cautiously in pregnancy, with at least monthly monitoring of blood concentrations. If possible, lithium should be discontinued slowly or the dose lowered during the first trimester because of the association between lithium use and congenital malformations (birth defects) in this early period. Discuss risks and benefits of continuing, lowering, or interrupting lithium treatment during pregnancy and after childbirth with your doctor. During the third trimester, lithium blood levels should be monitored weekly. It is not necessary to stop lithium before delivery

Postpartum If lithium is discontinued during pregnancy, it should be restarted immediately after delivery, due to increased risk of relapses then. Target lithium levels should be relatively high (0.8–1.0 mEq/L) temporarily during the first month after delivery to minimize relapse risk, and checked twice weekly during the first 2 weeks after delivery. Do not breast-feed while taking lithium

Lithium intoxication Signs of high lithium blood levels include: severe tremor, confusion, vomiting, abdominal pain, diarrhea, speech difficulties, cardiac arrhythmia, hypotension, and convulsions. Some signs of intoxication may occur despite normal plasma levels of lithium. If the blood level of lithium is above 2 mEq/L, dialysis may be needed to remove lithium. Call your doctor or an emergency number immediately on suspicion of lithium intoxication

Discontinuation Interrupting lithium should be done gradually and under medical supervision to avoid relapse into mania or depression, unless an acute medical problem requires rapid discontinuation under close medical supervision. Dose-reduction of lithium can be done safely by lowering the daily dose by 20–25% every 2 weeks