Download Guidance for the use of lithium in South West Yorkshire Partnership

Guidance for the use of lithium in South West
Yorkshire Partnership NHS Foundation Trust
Document name:
Guidance for the use of lithium in
South West Yorkshire Partnership
NHS Foundation Trust
Portfolio
Document type:
Medicines Management
Drug and Therapeutics Trust Action
Group
Staff group to whom it
applies:
Clinical Staff
Distribution:
The whole of the Trust
How to access:
Intranet and ward folder
Issue date:
Version 2
Next review:
April 2013
Approved by:
Drug and Therapeutic Committee
Developed by:
Adrienne Crockett and Diane
McGowan. Updated by Lynn
Haygarth
Director leads:
Medical Director
Contact for advice:
Medicines Information
Med.information @swyt.nhs.uk
Contents
1
Introduction ……………………………………………………….
3
2
Standards for prescribing ………………………………………
Indications ……………………………………………………….
Prescribing ……………………………………………………….
Unlicensed use …………………………………………………..
Consent …………………………………………………………..
3
3
4
4
4
3
Service User Information ……………………………………….
5
4
i
ii
Initiation and Monitoring of lithium treatment …………………
Routine Baseline Assessment …………………………………
Routine follow up monitoring ………………………………….
6
6
7
5.1
5.2
5.3
5.4
5.5
5.6
Risk Management ………………………………………………
Contra-indications to the use of lithium ……………………….
Special precautions to the use of lithium ……………………..
Drug interactions …………………………………………………
Serious Adverse Effects ………………………………………...
Toxic Effects ……………………………………………………...
Communication …………………………………………………..
8
8
8
9
10
10
10
i
ii
Iii
iv
5
6
Training and Awareness ………………………………………... 11
7
Legislation, supporting policies and guidance ………………..
8
References and associated documents ………………………. 11
9
Monitoring of policy ……………………………………………… 12
Appendices:
1
Lithium Shared Care Guidelines ………………………………
2
Lithium Treatment Card ………………………………………..
3
Lithium Therapy Record Book ………………………………...
11
13
16
18
2
1.
Introduction
South West Yorkshire Partnership NHS Foundation Trust will support the use
of the mood stabiliser lithium in all appropriate cases. The purpose of this
policy is to set out the standards for clinicians, pharmacists, nursing staff and
other health care professionals involved in the prescribing, administration and
monitoring of lithium.
The preparations currently used in the Trust are lithium carbonate as
Camcolit® and Priadel® and lithium citrate as Li-liquid® or Priadel liquid®.
The policy supports the implementation of the NPSA alert entitled ‘Safer
Lithium Therapy which states that:
1. Patients 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 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.
2.
Standards for prescribing
i. Indications
The licensed indications for lithium are:
•
The treatment and prophylaxis of mania.
•
The treatment and prophylaxis of bi-polar disorder.
•
The treatment and prophylaxis of recurrent depression.
•
The treatment of aggressive or self-mutilating behaviour.
Lithium is not recommended in children and adolescents.
3
ii. Prescribing
•
The initiation of lithium is restricted to specialist mental health services
normally in secondary care
•
The NPSA Lithium Therapy booklet must be given to the patient. The
South West Yorkshire orange lithium treatment card can also be used if
the patient prefers.
o
The booklets and orange cards are available from the pharmacy
office at Dean Clough 01422 281351 or by emailing
[email protected]
•
For ongoing prescribing, lithium must be prescribed by the individual’s
hospital specialist until the maintenance regime is established.
•
Once lithium levels are stable prescribing can transfer to the G.P in
accordance with the shared care guideline. The G.P. will receive a
letter informing him of
¾ Diagnosis and target lithium range.
¾ Concurrent medication prescribed via secondary care including
dose and preparation of lithium
¾ Record of recent lithium monitoring, levels and dates next due
¾ Patient’s follow up details including care plan.
¾ Details of any identified problems e.g. compliance with treatment.
¾ Copy of the Lithium Shared Care Guideline (Appendix 1).
•
Each Consultant team should either have a lithium register or use a
lithium clinic (see page 10). The register should include:
¾ Patient details
o Date lithium started.
o The care plan for each patient including monitoring
arrangements, relevant blood results, brand of lithium and the
most recent dose.
o Whether prescribing is continued in primary care or secondary
care
o If primary care the date the shared care agreement was agreed
and the details of the GP.
iii. Unlicensed Use
•
For unlicensed use refer to the South West Yorkshire Partnership NHS
Foundation Trust Unlicensed Drug Policy. This is section 17 of the
Medicines Code. Unlicensed use is not covered by the shared care
guideline and prescribing should continue in secondary care.
iv. Consent
•
In the case of adult service users, lithium treatment is usually given
after informed consent has been obtained. Prior to the commencement
of therapy, agreement must be reached with the service user to comply
with the treatment/blood monitoring regime as clinically indicated.
