Lithane


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lithium carbonate

Apo-Lithium Camcolit (UK), Apo-Lithium Carbonate (CA), Carbolith (CA), Duralith (CA), Euro-Lithium (CA), Liskonum (UK), Lithane, Lithobid, Lithonate (UK), PHL-Lithium Carbonate (CA), PMS-Lithium Carbonate (CA), Priadel (UK)

lithium citrate

PMS-Lithium Citrate (CA)

Pharmacologic class: Miscellaneous CNS drug

Therapeutic class: Antimanic drug

Pregnancy risk category D

FDA Box Warning

• Lithium toxicity is closely related to lithium blood level and can occur at doses close to therapeutic levels. Before starting therapy, ensure that resources for prompt, accurate blood lithium testing are available.

Action

Unknown. Thought to disrupt sodium exchange and transport in nerves and muscles and control reuptake of neurotransmitters.

Availability

Capsules: 150 mg, 300 mg, 600 mg

Syrup (citrate): 300 mg (8 mEq lithium)/5 ml

Tablets: 300 mg

Tablets (extended-release): 300 mg, 450 mg

Tablets (slow-release): 300 mg

Indications and dosages

Manic episodes of bipolar disorder

Adults and children ages 12 and older: 900 to 1,800 mg P.O. daily in divided doses (for example, 300 to 600 mg t.i.d. or 450 to 900 mg b.i.d. of controlled- or slow-release form) to achieve blood level of 1 to 1.5 mEq/L; measure blood level twice weekly until patient stabilizes. Maintenance dosage is 900 to 1,200 mg/day in divided doses (forexample, 300 to 400 mg t.i.d. or 450 to 600 mg b.i.d. of controlled- or slow-release form) to maintain blood level of 0.6 to 1.2 mEq/L. Monitor blood level at least q 2 months.

Dosage adjustment

• Impaired renal function

• Elderly patients

Off-label uses

• Acute manic episodes in children

• Corticosteroid-induced psychosis

• Neutropenia secondary to antineoplastic therapy

• Tardive dyskinesia

• Alcoholism

• Bulimia

Contraindications

None

Precautions

Use cautiously in:

• hepatic or thyroid disease, severe cardiovascular or renal disease, diabetes mellitus, seizure disorders, systemic infections, brain trauma, organic brain syndrome, urinary retention, severe sodium depletion

• elderly patients

• pregnant or breastfeeding patients

• children (safety not established).

Administration

Be aware that dosages are individualized according to lithium blood level and response.

• Give with food or milk to minimize GI upset.

• Make sure patient swallows slow-release tablet whole without chewing or crushing.

• When switching patient from immediate-release to controlled- or slow-release form, give same total daily dosage.

Adverse reactions

CNS: dizziness, drowsiness, headache, tremor, tics, EEG changes, ataxia, choreoathetotic movements, abnormal tongue movements, extrapyramidal reactions, cogwheel rigidity, blackout spells, psychomotor retardation, slow mental functioning, slurred speech, startled response, restlessness, agitation, confusion, hallucinations, poor memory, worsening of organic brain syndrome, stupor, coma, epileptiform seizures

CV: bradycardia, ECG changes, hypotension, sinus node dysfunction with severe bradycardia and syncope, arrhythmias, peripheral circulatory collapse

EENT: blurred vision, nystagmus, tinnitus

GI: nausea, vomiting, diarrhea, abdominal pain, fecal incontinence, gastritis, flatulence, dyspepsia, anorexia, increased salivation, salivary gland swelling, dry mouth

GU: urinary incontinence, glycosuria, albuminuria, erectile or other sexual dysfunction, polyuria or other signs of nephrogenic diabetes insipidus, oliguria

Hematologic: leukocytosis

Metabolic: hypothyroidism or hyperthyroidism, goiter, hyperglycemia, hypercalcemia, hyponatremia, hyperparathyroidism

Musculoskeletal: swollen or painful joints, muscle weakness, muscle fasciculations and twitching, clonic arm or leg movements, hypertonicity, hyperactive deep tendon reflexes, polyarthralgia

Skin: dry thin hair, alopecia, diminished or absent skin sensations, chronic folliculitis, eczema with dry skin, new onset or exacerbation of psoriasis, pruritus (with or without rash), cutaneous ulcers, angioedema

Other: altered, metallic, or salty taste; dental caries; weight gain; excessive thirst; polydipsia; fever; edema of lips, ankles, and wrists

Interactions

Drug-drug. Acetazolamide, alkalinizing agents (such as sodium bicarbonate), urea, verapamil, xanthines: decreased lithium blood level

Calcium channel blockers, carbamazepine, haloperidol, methyldopa: increased risk of neurotoxicity

Diuretics: increased sodium loss, increased risk of lithium toxicity

Fluoxetine, loop diuretics, metronidazole, nonsteroidal anti-inflammatory drugs: increased risk of lithium toxicity

Iodide salts: synergistic effects, increased risk of hypothyroidism

Neuromuscular blockers: prolonged neuromuscular blockade, severe respiratory depression

