Download Lithium CC Guidelines - North Essex Partnership University NHS

POLICY DOCUMENT
Document Title
Continuing Care Guideline for Lithium Therapy
Reference Number
Policy Type
Continuing Care Guidelines
Electronic File / Location
N:\Pharmacy\Intranet
Intranep Location
http://intranep/TeamCentre/pharm/PublishedDocuments/Forms/Sh
ared%20Care.aspx
Status
FINAL
Version No / Date
Version 2.0 – June 2016
Dr R Gupta, Consultant Psychiatrist
Author(s) Responsible for
Writing and Monitoring
R Parekh, AD for Pharmacy
C Banham, Pharmacy Manager
J Dattani, Lead Pharmacist for Mid Essex
Approved By and Date
Medicines Management Group, July 2016
Implementation Date
August 2016
Review Date
6 July 2019
Copyright
©North Essex Partnership University NHS Foundation Trust (2016). All
rights reserved. Not to be reproduced in whole or in part without the
permission of the copyright owner.
All matters or concerns regarding fraud or corruption should be reported to: Chris Rising, Senior
Manager ([email protected] 07768 873 701), Mark Kidd ([email protected]), Mark
Trevallion, LCFS Lead ([email protected] 07800 718 680) or the National Fraud and
Corruption Line on 0800 028 40 60 https://www.reportnhsfraud.nhs.uk/
CONTENTS
Item No
Item
Page No
1
Introduction
3
2
Aim
3
3
Scope
4
4
Reference to other standards, policies or procedures
4
5
Responsibilities
Consultant
General Practitioner
Patient / Carer
Procedure
Indications and licensing
Administration
Brand prescribing
Monitoring standards
Monitoring guidance
Prescribing in specialist groups
Pregnancy
Children
Elderly
Renal impairment
Side effects
Toxicity
Cautions
Interactions
Contraindications
5
5.1
5.2
5.3
6
6.1
6.2
6.3
6.4
6.5
7
7.1
7.2
7.3
7.4
8
8.1
8.2
8.3
8.4
7
Summary of Changes
5&6
6&7
8
8
8
8
8&9
9
10 & 11
12
12
13
13
13 & 14
14
14 & 15
15
15
15 & 16
16
APPENDICES
App. No
Appendix
Page No
1
2
Lithium monitoring form
Initial letter to GP
17
18
3
Second letter to GP to start continuing care
19
4
NEP Algorithm for Prescribing & monitoring Lithium
20
Page 2 of 20
CONTINUING CARE GUIDELINE PROCESS FOR LITHIUM
1. INTRODUCTION
This is a document that provides information allowing patients to be managed safely across primary
care, secondary care and across the interface.
It is a partnership /agreement between Secondary care, Primary care and the patient which sets out
responsibilities for each party.
The patients should be clearly explained about the intentions for shared care and should give their
agreement.
There should be good communication and cooperation between the parties involved in ensuring
patient safety and management.
The doctor who is prescribing the medication should have clinical responsibility for the drug and the
consequence of its use.
2. AIM
The aims and objectives of these continuing care guidelines are to ensure that lithium therapy is
initiated, prescribed, dispensed and monitored appropriately and according to the National Patient
Safety Alert (NPSA) guidelines and NICE guidance.
This is to ensure that patients on lithium therapy are managed safely across the interface of primary
and secondary care.
Arrangements should be put in place to ensure that:
1.
Patients who are prescribed lithium are monitored in accordance with NICE guidance
2.
There are reliable systems to ensure blood test results are communicated between laboratories
and prescribers
3.
At the start of lithium therapy and throughout their treatment patients receive appropriate ongoing verbal and written information and a record book to track lithium blood levels and
relevant clinical tests.
4.
Prescribers and pharmacists (hospital and community) check that blood tests are monitored
regularly and that it is safe to issue a repeat prescription and/or dispense the prescribed
lithium.
5.
Systems are in place to identify and deal with medicines that might adversely interact with
lithium therapy.
Page 3 of 20
3. SCOPE
All practitioners within NEP and third parties dealing with Lithium therapy in respect to NEP
patients.
4. REFERENCES TO OTHER STANDARDS, POLICIES OR PROCEDURES
NICE guidance on Bipolar Affective disorder [Nice Guidance CG185 published in Sept 2014]
NICE guidance on Antenatal and Postnatal mental health [Nice Guidance CG192 published in
December 2014]
The Maudsley Prescribing Guidelines.12th edition.
British National Formulary.
Close monitoring of patients prescribed Lithium NSPA Dec. 2009
Lithium monitoring app, available on the App Store.
Page 4 of 20
5. RESPONSIBILITIES
5.1 Initiation of Lithium Therapy - Consultants’ Responsibilities
Lithium therapy will usually be initiated by a consultant psychiatrist. A GP may consider restarting
lithium (preferably in consultation with a psychiatrist) for the same diagnosis if the patient has
previously benefited but has relapsed since discontinuation.
Baseline investigation will be undertaken before initiating lithium (Table 1).
A lithium monitoring book will be provided containing a lithium alert card complete with relevant
details e.g. baseline checks, current dose, target lithium level.
Appropriate on-going verbal and written information will be provided to the patient.
Clinicians are to update the lithium monitoring booklet where appropriate.
It must be ensured that the first blood test is done and checked.
Monitoring of side effects is to be agreed by both parties.
A comprehensive referral letter to the GP is to be provided also indicating when the patient should
be referred back to the consultant (see Appendices 2 and 3).
Conditions of assuming responsibility by the GP agreed and a continuing care document is to be
sent.
Patients on CPA (Care Programme Approach) should remain with Secondary Care unless agreed by
GP and stated on the CPA.
Both parties should ensure that results are shared by both sectors and means of doing this should
be agreed.
Criteria for transferring prescribing and/or discharging to GP
Prescribing responsibility will only be transferred when the consultant and the GP are in agreement
that the patient’s condition is stable or predictable.
The patients will only be referred to the GP once the GP has agreed each individual case and the
hospital will continue to provide prescriptions until successful transfer of responsibilities as outlined
below.
The hospital will provide the patient with a minimum initial supply of 2 weeks therapy on discharge.
Areas of responsibility
In general the various responsibilities will be shared as outlined below, but for an individual patient
there may be some variation in the detail (e.g. on who does which blood tests) but this must be
clearly agreed between the consultant and the GP.
Page 5 of 20
It should be clearly explained to patients about the intentions for continuing care and their consent
given.
There should be good communication and cooperation between the parties involved to ensure
patients are safely managed.

