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(lith' ee um)

lithium carbonate
Carbolith (CAN), Duralith (CAN), Eskalith, Eskalith CR, Lithizine (CAN),
Lithobid, Lithonate, Lithotabs, PMS-Lithium Carbonate (CAN)

lithium citrate
Cibalith-S (CAN)

Pregnancy Category D

Drug class
Antimanic drug

Therapeutic actions
Mechanism is not known; alters sodium transport in nerve and muscle cells; inhibits
release of norepinephrine and dopamine, but not serotonin, from stimulated neurons;
slightly increases intraneuronal stores of catecholamines; decreases intraneuronal content
of second messengers and may thereby selectively modulate the responsiveness of
hyperactive neurons that might contribute to the manic state.

• Treatment of manic episodes of manic-depressive illness; maintenance therapy to
prevent or diminish frequency and intensity of subsequent manic episodes
• Unlabeled use: Improvement of neutrophil counts in patients with cancer
chemotherapy–induced neutropenia and in children with chronic neutropenia and
HIV patients on zidovudine therapy (doses of 300–1,000 mg/day, serum levels of
0.5 and 1 mEq/L); prophylaxis of cluster headache and cyclic migraine headache,
treatment of SIADH, hypothyroidism (doses of 600–900 mg/day)

Contraindications and cautions

• Contraindicated with hypersensitivity to tartrazine; significant renal or CV
disease; severe debilitation, dehydration; sodium depletion, patients on diuretics
(lithium decreases sodium reabsorption, and hyponatremia increases lithium
retention); pregnancy; lactation.
• Use cautiously with protracted sweating and diarrhea; suicidal or impulsive
patients; infection with fever.

Available forms
Capsules—150, 300, 600 mg; tablets—300 mg; SR tablets—300 mg; CR tablets—
450 mg; syrup—300 mg/5 mL

Individualize dosage according to serum levels and clinical response.
• Acute mania: 600 mg PO tid or 900 mg slow-release form PO bid to produce
effective serum levels between 1 and 1.5 mEq/L. Serum levels should be
determined twice per wk in samples drawn immediately before a dose (at least 8–
12 hr after previous dose).
• Long-term use: 300 mg PO tid to qid to produce a serum level of 0.6 to
1.2 mEq/L. Serum levels should be determined at least every 2 mo in samples
drawn immediately before a dose (at least 8–12 hr after previous dose).
• Conversion from conventional to slow-release dosage forms: Give the same total
daily dose divided into 2 or 3 doses.
Safety and efficacy for children < 12 yr not established.
Reduced dosage may be necessary. Elderly patients often respond to reduced dosage and
may exhibit signs of toxicity at serum levels tolerated by other patients. Plasma half-life
is prolonged in renal impairment.

Route Onset Peak
Oral 5–7 days 10–21 days

Metabolism: Hepatic; T1/2: 17–36 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine

Adverse effects
Reactions are related to serum lithium levels (toxic lithium levels are close to therapeutic
levels: therapeutic levels in acute mania range between 1 and 1.5 mEq/L; therapeutic
levels for maintenance are 0.6 to 1.2 mEq/L).
< 1.5 mEq/L
• CNS: Lethargy, slurred speech, muscle weakness, fine hand tremor
• GI: Nausea, vomiting, diarrhea, thirst
• GU: Polyuria
1.5–2 mEq/L (mild to moderate toxic reactions)
• CNS: Coarse hand tremor, mental confusion, hyperirritability of muscles,
drowsiness, incoordination
• CV: ECG changes
• GI: Persistent GI upset, gastritis, salivary gland swelling, abdominal pain,
excessive salivation, flatulence, indigestion
2–2.5 mEq/L (moderate to severe toxic reactions)
• CNS: Ataxia, giddiness, fasciculations, tinnitus, blurred vision, clonic
movements, seizures, stupor, coma
• CV: Serious ECG changes, severe hypotension with cardiac arrythmias
• GU: Large output of dilute urine
• Respiratory: Fatalities secondary to pulmonary complications
> 2.5 mEq/L (life-threatening toxicity)
• General: Complex involvement of multiple organ systems, including seizures,
arrythmias, CV collapse, stupor, coma
Reactions unrelated to serum levels
• CNS: Headache, worsening of organic brain syndromes, fever, reversible short-
term memory impairment, dyspraxia
• CV: ECG changes; hyperkalemia associated with ECG changes; syncope;
tachycardia-bradycardia syndrome; rarely, arrhythmias, CHF, diffuse myocarditis,
• Dermatologic: Pruritus with or without rash; maculopapular, acneiform, and
follicular eruptions; cutaneous ulcers; edema of ankles or wrists
• Endocrine: Diffuse nontoxic goiter; hypothyroidism; hypercalcemia associated
with hyperparathyroidism; transient hyperglycemia; irreversible nephrogenic
diabetes insipidus, which improves with diuretic therapy; impotence or sexual
• GI: Dysgeusia (taste distortion), salty taste; swollen lips; dental caries
• Miscellaneous: Weight gain (5–10 kg); chest tightness; swollen or painful joints,
eye irritation, worsening of cataracts, disturbance of visual accommodation,