Phenothiazines: decreased phenothiazine blood level or increased lithium blood level, greater risk of neurotoxicity

Selective serotonin reuptake inhibitors: increased risk of tremor, confusion, dizziness, agitation, and diarrhea

Sympathomimetics: decreased pressor sensitivity

Tricyclic antidepressants: increased antidepressant effects

Drug-diagnostic tests. Albumin, creatinine, sodium, thyroxine, triiodothyronine: decreased levels

Calcium, glucose,131I uptake, white blood cells (WBCs): increased levels

Drug-food. Caffeine-containing foods and beverages: decreased lithium blood level and efficacy

Drug-herbs. Caffeine-containing herbs (cola nut, guarana, yerba maté): decreased lithium blood level and efficacy

Patient monitoring

• Obtain baseline ECG and electrolyte levels before and periodically during therapy.

• Assess neurologic and psychiatric status. Institute safety measures as needed to prevent injury.

• Monitor lithium blood level, WBC count, and thyroid and kidney function tests.

• Assess cardiovascular status regularly.

• Monitor fluid intake and output. Watch for edema and weight gain.

Patient teaching

• Advise patient to take with food or milk to minimize GI upset.

• Instruct patient to swallow slow-release tablet whole without chewing or crushing.

• Tell patient that beneficial effects may take 1 to 3 weeks to appear.

• Advise patient to limit foods and beverages containing caffeine, because they may interfere with drug action.

• Tell patient to maintain adequate fluid intake.

• Explain that drug may cause adverse CNS effects. Advise patient to avoid activities requiring mental alertness until effects are known.

Emphasize importance of having regular blood tests, to help detect and prevent serious adverse reactions.

• Instruct patient to carry appropriate medical identification at all times.

• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above.

lithium

(lith-ee-um) ,

Carbolith

(trade name),

Lithane

(trade name),

Lithmax

(trade name),

Lithobid

(trade name)

Classification

Therapeutic: mood stabilizers
Pregnancy Category: D

Indications

Manic episodes of bipolar I disorder (treatment, maintenance, prophylaxis).

Action

Alters cation transport in nerve and muscle.
May also influence reuptake of neurotransmitters.

Therapeutic effects

Prevents/decreases incidence of acute manic episodes.

Pharmacokinetics

Absorption: Completely absorbed after oral administration.
Distribution: Widely distributed into many tissues and fluids; CSF levels are 50% of plasma levels. Crosses the placenta; enters breast milk.
Metabolism and Excretion: Excreted almost entirely unchanged by the kidneys.
Half-life: 20–27 hr.

Time/action profile (antimanic effects)

ROUTEONSETPEAKDURATION
PO, PO–ER5–7 days10–21 daysdays

Contraindications/Precautions

Contraindicated in: Hypersensitivity;Severe cardiovascular or renal disease;Dehydrated or debilitated patients;Brugada syndrome;Should be used only where therapy, including blood levels, may be closely monitored;Some products contain alcohol or tartrazine and should be avoided in patients with known hypersensitivity or intolerance; Lactation: Lactation.
Use Cautiously in: Any degree of cardiac, renal, or thyroid disease;Diabetes mellitus; Obstetric: Fetal cardiac anomalies are associated with lithium use; however, potential maternal benefit may warrant use in some pregnant women; Geriatric: Initial dosage ↓ recommended.

Adverse Reactions/Side Effects

Central nervous system

  • seizures (life-threatening)
  • fatigue (most frequent)
  • headache (most frequent)
  • impaired memory (most frequent)
  • ataxia
  • sedation
  • confusion
  • dizziness
  • drowsiness
  • psychomotor retardation
  • restlessness
  • stupor

Ear, Eye, Nose, Throat

  • aphasia
  • blurred vision
  • dysarthria
  • tinnitus

Cardiovascular

  • ECG changes (most frequent)
  • arrhythmias
  • edema
  • hypotension
  • unmasking of Brugada syndrome

Gastrointestinal

  • abdominal pain (most frequent)
  • anorexia (most frequent)
  • bloating (most frequent)
  • diarrhea (most frequent)
  • nausea (most frequent)
  • dry mouth
  • metallic taste

Genitourinary

  • polyuria (most frequent)
  • glycosuria
  • nephrogenic diabetes insipidus
  • renal toxicity

Dermatologic

  • acneiform eruption (most frequent)
  • folliculitis (most frequent)
  • alopecia
  • diminished sensation
  • pruritus

Endocrinologic

  • hypothyroidism (most frequent)
  • goiter
  • hyperglycemia
  • hyperthyroidism

Fluid and Electrolyte

  • hyponatremia

Hematologic

  • leukocytosis (most frequent)

Metabolic

  • weight gain

Musculoskeletal

  • muscle weakness (most frequent)
  • hyperirritability
  • rigidity

Neurologic

  • tremors (most frequent)