•
Where the service user does not have the capacity to consent to
treatment but does not object, lithium can be given under the Mental
Capacity Act 2005:
4
o
o
necessary to save life or prevent a deterioration or ensure an
improvement in the patient’s physical or mental health
in the best interests of the patient.
•
Consideration must be given to whether the service user will comply
with the blood testing regime. Blood tests are part of the treatment and
can be taken from service users without capacity who do not object to
the procedure if it is in their best interests and has been agreed by the
multidisciplinary team.
•
When a service user is detained for treatment under the Mental Health
Act and withholds consent, blood testing is legal under section 63, and
then if necessary a section 58 certificate. It must be deemed necessary
at that particular time having considered the benefits to outweigh the
adverse effects to the patient and minimal force must be used.
•
Consent may be given by adolescents if they are considered by the
treating physician to have the capacity to consent to lithium treatment,
i.e. they are aged 16 to 17 years old and have sufficient understanding
to give consent to that treatment (Family Law Reform Act 1969, s.8(1)).
A child under the age of 16 can give valid consent if deemed to be
“Gillick competent”. It is good practice to involve the family in the
decision to initiate lithium treatment. If the individual is not of a
sufficient age or understanding, a person with parental responsibility
will normally give consent. However the use of lithium in adolescents is
an unlicensed use therefore this would require discussion with the
allocated pharmacist and completion of the “unlicensed use of licensed
medicines form”.
3.
Service User Information
Prior to initiation, service users and where appropriate their carers, must
have a full discussion with their clinicians regarding the risks and benefits
of lithium treatment. The range of common side effects and potential
medical complications should be discussed. Clear instructions regarding
the symptoms of toxicity should be given to all patients on long-term
lithium therapy.
Service users should be supplied with the new NPSA Lithium Therapy
Record Book. This is also available online. The Trust’s orange card can
also be issued if this is more acceptable. An entry should be made in the
service user’s records that this information has been given, how it has
been given and how it was received.
The current Camcolit (Norgine), Priadel (Sanofi-Synthelabo) and Li-Liquid
(Rosemont) SPCs contain a comprehensive list of cautions and
contraindications and this should be available in all lithium clinics, and to
prescribing physicians and clinicians involved in the care of service users
on lithium.
Throughout their treatment service users should receive appropriate
ongoing verbal and written information and their lithium blood levels and
5
other relevant clinical tests should be recorded in their NPSA Lithium
Therapy Record Book or on the SWYPFT orange lithium card.
If the service user has little or no English and the member of staff does not
speak their language, they should be offered the opportunity of discussing
their treatment through an interpreter. Leaflets on lithium in foreign
languages are also available on the intranet. These can be found on the
intranet in the A-Z list of sections, patient information leaflets (pharmacy)
or email [email protected] with your request.
4.
Initiation and Monitoring of Lithium Treatment
Relevant medical conditions and special precautions should be
considered. Contraindicated medications should be discontinued prior to
initiation of lithium therapy, and other medications reviewed.
i. Routine Baseline Assessment
•
•
•
•
•
Full medical and psychiatric history
Physical examination: weight, pulse and blood pressure
The appropriate risk assessment
Blood tests: Serum creatinine, eGFR, TFTs, electrolytes and Serum
calcium.
Electrocardiogram (ECG) if possible.
During Lithium Treatment initiation
•
•
•
The lithium plasma level should be checked 7 days after starting
lithium.
The lithium plasma level should be checked 7 days after every dose
change.
This procedure should continue until the desired plasma level is
achieved.
6
ii Routine Monitoring
It is recommended that the service user attends their GP for a regular
physical examination.
Parameter
Standard
care
3 monthly
Special considerations
Over 65yr, significant cardiac or renal disease or
concomitant medication which could affect lithium
therapy at least 2 monthly
Over 65yr, significant cardiac or renal disease, or
Serum
6 monthly
concomitant medication which could affect lithium
creatinine and
therapy, every 4 months
eGFR*
eGFR less than 60ml/min; with every serum
lithium test.