All patients to have been counselled and have an up to date lithium monitoring book.

All patients will continue with hospital prescribing until the patient has stable dose and only
routine monitoring required (Table 1).

The consultant/specialist will send a full referral letter giving details of patient’s response to
therapy.

The letter will list any drugs or investigations recommended by the consultant and previous
test results.

The consultant will request that the GP consider taking over the monitoring requirements as
per continuing care guidelines, which is considered safer than splitting the prescribing and
monitoring across care sectors.

The patient will continue to be monitored until deemed stable to be discharged from mental
health services.
5.2 Lithium Therapy - General Practitioner Responsibilities

Reply to the request for continuing care within 2 weeks and clarify with the hospital specialist
who is to take responsibility for issuing the blood tests and monitoring. Whoever issues the
blood requests must act upon the results.

Ensure patient brings their monitoring book with them, whenever requesting a further supply
of lithium.

Check lithium dose and blood results prior to deciding if safe to continue to prescribe.

Update patient’s monitoring book where appropriate. Check with the relevant pathology lab if
patient has been tested but no results are available.

Prescribe lithium by brand.

Ensure patient understands that branded product is lithium.

Use of phrases such as 'as directed' should be avoided and should state specific instructions,
for example, ‘take one tablet (400mg) at night’.

Prescriptions are recommended to be provided as acute prescription or with appropriate
safeguarding.
Page 6 of 20

Where repeat prescriptions are necessary, it is recommended that 28-day prescription is
adopted unless not deemed appropriate.

Ensure patients are aware of their blood testing requirements. Measure lithium plasma levels
every 3 months (see below for further information regarding lithium levels) and check they are
within desired therapeutic range as advised by the consultant. Samples should be taken 12
hours post dose (trough). Patients should be encouraged to know acceptable levels and their
most recent results.

