Review Question - QID 105723

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Lithium QID: 105723 (M2.PY.14.53)

QID 105723 (Type "105723" in App Search)

A 28-year-old male is referred to psychiatry by his PCP after 3 weeks of erratic behavior. The patient initially presented to primary care at the urging of his wife after staying up until 4AM every night playing online poker. He stresses, however, that "it isn't a problem" because he is still "full of energy" during the day at his banking job, which he "could do in [his] sleep anyway." The patient is determined to compete in the world series of poker next year. He has not sought psychiatric treatment in the past, but reports an episode of self-diagnosed depression 2 years ago. During the interview, the psychiatrist notes pressured speech, flight of ideas, and easy distractibility of the patient. The patient's toxicology screen is negative for illicit drugs in the PCP's office. Which of the following lab tests should be checked before initiating lithium in this patient?

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Basic metabolic panel and thyroid stimulating hormone

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2/3

Liver function tests and thyroid stimulating hormone

33%

1/3

Iron studies and liver function tests

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Iron studies and thyroid stimulating hormone

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Basic metabolic panel and liver function tests

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This patient has bipolar disorder, for which lithium is first line therapy. Baseline thyroid stimulating hormone (TSH) and basic metabolic panel (BMP) should be checked before initiating lithium, because of the risk of hypothyroidism and nephrotoxicity (Illustration A).

The patient meets the diagnostic criteria for Bipolar I (an episode of mania with or without episodes of depression), where mania is defined by having 3 of the following: grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-oriented activity, psychomotor agitation, and hedonism. Lithium, which is a first line therapy for bipolar disorder, is notorious for having a narrow therapeutic window. Side effects include: tremor, sedation, acne, heart block, hypothyroidism, nephrogenic diabetes insipidus, leukocytosis, and Ebstein anomaly in developing fetuses if given during pregnancy (illustration B). Coingestion of thiazide diuretics, NSAIDs, and ACE-inhibitors increases the risk of these side effects.

Incorrect answers:
Answers 2-5: Lithium is not associated with hepatic toxicity or impaired iron metabolism.

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