Lithium treatment initiation

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Baseline pre-treatment tests

For full information see Lithium Standards

Baseline Parameter/checks Comments

ECG

For patients with known cardiac disorders or cardiac risk factors including those on medications known to prolong QTc e.g. antipsychotics, citalopram

U&Es

Include Sodium, Potassium, Urea, Creatinine & eGFR. Patients must have adequate renal function (eGFR>60ml/min) before commencing lithium. Note in some populations the eGFR may over estimate renal function and therefore calculation of creatinine clearance would be more appropriate. For further advice see impaired renal function section

Thyroid function  
Calcium

Request via bone profile from biochemistry

Weight

Lithium can cause significant weight gain. Baseline weight is useful to support on-going physical health monitoring

Review for potential drug interactions

NSAIDs, diuretics, ACE inhibitors and other drugs that may adversely affect renal function or increase lithium levels. Note there is an increased risk of neurotoxicity when lithium is combined with antipsychotics

Initial patient education

Patients will be provided with appropriate education prior to commencing lithium treatment. This should focus on

  • The indication – i.e. what it is for
  • What to expect in terms of outcome
  • Risk of relapse or worsening outcome with poor compliance
  • Likely dose
  • The need for, and rationale of, regular monitoring including blood tests
  • Side effects which occur within the normal blood levels
  • Signs of toxicity
  • Drug interactions especially with regards to ‘over the counter’ medications
  • Need for adequate and consistent hydration and consistent dietary salt intake

Use the Choice & Medication website to provide information

Initial prescribing

Priadel, as either lithium carbonate (tablets) or lithium citrate (liquid) is the recommended lithium preparation in NHS Greater Glasgow & Clyde. Different preparations may vary in bioavailability.

The recommended starting dose is 200 – 400mg* once daily (100 – 200mg daily in older adults) in the case of the tablets or in divided doses in the case of the liquid preparation. Note: 5ml (520mg) of Priadel liquid is considered equivalent to 200mg of Priadel tablets.

Lithium tablets should be prescribed once daily at night to enable morning trough plasma levels. Lithium liquid is usually prescribed twice daily.

*Note the SPC for Priadel and the BNF entry make reference to dosing by patient weight and allow a starting dose range of 0.2 – 1.2g daily. However accepted practice is to start low for all patients and titrate the dose upwards depending on response, level measurements and adverse effects.

Initial monitoring
  • Take first lithium level after 5 - 7 days (12 hours after last dose). In twice daily dosing withhold morning dose until sample taken.
  • Take subsequent levels at least 5 -7 days after every dose change.
  • Target levels range for new lithium patients is 0.6 - 0.8mmol/L. Some patients may respond adequately to lower levels however some may require levels up to 1.0mmol/L.
  • The lower end of the range is usually target for treatment and maintenance therapy of older adults and special populations.

Editorial Information

Last reviewed: 03 September 2019

Next review: 12 July 2021

Author(s): PMG-MH

Version: 1

Approved By: PMG-MH

Reviewer Name(s): Andrew walker, Suzanne Burke