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