Respond to out of range results as outlined in the guidance.

Measure thyroid function and renal function every 6 months.

Provide appropriate on-going verbal and written information to patient.

Monitor for drug interactions.

Monitor for side-effects or adverse effects as specified later.

Perform/request additional tests and investigations during maintenance therapy if abnormal
results obtained or as stated by the consultant.

Consider referral back to consultants for review of stable patients on lithium for 3 years.

Lithium patients discharged from Mental Health Services can be referred urgently to the Access
and Assessment teams /Community Mental Health Teams.
Response to results:

If Lithium levels are above or below the range, confirm with patients the timing of the blood
test and adherence with lithium.

Lithium levels below the range should be discussed with the specialist services contact and
consideration given to increasing the dosage.

Levels above the range should also be discussed urgently with the specialist service contact and
consideration given to referring patients to A&E or stopping the lithium for a period of time
and restarting at a lower dose once the lithium level is within the normal range.

All lithium levels above the range should be rechecked urgently and consider urgent medical
review.

Review patient and look for signs of toxicity and side-effects.
The patient lithium monitoring booklet must be updated at each visit. If the hospital has the
monitoring responsibility, the hospital is responsible for contacting the patient if any action is
required. If the GP has the monitoring responsibility, the GP is responsible for contacting the
patient if any action is required.
Page 7 of 20
5.3 Patient/ Carer Responsibilities

Report any adverse effects to their GP and/or specialist.

Ensure that they have a clear understanding of their treatment.

Report any changes in disease symptoms to GP and/or specialist.

Alert GP and/or specialist of any changes of circumstance which could affect management of
disease e.g. plans for pregnancy.

Take/ administer the medication as prescribed.

Undertake any monitoring as requested by the GP and/or specialist.

Ensure that their monitoring booklet is kept up to date and taken to all appointments.

Inform their GP in sufficient time to obtain repeat prescriptions.

Keep monitoring booklet safe and bring to hospital/GP appointments.

Show monitoring booklet to pharmacist when collecting medication.
6. PROCEDURE
6.1 Indications and Licensing

Management of acute mania or hypomanic episodes.

Management of refractory depressive disorders where Lithium is used for augmentation of
antidepressants.

Prophylaxis of Bipolar Affective disorder.
6.2 Administration
The usual starting dose is 400mg at night (200mg in the elderly). Once daily dosing at night is
preferred due to monitoring of plasma lithium levels. The dose of lithium is adjusted to achieve a
lithium concentration of 0.4-1mmol/litre.
6.3 Brand Prescribing
Lithium should be prescribed by brand name because of its narrow therapeutic range and difference
in product bioavailability. Not all products are modified release (MR).
Page 8 of 20
The brand Priadel® is recommended within NEP and is available as 200mg and 400mg tablets.
Priadel contains lithium carbonate and are scored tablets which can be halved. Particular care is
needed with Priadel 520mg / 5ml sugar free liquid, which actually contains lithium citrate where 5ml
= 200mg lithium carbonate (=5.4mmol Lithium). Using a single brand (Priadel) throughout the
locality should help to reduce medication errors.
Camcolit® tablets are film coated immediate release. (Note from 1st October 2015 Camcolit 250mg
tablets changed name to Lithium Carbonate Essential Pharma 250mg film-coated tablets. The name
of Camcolit 400mg modified release tablets remains unchanged).
Care should be taken, including additional monitoring, when changing brands for formulations.
Tablets contain lithium carbonate 200mg  lithium citrate 520mg.
6.4 Monitoring Standards
When starting lithium
Advise patients that poor adherence or rapid discontinuation may increase risk of relapse.

Ensure that the patient is given appropriate information on taking lithium safely, including
monitoring booklet which is to be requested and issued from NEP Pharmacy with the
medication.

Establish a continuing care arrangement with the patient’s GP for prescribing and monitoring
adverse effects.
When stopping lithium

Gradually reduce the dose over at least 4 weeks and preferably up to 3 months, even if the
person has started taking another anti-manic drug.