Interactions

Drug-Drug interaction

May prolong the action of neuromuscular blocking agents.↑ risk of neurologic toxicity with haloperidol.Diuretics, methyldopa, probenecid, fluoxetine, and NSAIDs may ↑ risk of toxicity.Blood levels may be ↑ by ACE inhibitors.Lithium may ↓effects of chlorpromazine.Chlorpromazine may mask early signs of lithium toxicity.Hypothyroid effects may be additive with potassium iodide or antithyroid agents.Aminophylline, phenothiazines, and drugs containing large amounts of sodium ↑ renal elimination and ↓ effectiveness.Psyllium can ↓ lithium levels.Caffeine-containing herbs (cola nut, guarana, mate, tea, coffee) may ↓ lithium serum levels and efficacy.Large changes in sodium intake may alter the renal elimination of lithium. ↑ sodium intake will ↑ renal excretion.

Route/Dosage

Precise dosing is based on serum lithium levels. 300 mg lithium carbonate contains 8–12 mEq lithium
Oral (Adults and children ≥12 yr) Tablets/capsules—300–600 mg 3 times daily initially; usual maintenance dose is 300 mg 3–4 times daily. Extended-release tablets—450–900 mg twice daily or 300–600 mg 3 times daily initially; usual maintenance dose is 450 mg twice daily or 300 mg 3 times daily.
Oral (Children <12 yr) 15–20 mg (0.4–0.5 mEq)/kg/day in 2–3 divided doses; dosage may be adjusted weekly.

Availability (generic available)

Capsules: 150 mg, 300 mg, 600 mg Cost: Generic — 150 mg $13.97 / 100, 300 mg $17.91 / 100, 600 mg $39.11 / 100
Tablets: 300 mg Cost: Generic — $21.52 / 100
Extended-release tablets: 300 mg, 450 mg Cost: Generic — 300 mg $46.52 / 100, 450 mg $50.05 / 100
Oral solution: 300 mg (8 mEq lithium)/5 mL

Nursing implications

Nursing assessment

  • Assess mental status (orientation, mood, behavior) initially and periodically. Initiate suicide precautions if indicated.
  • Monitor intake and output ratios. Report significant changes in totals. Unless contraindicated, fluid intake of at least 2000–3000 mL/day should be maintained. Weight should also be monitored at least every 3 mo.
  • Lab Test Considerations: Evaluate renal and thyroid function, WBC with differential, serum electrolytes, and glucose periodically during therapy.
  • Monitor serum lithium levels twice weekly during initiation of therapy and every 2 mo during chronic therapy. Draw blood samples in the morning immediately before next dose. Therapeutic levels range from 0.5 to 1.5 mEq/L for acute mania and 0.6–1.2 mEq/L for long term control. Serum concentrations should not exceed 2.0 mEq/L.
    • Assess patient for signs and symptoms of lithium toxicity (vomiting, diarrhea, slurred speech, decreased coordination, drowsiness, muscle weakness, or twitching). If these occur, report before administering next dose.

Potential Nursing Diagnoses

Disturbed thought process (Indications)
Ineffective coping (Indications)
Imbalanced nutrition: risk for more than body requirements (Side Effects)

Implementation

  • Do not confuse lithium carbonate with lanthanum carbonate.
  • Oral: Administer with food or milk to minimize GI irritation. Extended-release preparations should be swallowed whole; do not break, crush, or chew.

Patient/Family Teaching

  • Instruct patient to take medication as directed, even if feeling well. Take missed doses as soon as remembered unless within 2 hr of next dose (6 hr if extended release).
  • Lithium may cause dizziness or drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
  • Low sodium levels may predispose patient to toxicity. Advise patient to drink 2000–3000 mL fluid each day and eat a diet with consistent and moderate sodium intake. Excessive amounts of coffee, tea, and cola should be avoided because of diuretic effect. Avoid activities that cause excess sodium loss (heavy exertion, exercise in hot weather, saunas). Notify health care professional of fever, vomiting, and diarrhea, which also cause sodium loss.
  • Advise patient that weight gain may occur. Review principles of a low-calorie diet.
  • Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially NSAIDs.
  • Review side effects and symptoms of toxicity with patient. Instruct patient to stop medication and report signs of toxicity to health care professional promptly.
  • Advise patient to notify health care professional if fainting, irregular pulse, or difficulty breathing occurs.
  • Advise patient to use contraception and to consult health care professional if pregnancy is suspected or if breast feeding.
  • Emphasize the importance of periodic lab tests to monitor for lithium toxicity.

Evaluation/Desired Outcomes

  • Resolution of the symptoms of mania (hyperactivity, pressured speech, poor judgment, need for little sleep).
  • Decreased incidence of mood swings in bipolar disorders.
  • Improved affect in unipolar disorders. Improvement in condition may require 1–3 wk.
  • Decreased incidence of acute manic episodes.

Lithane

a trademark for an antimanic drug (lithium carbonate).

Lithium (Lithane, Lithromate)

Medication prescribed to treat manic (excited) phases of bipolar disorder.