Updated: 11/30/2019

Lithium

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Snapshot
  • A 32-year-old male is brought to the emergency department by his wife.  She states that during the past year he has suffered from what she believes is depression.  However, as of lately he has not slept the past week and has been working on a project in the garage.  She also states that he has been very energetic, outgoing, and has had a voracious sexual appetite.  Upon questioning the patient you hear the patient describe his ideas with pressured speech and a flight of ideas.  He states that he is, "working on his latest invention," that will, "eradicate constipation."
Overview
  • Mechanism
    • unknown
    • may be related to inhibition of phosphoinositol recycling in neurons
  • Clinical use
    • basic lab panel required prior to starting lithium therapy (TSH, creatinine, urine hCG)  
      • elevated creatinine is a contraindication to lithium 
    • mood stabilizer
      • mainly in bipolar disorder
        • prevents relapse and treats acute manic events
        • only treatment for bipolar disorder that lowers mortality 
      • can be used in tandem with antidepressants
      • due to slow onset, may first give patient with an acute manic episode a benzodiazepine or neuroleptic
    • SIADH
  • Toxicity   
    • very narrow therapeutic index
      • requires blood monitoring
      • avoidance of any drug that may reduce glomerular filtration rate as lithium is predominantly renally excreted
      • patients with renal failure should be managed with valproic acid 
      • avoid thiazide diuretics and NSAIDs
      • other drugs that increase lithium concentration include:
        • tetracyclines, metronidazole, ACEi, ARB, and calcium channel blockers
    • tremor
    • sedation/AMS
    • acne
    • edema
    • heart block
    • hypothyroidism 
    • polyuria 
      • ADH antagonist resulting in nephrogenic diabetes insipidus
      • reason for use in SIADH
    • leukocytosis
    • teratogenesis if given in pregnancy 

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(M2.PY.17.4871) A 37-year-old African American man is brought to the emergency department by police. The patient refused to leave a petting zoo after closing. He states that he has unique ideas to revolutionize the petting zoo experience. The patient has a past medical history of multiple suicide attempts. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 100/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient's cardiac and pulmonary exams are within normal limits. He denies any nausea, vomiting, shortness of breath, or systemic symptoms. The patient struggles to answer questions, as he is constantly changing the subject and speaking at a very rapid rate. The patient is kept in the emergency department overnight and is observed to not sleep and is very talkative with the nurses. Which of the following is the best long-term therapy for this patient? Tested Concept

QID: 109533
1

Lithium

73%

(123/169)

2

Valproic acid

7%

(12/169)

3

Risperidone

14%

(23/169)

4

Haloperidol

6%

(10/169)

5

Diphenhydramine

1%

(1/169)

M 7 D

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EXPERT COMMENTS (2)
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