During dose reduction and for 3 months after stopping Lithium, monitor closely for early signs
of mania or depression.
Page 9 of 20
6.5 Monitoring Guidance
The safe and effective use of lithium requires regular general physical monitoring (see Table 1) and
lithium levels (see Table 2).
Table 1 - General Checks
Checks
Baseline (PreTreatment)
After Treatment Commenced
Weight / BMI

Every 6 months
Urea & Electrolytes

Every 6 months (more frequent in renal
impairment – see 6.6.4 below)
eGFR

Every 6 months (more frequent in renal
impairment - eGFR<50ml/min)
Calcium

Every 6 months
(more frequent if raised)
Thyroid Functions

Every 6 months (more frequent if
impairment)
FBC

Every 6 months
People with
cardiovascular risk
factors.
Repeat only if appropriate.
Pulse

Annual
Blood pressure

Annual
ECG
Page 10 of 20
Table 2 Lithium Checks
Blood samples for lithium levels should be taken 10-14 hours (ideally 12 hours) post dose. For
patients on liquid preparations taking it twice daily, patients should be advised to delay the morning
dose until after the blood sample and taken 12 hours post the night time dose.
Checks
Stabilising Treatment
Maintenance
GENERAL
Once stable:
Every 3 months in first year, then
Every 6 months thereafter
Lithium Levels
5-7 days after starting
treatment
One week after every
dose change
Then monitor weekly
until dose and level is
stable to 4 weeks.
SPECIAL GROUPS
Every 3 months in following groups:
1. Older adults
2. Risk of impaired renal or thyroid
function
3. Raised calcium levels
4. Poor symptom control
5. Poor adherence
6. Last plasma level 0.8 mmol /l or
higher
7. Taking interacting drugs
PREGNANCY
(see advice below on prescribing in
pregnancy)
Every 4 weeks up to 36 weeks of
pregnancy then weekly till labour
starts.
Do not give lithium during labour.
After delivery measure levels 12
hours after last dose. Lithium to be
given after receipt of blood assay
results and dose adjusted according
to lithium levels (minimum of 24h
after last dose).
Levels <0.4mmol/l subtherapeutic
Target Levels
Aim for 0.6mmol/l-0.8mmol/l (first time treated with lithium)
0.8-1.0mmol/l previously on lithium who have relapsed
Page 11 of 20
6.6 Lithium Prescribing in Special Groups
6.6.1 Pregnancy
Do not offer lithium to women who are planning a pregnancy or pregnant, unless antipsychotic
medication has not been effective.
If antipsychotic medication has not been effective and lithium is offered to a woman who is planning
a pregnancy or is pregnant, ensure:

The woman knows that there is a risk of foetal heart malformations when lithium is taken in
the first trimester, but the size of the risk is uncertain

The woman knows that lithium levels may be high in breast milk with a risk of toxicity for the
baby

Lithium levels are monitored more frequently throughout pregnancy and the postnatal period
(see table 2 lithium level monitoring)

If a woman taking lithium becomes pregnant, consider stopping the drug gradually over 4
weeks if she is well. Explain to her that:
 Stopping medication may not remove the risk of foetal heart malformations
 There is a risk of relapse, particularly in the postnatal period, if she has bipolar disorder.

If a woman taking lithium becomes pregnant and is not well or is at high risk of relapse,
consider:
 Switching gradually to an antipsychotic or
 Stopping lithium and restarting it in the second trimester (if the woman is not planning to
breastfeed and her symptoms have responded better to lithium than to other drugs in the
past) or
 Continuing with lithium if she is at high risk of relapse and an antipsychotic is unlikely to be
effective.

If a woman continues taking lithium during pregnancy:





