3/8/2023

Bipolar Disorder: Part 2

LITHIUM: SIDE EFFECTS

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Excessive urination and thirst (polyuria and polydipsia):

Lithium-Induced Nephrogenic Diabetes insipidus

Lithium- Induced Tremor

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Lithium- Induced Hypothyroidism

Lithium- Induced Upset Stomach: Nausea & Diarrhea

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Lithium- Induced Acne & Psoriasis

Lithium Toxicity

• Lithium has a very narrow therapeutic window (0.6 – 1.2 mEq/ L)

• Definition: serum lithium levels > 1.5 mEq/L
• Risk factors:
• Renal impairment
• Medications that can precipitate lithium toxicity by increasing renal absorption of lithium
• Thiazide diuretics
• NSAIDs (except aspirin)
• ACE-inhibitors
• Low effective circulating volume (e.g., due to dehydration, loop
diuretic use , cirrhosis, congestive heart failure)
• Other medications: tetracyclines, cyclosporine
• Low-sodium diet or increased perspiration

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Lithium toxicity: clinical features

Neurologic
• Coarse tremor
• Myotonic twitches, muscle fasciculations
• Altered mental status: confusion, delirium, somnolence, coma
• Cerebellar dysfunction: dysarthria, vertigo, ataxia, nystagmus , dysdiadochokinesia
• Hyperreflexia, seizures
Gastrointestinal
• Vomiting, diarrhea
• Abdominal pain
Cardiovascular
• SA block, interventricular conduction delay
• ECG findings: prolonged QT interval, ST elevations
Renal: acute kidney injury
Endocrine: myxedema coma
Psychiatric: apathy, psychomotor impairment

Lithium toxicity: Management

• Discontinue lithium
• Hydration with isotonic fluid and electrolyte correction to
promote lithium clearance
• Hemodialysis
• First-line treatment for severe lithium toxicity
• Indications
• Serum lithium concentration > 5.0 mEq/L
• Serum lithium concentration > 4.0 mEq/L with kidney dysfunction
• Altered mental status, seizures, and/or life-threatening arrhythmias

• Ventilatory support, if required

• Whole bowel irrigation with polyethylene glycol can also be considered.