• Increased risk of toxicity with thiazide diuretics due to decreased renal clearance
of lithium—reduced lithium dosage may be necessary
• Increased plasma lithium levels with indomethacin and some other NSAIDs—
phenylbutazone, piroxicam, ibuprofen, as well as fluoxetine and methyldopa
• Increased CNS toxicity with carbamazepine
• Encephalopathic syndrome (weakness, lethargy, fever, tremulousness, confusion,
extrapyramidal symptoms, leukocytosis, elevated serum enzymes) with
irreversible brain damage when taken with haloperidol
• Greater risk of hypothyroidism with iodide salts
• Decreased effectiveness due to increased excretion of lithium with urinary
alkalinizers, including antacids, tromethamine
Drug-alternative therapy
• Increased effects and toxicity with juniper, dandelion

Nursing considerations
• History: Hypersensitivity to tartrazine; significant renal or CV disease; severe
debilitation, dehydration; sodium depletion, patients on diuretics; protracted
sweating, diarrhea; suicidal or impulsive patients; infection with fever; pregnancy;
• Physical: Weight and T; skin color, lesions; orientation, affect, reflexes;
ophthalmic exam; P, BP, R, adventitious sounds; bowel sounds, normal output;
normal fluid intake, normal output, voiding pattern; thyroid, renal glomerular and
tubular function tests, urinalysis, CBC and differential, baseline ECG
• Give with caution and daily monitoring of serum lithium levels to patients with
renal or CV disease, debilitation, or dehydration or life-threatening psychiatric
• Give drug with food or milk or after meals.
• Monitor clinical status closely, especially during initial stages of therapy; monitor
for therapeutic serum levels of 0.6–1.2 mEq/L.
• Individuals vary in their reponse to this drug; some patients may exhibit toxic
signs at serum lithium levels considered within the therapeutic range.
• Advise patient that this drug may cause serious fetal harm and cannot be used
during pregnancy; urge use of barrier contraceptives.
• Decrease dosage after the acute manic episode is controlled; lithium tolerance is
greater during the acute manic phase and decreases when manic symptoms
• Ensure that patient maintains adequate intake of salt and adequate intake of fluid
(2,500–3,000 mL/day).

Teaching points
• Take this drug exactly as prescribed, after meals or with food or milk.
• Eat a normal diet with normal salt intake; maintain adequate fluid intake (at least
2.5 quarts/day).
• Arrange for frequent checkups, including blood tests. Keep all appointments for
checkups to receive maximum benefits and minimum risks of toxicity.
• Use contraception to avoid pregnancy. If you wish to become pregnant or believe
that you have become pregnant, consult your care provider.
• Discontinue drug, and notify care provider if toxicity occurs—diarrhea, vomiting,
ataxia, tremor, drowsiness, lack of coordination or muscular weakness.
• These side effects may occur: Drowsiness, dizziness (avoid driving or performing
tasks that require alertness); GI upset (eat frequent small meals); mild thirst,
greater than usual urine volume, fine hand tremor (may persist throughout
therapy; notify heath care provider if severe).
• Report diarrhea or fever.

Adverse effects in Italic are most common; those in Bold are life-threatening.