Check plasma lithium levels as above ( Table 2)
Adjust the dose to keep plasma lithium levels in the woman's therapeutic range
Ensure the woman maintains an adequate fluid balance
Ensure the woman gives birth in hospital
Ensure monitoring by the obstetric team when labour starts, including checking plasma
lithium levels and fluid balance because of the risk of dehydration and lithium toxicity
 Stop lithium during labour and check plasma lithium levels 12 hours after her last dose.
Restart lithium at least 24 hours after last dose and only after reviewing the blood assay
results (as dose may need to be readjusted).
Page 12 of 20
6.6.2 Children
The use in children is not recommended.
The decision to give prophylactic lithium requires specialist advice, and must be based on careful
consideration of the likelihood of recurrence in the individual child, and the benefit of treatment
weighed against the risks.
Serum- lithium concentration needs to be monitored and should therefore not be prescribed unless
facilities for monitoring serum-lithium concentration are available.
Lithium is approved to treat mania in children 12-17 yrs. However adherence to treatment and
regular blood tests may be challenging in adolescents.
Although Lithium can be used to treat severe aggressive behaviour in conduct disorder, it is not
licensed for this purpose.
6.6.3 Elderly Patients
Elderly patients are particularly liable to lithium toxicity and may exhibit adverse reactions at serum
levels ordinarily tolerated by younger patients.
Caution is also advised since lithium excretion may be reduced in the elderly due to age related
decrease in renal function (see also Renal Impairment section).
Elderly patients or those below 50kg in weight, often require lower lithium dosage to achieve
therapeutic serum lithium levels and serum concentrations of lithium need to be reduced in the
elderly population and particularly so in the very old and frail elderly. The summary of product
characteristics (SPC) for Priadel tablets states that for prophylaxis, the dosage needed to reach a
blood lithium level of 0.4-0.8mmol/L is generally in the range 600mg – 1200mg/day.
Reduced lithium clearance is expected in patients with hypertension, congestive heart failure or
renal dysfunction.
The most clinically significant pharmacokinetic drug interactions associated with lithium involve
drugs which are commonly used in the elderly. Some examples of these are ACE inhibitors,
Angiotensin –II Receptor Antagonists, diuretics and NSAIDs that can increase serum lithium
concentration. Especially troublesome is the interaction between lithium and diuretics as lithium
toxicity is made worse by sodium depletion; therefore concurrent use of diuretics (particularly
thiazides) is hazardous and should be avoided.
6.6.4 Renal impairment
Since lithium is primarily excreted via the renal route, significant accumulation of lithium may occur
in patients with renal insufficiency. Therefore, if patients with mild or moderate renal impairment
are being treated with lithium, serum lithium levels should be closely monitored, and the dose
should be adjusted accordingly.
Page 13 of 20
Renal impairment is classified according to NICE CG182 using eGFR and ACR (albumin:creatinine
ratio). For further information on this, please see the NICE guideline. As a guide, based on NICE
CG182:


Mild – moderate eGFR reduction = 45-59 ml/min = G3a NICE classification
Moderate – severe eGFR reduction = 30-44 mol/min = G3b NICE classification
A classification of ‘G3’ (a or b) is equivalent to the previous CKD 3 classification.
If very regular and close monitoring of serum lithium levels and plasma creatinine levels is not
possible, lithium should not be prescribed in this population.
Lithium is contraindicated in patients with severe renal insufficiency – eGFR 15-29 ml/min (G4 NICE
classification)
Lithium is a nephrotoxic drug and the possibility of hypothyroidism and renal dysfunction arising
during prolonged treatment should be borne in mind and periodic assessments made. Patients
should be warned to report if polyuria or polydipsia develop. In patients who develop polyuria
and/or polydipsia, renal function should be monitored in addition to the routine serum lithium
assessment.
Cases of Renal tumours; microcysts, oncocytomas and collecting duct renal carcinoma have been
reported in patients with severe renal impairment who received lithium for more than 10 years.
Acute renal failure has also been reported rarely with lithium toxicity.
6.7 Side Effects of Lithium
Most common side effects include fine tremor, stomach upset, polyuria and polydipsia.
Other side effects include metallic taste in mouth, weight gain, ankle oedema, hypothyroidism and
rashes.
Some skin conditions such as psoriasis and acne can be aggravated.
6.7.1 Signs of toxicity
Toxicity is likely above 1.5mmol/litre, however can occur within range i.e. in the elderly.
Symptoms include blurring of vision, anorexia, vomiting, diarrhoea, drowsiness, giddiness, ataxia,
coarse tremor and lack of co-ordination, muscle twitching and weakness.
At very high levels, above 2 mmol/litre hyper-reflexia, hyperextension of limb, increased
disorientation progressing to coma and ultimately death.
Monitor for symptoms of neurotoxicity, including paraesthesia, ataxia, tremor and cognitive
impairment, which can occur at therapeutic doses.
On rare occasions within normal range, symptoms of lithium toxicity can occur.
Elderly patients are particularly liable to lithium toxicity.
Page 14 of 20
If any of the symptoms are experienced by the patient, then lithium therapy should be stopped
immediately and lithium levels checked urgently. Consider urgent medical referral and psychiatric
advice, and refer back to consultant psychiatrist.
6.7.2 Cautions
Cautions are vomiting, diarrhoea and inter-current infection (especially if sweating profusely) which
may require dose reduction or discontinuation.
Elderly patients may exhibit adverse reactions at serum levels ordinarily tolerated by younger
patients and lithium excretion may be reduced.
6.7.3 Interactions
Lithium is excreted through the renal route (it is not metabolised).
Lithium toxicity is made worse by sodium depletion, therefore concurrent use of diuretics
particularly thiazides is hazardous and should be used with caution and monitored appropriately.
Interactions which increase lithium concentrations:





