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Lithium

Brand and Generic Names

• Brand names:
  • Eskalith® Capsules: 300 mg
  • Eskalith CR®– slow–release : Tablets: 450 mg
  • Lithobid®– slow–release - Tablets: 300 mg
  
  
• Generic name: lithium carbonate (tablets and capsules), or lithium citrate (liquid)
  • Tablets: 300 mg
  • Capsules: 150 mg, 300 mg, 600 mg
  • Slow-release tablets: 300 mg, 450 mg
  • Liquid: 300 mg/5 mL (300 mg per teaspoonful)

What is lithium and what does it treat?

Lithium carbonate is a salt that was first approved in the United States in 1970 to treat bipolar disorder (also known as manic-depression). Today, it remains a commonly used medication for this illness. In some cases, lithium is used to treat people with depression even though they have never experienced a manic episode. Many of these patients have not responded adequately to antidepressants alone, so lithium is added to help improve depression symptoms

A manic episode, or mania, is when a person experiences several of the following symptoms at the same time: "high" or irritable mood, very high self esteem, decreased need for sleep, pressure to keep talking, racing thoughts, being easily distracted, frequently involved in activities with a large risk for bad consequences (for example, excessive buying sprees).

A depressive episode, or depression, is when a person experiences several of the following symptoms at the same time: "low" or depressed mood (for example, sad, empty, tearful), decreased interest in most or all activities, changes in appetite (usually decreased), changes in sleep (usually poor sleep), loss of energy, feeling worthless/guilty/ hopeless/ helpless, difficulty concentrating, thoughts of death (suicidal thinking).

Bipolar disorder is a brain disorder (mental illness) that exposes people to these mood changes over the course of time. Bipolar disorder affects more than two million Americans each year, but patients with this disorder can lead fulfilling lives when they receive proper treatment. Unfortunately, many people with this illness do not receive treatment.

Medication is an essential part of successful treatment for bipolar disorder.  With the proper dosage, lithium can reduce symptoms of mania or depression, shorten hospitalizations, help prevent future manic episodes, and make it possible for an individual to live productively.

What is the most important information I should know about lithium?

Bipolar disorder requires long-term treatment. Do not stop taking the lithium, even when you feel better. Only your healthcare provider can determine the length of lithium treatment that is right for you. Missing doses of lithium may increase your risk for a relapse in your mood symptoms.

• Do not stop taking lithium or change your dose without first talking with your healthcare provider.
• Lithium may make you drowsy.  Do not drive or operate machinery until you know how this medication affects you.
• You should not drink alcohol or use illegal drugs while taking lithium.
• Lithium may be prescribed by itself or along with other medications to manage your mood symptoms.
• The amount of lithium in the blood can be measured. Studies have generally shown that blood levels between 0.6–1.2 (mmol/L) give patients the best chance of response to lithium. In the beginning of treatment, your doctor may check your blood once or twice a week. Once your symptoms are well controlled, blood samples are drawn less frequently.  High blood levels can result in more side effects, and low blood levels may not treat symptoms.
• Tell your healthcare provider if you take medications for pain or for high blood pressure as some of these types of medication may interact with lithium.
• The loss of too much water or salt from your body can lead to serious side effects from this medication. Make sure you drink enough water in hot weather, during activities that cause you to sweat (exercise, saunas, hot baths), or when you have the flu and are experiencing vomiting and/or diarrhea.
• Lithium has been associated with a decrease in suicidal thinking and action and may reduce risk of this outcome.  Suicide prevention requires many other intervention elements as well for most people.

Are there specific concerns about lithium and pregnancy?

If you are planning on becoming pregnant, notify your healthcare provider so that he/she can best manage your medications. People living with bipolar illness who wish to become pregnant face important decisions, each with risks and benefits as it relates to how the illness, medications, and the risks to the fetus may interact.  This is complex as untreated bipolar illness has risk as well to mother and fetus.  There are many dimensions to these choices, so be sure to confer with your doctor and caregivers.

