disorders.muscle weakness.myasthenia gravis.nausea.
neoplasms.nystagmus.peripheral neuropathy.
peripheral oedema.polydipsia.polyuria.QT interval
prolongation.reflexes abnormal.renal disorders.renal
impairment.rhabdomyolysis.seizure.sexual dysfunction
.skin reactions.skin ulcer.speech impairment.taste
altered.thyrotoxicosis.tremor.vertigo.vision disorders.
vomiting.weight increased
OverdoseSigns of intoxication require withdrawal of
treatment and include increasing gastro-intestinal
disturbances (vomiting, diarrhoea), visual disturbances,
polyuria, muscle weakness,fine tremor increasing to
coarse tremor, CNS disturbances (confusion and
drowsiness increasing to lack of coordination, restlessness,
stupor); abnormal reflexes, myoclonus, incontinence,
hypernatraemia. With severe overdosage seizures, cardiac
arrhythmias (including sino-atrial block, bradycardia and
first-degree heart block), blood pressure changes,
circulatory failure, renal failure, coma and sudden death
reported.
For details on the management of poisoning, see
Lithium, under Emergency treatment of poisoning p. 832.lCONCEPTION AND CONTRACEPTIONManufacturer advises
effective contraception during treatment for women of
child bearing potential.
lPREGNANCYAvoid if possible, particularly in thefirst
trimester (risk of teratogenicity, including cardiac
abnormalities).
Dose adjustmentsDose requirements increased during the
second and third trimesters (but on delivery return
abruptly to normal).
MonitoringClose monitoring of serum-lithium
concentration advised in pregnancy (risk of toxicity in
neonate).
lBREAST FEEDINGPresent in milk and risk of toxicity in
infant—avoid.
lRENAL IMPAIRMENTCaution in mild to moderate
impairment. Avoid in severe impairment.
MonitoringIn renal impairment monitor serum-lithium
concentration closely and adjust dose accordingly.
lMONITORING REQUIREMENTS
▶Serum concentrationsLithium salts have a narrow
therapeutic/toxic ratio and should therefore not be
prescribed unless facilities for monitoring serum-lithium
concentrations are available.
Samples should be taken 12 hours after the dose to achieve
a serum-lithium concentration of 0. 4 – 1 mmol/litre (lower
end of the range for maintenance therapy).
A target serum-lithium concentration of 0. 8 – 1 mmol/litre
is recommended for acute episodes of mania, and for
patients who have previously relapsed or have sub-
syndromal symptoms. It is important to determine the
optimum range for each individual patient.
Routine serum-lithium monitoring should be performed
weekly after initiation and after each dose change until
concentrations are stable, then every^3 months thereafter.
Additional serum-lithium measurements should be made
if a patient develops significant intercurrent disease or if
there is a significant change in a patient’s sodium orfluid
intake.
▶Manufacturer advises to assess renal, cardiac, and thyroid
function before treatment initiation.gAn ECG is
recommended in patients with cardiovascular disease or
risk factors for it. Body-weight or BMI, serum electrolytes,
and a full blood count should also be measured before
treatment initiation.
▶Monitor body-weight or BMI, serum electrolytes, eGFR,
and thyroid function every 6 months during treatment,
and more often if there is evidence of impaired renal or
thyroid function, or raised calcium levels.h
Manufacturer also advises to monitor cardiac function
regularly.
lTREATMENT CESSATIONWhile there is no clear evidence of
withdrawal or rebound psychosis, abrupt discontinuation
of lithium increases the risk of relapse. If lithium is to be
discontinued, the dose should be reduced gradually over a
period of at least 4 weeks (preferably over a period of up to
3 months). Patients and their carers should be warned of
the risk of relapse if lithium is discontinued abruptly. If
lithium is stopped or is to be discontinued abruptly,
consider changing therapy to an atypical antipsychotic or
valproate.
lPATIENT AND CARER ADVICEPatients should be advised to
report signs and symptoms of lithium toxicity,
hypothyroidism, renal dysfunction (including polyuria and
polydipsia), and benign intracranial hypertension
(persistent headache and visual disturbance). Maintain
adequatefluid intake and avoid dietary changes which
reduce or increase sodium intake.
Lithium treatment packsA lithium treatment pack should be
given to patients on initiation of treatment with lithium.
The pack consists of a patient information booklet, lithium
alert card, and a record book for tracking serum-lithium
concentration. Packs may be purchased from
3 M
0845 610 1112
[email protected]
Driving and skilled tasksMay impair performance of skilled
tasks (e.g. driving, operating machinery).eiiiiF 232Lithium carbonate
lINDICATIONS AND DOSE
Treatment and prophylaxis of mania|Treatment and
prophylaxis of bipolar disorder|Treatment and
prophylaxis of recurrent depression|Treatment and
prophylaxis of aggressive or self-harming behaviour
▶BY MOUTH
▶Child 12–17 years:Dose adjusted according to serum-
lithium concentration, doses are initially divided
throughout the day, but once daily administration is
preferred when serum-lithium concentration stabilised
DOSE EQUIVALENCE AND CONVERSION
▶Preparations vary widely in bioavailability;
changing the preparation requires the same
precautions as initiation of treatment.
CAMCOLIT®IMMEDIATE-RELEASE TABLET
Treatment of mania|Treatment of bipolar disorder|
Treatment of recurrent depression|Treatment of
aggressive or self-harming behaviour
▶BY MOUTH
▶Child 12–17 years:Initially 1 – 1. 5 g daily, dose adjusted
according to serum-lithium concentration, doses are
initially divided throughout the day, but once daily
administration is preferred when serum-lithium
concentration stabilised
Prophylaxis of mania|Prophylaxis of bipolar disorder|
Prophylaxis of recurrent depression|Prophylaxis of
aggressive or self-harming behaviour
▶BY MOUTH
▶Child 12–17 years:Initially 300 – 400 mg daily, dose
adjusted according to serum-lithium concentration,
doses are initially divided throughout the day, but once
daily administration is preferred when serum-lithium
concentration stabilised continued→BNFC 2018 – 2019 Bipolar disorder and mania 233
Nervous system4