NSAIDs
ACEIs
Diuretics
Tetracyclines
Metronidazole
Interactions which may decrease lithium concentrations:


Theophylline
Sodium bicarbonate containing products
Interactions causing neurotoxicity:




Antipsychotics
SSRIs
Carbamazepine
Methyldopa
If no other alternative can be found and interacting medications are used, then lithium levels need
more frequent monitoring (on initiation and discontinuation).
6.7.4 Contra-indications / precautions
Avoid if there is hypersensitivity to lithium or to any of the excipients.
Avoid in patients with low body sodium levels, including for example dehydrated patients or those
on low sodium diets.
Page 15 of 20
Avoid in patients with cardiac disease or family history of QT prolongation.
Avoid in patients with conditions with sodium imbalance such as Addison’s disease.
Avoid in patients who are breastfeeding.
In patients with renal impairment – eGFR < 50ml/min (avoid if possible or reduce dose and monitor
serum-lithium carefully).
In patients with untreated hypothyroidism (Patients are to be euthyroid before initiation of lithium
therapy)
Contact Details
NEP Pharmacy
Units E & F
Chelford Court
37 Robjohns Road
Widford Industrial Estate
Chelmsford
CM1 3AG
Tel: (01245) 315500
7.
SUMMARY OF CHANGES
Date
May
2016
June
2016
Page No
Summary of Changes
All
None – new document
All
Formatting changes – change of font and presentation, added
numbering system and rearranged the order of the document, no
changes to content.
Page 16 of 20
APPENDIX 1 - LITHIUM MONITORING FORM
Dates
inc
Dose of
Lithium
Lithium
Levels
TFT
T4
TSH
eGFR
U&E
Ur C
N
Calcium
K
Page 17 of 20
BMI /
Weight
Side Effects
APPENDIX 2 - INITIAL LETTER
[Address]
[Date]
Dear Dr [Name]
Re:
Patient:
[Drug name] Continuing Care Guidelines
[Name, address, Remedy No, NHS No.]
I have seen this patient in clinic and believe that [he / she] is suitable for treatment with [drug name].
I have initiated this patient on [drug name, form, dose, frequency] and will be monitoring and prescribing for
this patient at our clinics until such time that the patient is deemed stable, which is likely to be in the region of
[No.] months.
I would like to seek your agreement for you to take over the prescribing and monitoring of this patient’s
treatment after this stabilisation period as per agreed Continuing Care Guidelines. A copy of these guidelines
can be found at www.nep.nhs.uk .
Please complete the form below and either fax it back to the safe haven fax number below or scan and email it
from a secure nhs.net account to our secure nhs.net account below.
I thank you in anticipation.
Yours sincerely
[Name]
[Job title]
Fax back to:
[Name of NEP consultant and safe haven fax no.]
[Clinical Commissioning Group and safe haven fax no.]
Scan and email from
[NEP consultant secure nhs.net email address]
nhs.net email to: [Clinical Commissioning Group secure nhs.net email address]
[*Delete as applicable]:
*I agree to take over prescribing and monitoring responsibility for this patient as per Continuing Care
Guidelines from such date as the patient is deemed stable.
or
*I am not willing to undertake continuing care for this patient because [reason].
[Patient name]
[NHS No]
Yours sincerely,
[Dr]
[Date]
[Practice address]
Page 18 of 20
APPENDIX 3 - SECOND LETTER TO START CONTINUING CARE
[Address]
[Date]
Dear Dr [Name]
Re:
[Drug name] Continuing Care Guidelines
Patient: [Name, address, Remedy No, NHS No.]
Thank you for agreeing to continuing care for the above named patient as per my initial letter dated [date].
I have been monitoring and prescribing for this patient for [no.] months and the patient is deemed stable as
per agreed Continuing Care Guidelines.
The patient is doing well and is currently on [details of dosage regimen]. I would like to discharge this patient