For example, exposure to lithium during the first three months of pregnancy is associated with a slightly increased risk of "Ebstein’s Anomaly", a heart valve defect. The risk of this heart valve problem in the general population is approximately 1 in every 20,000 births. The risk to a baby exposed to lithium during the first three months of pregnancy is between 1 in every 2,000 (0.05%) to 1 in every 1,000 (0.1%) births. Thus, although lithium increases the risk above the general population risk, the risk of having a child with this problem remains relatively low. In order to try and avoid this risk, exposure to lithium during the first three months should be avoided if possible. Some patients may require continuation of lithium in order to avoid going back into either mania or depression. If lithium is used during pregnancy, use of the lowest possible dose, close monitoring of serum levels, and appropriate monitoring of the baby are recommended. Cases of newborn infants having too much lithium in their bodies has caused muscle weakness, poor sucking and grasp reflexes, shallow respirations, and lethargy. Rare cases of thyroid abnormalities in the newborn have also been reported.

Breast feeding mothers should be aware that lithium does pass into breast milk. Adverse effects such as lethargy, muscles weakness, and changes in heart rhythm have been observed in breast– fed infants.  Therefore, use of lithium is not recommended during breastfeeding.

What should I discuss with my healthcare provider before taking lithium?

• Tell your doctor if you have taken lithium before. If you are allergic to lithium, tell your doctor and pharmacist exactly what the medication did to you before taking even one dose.
• Symptoms that are most bothersome to you about your condition
• If you have thoughts of suicide
• Medications you have taken in the past to treat bipolar disorder, whether they were effective or caused any adverse effects.
• All other medications you are currently taking (including over the counter, herbal and nutritional supplements) and any medication allergies you have
• Any medication side effects that you may have experienced in the past, or are currently experiencing
• If you are pregnant, plan to become pregnant, or are breast-feeding
• If you drink alcohol or use illegal drugs
• Any medical problems you have, especially kidney disease, thyroid disease, heart disease, or diabetes
• If you have psoriasis -- lithium may worsen this condition
• If you experience difficulty urinating

How should I take lithium?

• Lithium tablets or capsules are usually taken 2 or 3 times daily, however, lithium may be taken once daily as long as a person tolerates the possible stomach upset. Your healthcare provider will determine the dose that is right for you based upon blood level and your response. While many people take 900–1200 mg/day, you may need higher or lower doses.
• If you are taking a slow-release formulation (Eskalith CR® or Lithobid®), be sure to swallow the tablets whole.  Do not crush or chew the tablets.
• If you are taking the liquid formulation (lithium citrate), ask your pharmacist for a measuring device (spoon or oral syringe) to make sure you get the right amount of medication.
• Lithium liquid may be mixed with juice, but should not be mixed with coffee, tea, or cola.
• Taking lithium with food can help decrease or avoid stomach upset.
• Use a pillbox or calendar to help you remember to take your medication.

What happens if I miss a dose?

If you miss a dose of lithium, take it as soon as you remember if it is not too close to when your next dose is due - discuss this with your healthcare provider. If it is close to your next dose, wait until then to take the medication and skip the missed dose. Do not double your next dose or take more than what you have been told to take.

What should I avoid while taking lithium?

• Avoid drinking alcohol or using illegal drugs while taking lithium.  The beneficial effects of the medication may be decreased and adverse effects may be increased (e.g. sedation).  Additionally, alcohol can lead to dehydration, which increases the risk of lithium toxicity.
• Lithium may cause dizziness or drowsiness, especially when first starting the medication. Make sure you know how you react to the medication before you drive, operate machinery, or do other activities that may be dangerous if you are not alert.
• Patients taking lithium should not start a low salt diet without talking with their healthcare provider, since low sodium blood levels can increase the risk of lithium toxicity.
• Avoid excessive intake of caffeinated beverages, such as coffee, tea, cola or energy drinks, since these may decrease levels of lithium and decrease effectiveness of the medication

What happens if I overdose?

