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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.
Unknown. Thought to disrupt sodium exchange and transport in nerves and muscles and control reuptake of neurotransmitters.
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.
• Impaired renal function
• Elderly patients
• Acute manic episodes in children
• Corticosteroid-induced psychosis
• Neutropenia secondary to antineoplastic therapy
• Tardive dyskinesia
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).
☞ 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.
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
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
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
• 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.
• 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.
ClassificationTherapeutic: mood stabilizers
Time/action profile (antimanic effects)
|PO, PO–ER||5–7 days||10–21 days||days|
Adverse Reactions/Side Effects
Central nervous system
- seizures (life-threatening)
- fatigue (most frequent)
- headache (most frequent)
- impaired memory (most frequent)
- psychomotor retardation
Ear, Eye, Nose, Throat
- blurred vision
- ECG changes (most frequent)
- unmasking of Brugada syndrome
- abdominal pain (most frequent)
- anorexia (most frequent)
- bloating (most frequent)
- diarrhea (most frequent)
- nausea (most frequent)
- dry mouth
- metallic taste
- polyuria (most frequent)
- nephrogenic diabetes insipidus
- renal toxicity
- acneiform eruption (most frequent)
- folliculitis (most frequent)
- diminished sensation
- hypothyroidism (most frequent)
Fluid and Electrolyte
- leukocytosis (most frequent)
- weight gain
- muscle weakness (most frequent)
- tremors (most frequent)
Drug-Drug interactionMay 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/DosagePrecise dosing is based on serum lithium levels. 300 mg lithium carbonate contains 8–12 mEq lithium
Availability (generic available)
- 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 DiagnosesDisturbed thought process (Indications)
Ineffective coping (Indications)
Imbalanced nutrition: risk for more than body requirements (Side Effects)
- 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.
- 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.
- 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.