to you for prescribing and general wellbeing of the patient within the parameters of the Continuing Care
Guidelines. I have prescribed for this patient for a further 14 days.
Yours sincerely
[Name]
[Job title]
[Contact number]
[Care coordinator & contact no.]
[Community team & contact no.]
Page 19 of 20
APPENDIX 4 – NEP ALGORITHM FOR PRESCRIBING & MONITORING LITHIUM
Traffic Light Classification – YELLOW
Lithium Initiated by Secondary Care (Mental Health)
Prescribe by Brand Name (usually Priadel®)
Indications include: mania, prophylaxis of bipolar disorder, treatment-resistant depression
Check patient has been given a copy of the Lithium Booklet.
Monitoring Required - Secondary Care (Mental Health)
Baseline
eGFR, thyroid function (TSH) tests, calcium, bodyweight, height, pulse, blood pressure and ECG if indicated. Exclude pregnancy. Discuss
adequate contraception, if relevant.
Check Lithium levels 5-7 days after initiation and repeat weekly until stable (sample taken 10-14 hours post-dose). Once stable, monitor
levels every 3 months in first year, then every 6 months. Recheck levels 7 days after dose changes and weekly until stable.
Patients with bipolar disorder should be advised that erratic compliance / rapid discontinuation of lithium may increase risk of relapse.
Stable mental state
Prescribing will only be transferred when
the consultant and GP are in agreement
that the patient’s condition is stable.
Transfer to Primary Care
The psychiatrist will send the GP a link to NEP Continuing Care Guidelines within a copy of the patient’s care plan including diagnosis, current
test results, list of concomitant medication and professional healthcare contact details. The brand, form, strength and dosage of lithium
must be clearly stated on any correspondence.
To ensure both the GP and psychiatrist receive a copy of any blood test results the name and address of both parties should be specified
on the sample forms.
Monitoring Required - Primary Care
Check serum lithium levels every 3 months in first year, then every 6 months
(more frequently if patient is physically unwell, taking interacting medications)
Check eGFR, TSH, calcium, weight every 6 months (more frequently if clinically indicated).
Check FBC and assess cardiac function if clinically indicated.
An annual health check should also include blood (plasma) glucose, lipid profile, cardiovascular (including BP and pulse), liver function,
diet, level of physical activity, smoking / alcohol and contraceptive advice (if relevant).
Lithium doses may need to be altered to maintain a level within the target range 0.6-0.8mmol/l (sample taken 10-14 hours post-dose).
Individual patients may have a target level just below (0.4-0.6mmol/l) or just above (0.8-1.0mmol/l) – refer to guideline. Recheck levels
7 days after dose changes and weekly until stable.
If lithium toxicity is suspected or level >1.5mmol/l – STOP lithium immediately and assess patient. Repeat serum lithium, U&Es and
creatinine levels and seek hospital advice. Levels >2.0mmol/l consider referral to A&E.
Circumstances in which patients may be referred back to secondary care
or secondary care (mental health) advice sought:




Problematic side effects, including signs of toxicity
(ataxia, tremor, cognitive impairment)
Deteriorating renal, thyroid function or hypercalcaemia
Deterioration of mental state, or where level of risk to
self or others is increased
Pregnancy


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Erratic / non-compliance or patient request to discontinue
lithium
Advice on drug interactions
To consider the appropriateness of continuing / stopping
lithium in people who have been stable for the last 4-5
years
Approved BY NEP MMG July 2016 - To be revised July 2019
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