• If an overdose occurs, whether intentional or accidental, immediate medical attention is necessary. Call your doctor or emergency medical service (911).  You may also contact the poison control center (1-800-222-1222).
• Symptoms that may occur in an overdose: confusion, difficulty concentrating, sluggishness, vomiting, diarrhea, poor coordination, tremor, and muscle weakness or twitching. In severe cases, people can develop seizures, respiratory difficulty, coma, and death is possible.

What are the possible side effects of lithium?

Like all medications, lithium has side effects. Most of these will get better or even go away completely as your body gets used to the medicine. Everyone responds differently so let your doctor, pharmacist, and other healthcare professionals know how the medication is affecting you.

Remember the lists of side effects below are only possible problems. Nobody gets them all and very few people get the more serious side effects. This list is to help you know when to contact your doctor or pharmacist. It is not meant to scare you. Talk with your healthcare provider if you experience side effects that are bothersome to you.

More common side effects are:

Sedation, nausea, loss of appetite, mild diarrhea, dizziness and hand tremors
Increased production of urine and excessive thirst are two common side effects that are usually not serious problems.

Less common side effects are:

Weight gain, increased white blood cell count, acne, skin rashes and hypothyroidism (low levels of thyroid hormone). Signs of hypothyroidism include dry skin, hair loss, cold sensitivity, hoarseness, mental depression, and weight gain.

Rare side effects are:

In rare cases, lithium may lead to a reversible condition known as diabetes insipidus.  If this occurs you would notice a drastic increase in thirst and how much fluid you drink as well as how much you urinate.
Talk with your healthcare provider if you experience side effects that are bothersome to you.

Are there any risks for taking this medication for long periods of time?

With long-term use of lithium, hypothyroidism can occur; however, it can be treated with thyroid supplementation. Kidney damage may also occur, but it is rare and usually associated with high levels of lithium. In order to minimize risk, your healthcare provider will periodically measure kidney function and lithium levels with a simple blood test.

What other drugs may interact with this medication?

People who are taking lithium should consult their doctor before taking or discontinuing the following:

• Diuretics may increase the amounts of lithium in the body.
  These include:
  • acetazolamide (Diamox®)
  • bumetanide (Bumex®)
  • chlorthalidone (Thalitone®) 
  • chlorothiazide (Diuril®) 
  • furosemide (Lasix®)
  • hydrochlorothiazide (Microzide®) and
  • torsemide (Demadex®).
• Anti-inflammatory medications may increase the amounts of lithium in the body.
  Some examples are:
• celecoxib (Celebrex®)
• ibuprofen (Advil®) and
• naproxen (Aleve®, Naprosyn®).
• Antihypertensive medications may increase or worsen the side effects of lithium.
  Some examples are:
• Angiotensin receptor blockers (ARBs)—valsartan, olmesartan, candesartan, losartan; and
• Angiotensin converting enzyme (ACE) inhibitors—enalapril, captopril, benazepril, fosinopril.
• Some substances may decrease the amounts of lithium in the body.
  These include:
  • caffeine and
  • theophylline (Theo–Dur®, Slo–Bid®).

How long does it take for lithium to work?

Several weeks are often required for lithium to reach maximum effectiveness; however, improvement in some symptoms may occur sooner.

It is very important to tell your doctor how you feel things are going during the first few weeks after you start taking lithium.  It will probably take several weeks to see enough changes in your symptoms to decide if lithium is helpful for you.

Lifelong mood stabilizer treatment is generally needed in persons with bipolar illness.  Your doctor can best discuss the duration of treatment you need based on your symptoms and course of illness.

Updated by Leena B. Menon, Pharm.D.
(November 2010)

 

 

NAMI wishes to thank the College of Psychiatric and Neurologic Pharmacists for producing this fact sheet.

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