PsychEd episode 52: How to Use Lithium

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Mar 30, 2023

Guest

Alex Raben

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INSIGHT

Lithium Underutilization

Lithium, despite being a first-line treatment for bipolar disorder, is often underutilized in current psychiatric practice.
This underutilization may be due to factors such as slower onset of action compared to other medications, required blood level monitoring, low cost, and lack of marketing.

ADVICE

Lithium Baseline Checks

Check baseline labs before starting lithium, including renal and endocrine function, BMI, and ECG.
Consider potential cardiac risks, especially in females of childbearing age, due to lithium's impact on fetal heart development.

ADVICE

Lithium Starting Dose

Typical lithium starting doses range from 300mg to 600mg orally at bedtime.
Adjust starting dose based on patient factors like size and the desired speed of response.

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Welcome to PsychEd — the psychiatry podcast for medical learners, by medical learners. This episode is an introduction to the use and monitoring of lithium in bipolar disorder. Join Tingting Yan (CC4) and Dr. Alex Raben (staff psychiatrist at CAMH and lecturer at the University of Toronto) for a lively case-based discussion.

Learning Objectives

The learning objectives for this episode are as follows:

By the end of this episode, the listener will be able to…

Describe the indications and process for starting lithium
Monitor and interpret serum lithium levels
List short and long-term adverse effects of lithium

Produced by: Tingting Yan CC4, Dr. Alex Raben (staff psychiatrist)

Hosts: Tingting Yan, Alex Raben

Audio editing by: Alex Raben

Show notes by: Alex Raben

Contents:

Learning objectives: 00:44
Lithium background and brief history: 2:48
Women’s health and lithium: 5:28
Underutilization of lithium: 8:02
Baseline blood work for lithium: 11:32
Choosing a lithium starting dose: 14:32
Lithium serum levels: 16:17
Lithium titration: 20:46
Lithium toxicity: 23:48
Lithium side effects: 26:52
Summary: 32:11

References

Baastrup PC, Poulsen JC, Schou M, Thomsen K, Amdisen A. Prophylactic lithium: double blind discontinuation in manic-depressive and recurrent-depressive disorders. Lancet. 1970;2(7668):326-330. doi:10.1016/s0140-6736(70)92870-9
Bauer LA. Chapter 17. Lithium. In: Bauer LA. eds. Applied Clinical Pharmacokinetics, 2e. McGraw Hill; 2008. Accessed March 16, 2023. https://accesspharmacy.mhmedical.com/content.aspx?bookid=510§ionid=40843106
Chokhawala K, Lee S, Saadabadi A. Lithium. StatPearls.
Davis J, Desmond M, Berk M. Lithium and nephrotoxicity: a literature review of approaches to clinical management and risk stratification. BMC nephrology. 2018 Dec;19:1-7.
Draaisma D. Lithium: the gripping history of a psychiatric success story. Nature. 2019 Aug 1;572(7769):584-6.
Hedya SA, Avula A, Swoboda HD. Lithium toxicity.
Malhi GS, Bell E, Outhred T, Berk M. Lithium therapy and its interactions. Australian Prescriber. 2020 Jun;43(3):91.
Malhi GS, Gessler D, Outhred T. The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. J Affect Disord. 2017;217:266-280. doi:10.1016/j.jad.2017.03.052
McKnight RF, Adida M, Budge K, Stockton S, Goodwin GM, Geddes JR. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728. doi:10.1016/S0140-6736(11)61516-X
Patorno E, Huybrechts KF, Bateman BT, Cohen JM, Desai RJ, Mogun H, Cohen LS, Hernandez-Diaz S. Lithium use in pregnancy and the risk of cardiac malformations. New England Journal of Medicine. 2017 Jun 8;376(23):2245-54.
Tondo L, Alda M, Bauer M, Bergink V, Grof P, Hajek T, Lewitka U, Licht RW, Manchia M, Müller-Oerlinghausen B, Nielsen RE. Clinical use of lithium salts: guide for users and prescribers. International journal of bipolar disorders. 2019 Dec;7(1):1-0.
Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, Sharma V, Goldstein BI, Rej S, Beaulieu S, Alda M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders. 2018 Mar;20(2):97-170.

CPA Note: The views expressed in this podcast do not necessarily reflect those of the Canadian Psychiatric Association.

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