Over 65yr or cardiac disorder; at least every 6
Serum calcium
12 monthly
months
Over 65yr or thyroid disorder; at least every 6
Thyroid
6 monthly
months
function test
Over 65yr; 4 monthly
U&Es
6 monthly
Additional monitoring for weight gain, goitre (neck measurements) and ECG
changes. Where renal impairment is present, FBC and BP are recommended.
Serum lithium
*Renal
Function
eGFR
How often should
the eGFR be
measured
Action
< 60ml /min
With every serum
lithium test
Refer to Consultant psychiatrist to review
ongoing need for lithium
30 – 59
ml/min
STAGE 3 CKD
(Chronic
Kidney
Disease)
With every serum
lithium test
Refer to Nephrologist if
• client is on three blood pressure
lowering agents and BP still more
than 130/80
• proteinuria >100mg/mmol
• unexplained anemia
15-29ml/ min
STAGE 4 CKD
Nephrologists to
monitor renal
function
Refer to Nephrologist
• probably not worth stopping lithium
now
• keep lithium at lower end of
therapeutic range
<15ml/min
STAGE 5 CKD
End stage
renal failure
5
Patient needs an informed discussion about
the risks and benefits of renal dialysis
Risk Management
7
5.1
Contra-indications to the use of lithium
•
A history of hypersensitivity or lithium or the excipients
•
Patients with significant renal disease.
•
Patients with cardiovascular disease.
•
Cardiac disease associated with rhythm disorder.
•
Patients with Addison’s disease and untreated hypothyroidism.
•
Patients who are breast-feeding.
5.2
Special precautions to the use of lithium
Refer to the SPC for a full list of special precautions.
•
Lithium is excreted in breast milk, mothers receiving lithium should
not breast feed.
•
In women of child bearing potential adequate contraceptive
measures must be advised as lithium is teratogenic and carries
a 1 in 1000 risk of Ebstein’s anomaly. If the use of lithium is
unavoidable close monitoring of serum concentration should be made
throughout pregnancy and parturition.
•
Use in the elderly requires a particularly low dose at initiation of
treatment, and the dose titrated up more slowly as the elderly are
more susceptible to side effects. Elderly patients are more liable to
lithium toxicity.
•
In practice, when using lithium in people with learning disability,
consideration should be given to any underlying medical condition
which may affect their tolerability to lithium.
8
5.3
Drug Interactions (Clinically most important in bold)
All health professionals responsible for prescribing drugs to lithium treated
service users should be aware of the potential for drug interactions. The list
is not exhaustive; please consult the latest edition of the BNF or your mental
health services pharmacist for more information. Queries on lithium can be
directed to [email protected]
Drugs which increase the
concentration of lithium
ALL increase the potential for
toxicity
ACE inhibitors
Tricyclic antidepressants
Monitor closely or use an
alternative especially in the
elderly.
Increases peak lithium
concentration
Monitor closely, theoretical
possibility of an interaction
Monitor closely as combined
effects are unpredictable
Monitor closely may cause a
neurotoxic reaction (if lithium
level>1mmol/l)
Caution required
May increase lithium’s
neurotoxicity, but this is rare in
practice unless lithium
level>1mmol/l.
Potential to cause serious
interactions
Use with caution and monitor
closely.
Reduce excretion of lithium
increasing the plasma level of
lithium. Monitor frequently,
always avoid intermittent use
and preferably avoid regular
use.
Increased incidence of CNS
toxicity. Recheck lithium level
soon after starting treatment .
Higher risk of toxicity than loop
diuretics
Potential for neurotoxicity
DRUGS WHICH DECREASE THE
CONCENTRATION OF LITHIUM
Aminophylline or Theophylline
Sodium Chloride
ALL DECREASE
EFFECTIVENESS
Decrease lithium levels
Decreases lithium levels
Alcohol
Angiotensin 2 antagonists
Calcium Channel Blockers
Carbamazepine
Cox 2 inhibitors
Haloperidol
Herbal diuretics
Loop diuretics
Non-steroidal anti-inflammatory
drugs
SSRIs
Thiazide diuretics
9
5.4
•
•
•
•
•
•
•
•
5.5
Serious Adverse Effects
Nausea, vertigo, muscle weakness, dazed feeling (frequently disappear
on stabilisation).
Fine hand tremor, polyuria and polydipsia may persist.
Long-term effects can include weight gain and oedema,
Hypercalcaemia, hypermagnesaemia and hyperparathyroidism,
Rash ,acne and other skin disorders,
Disturbance of thyroid function,
Memory impairment
Nephrotoxicity
Toxic Effects
•.
Toxic effects occurring at levels above 1.5mmol/l
Anorexia, diarrhoea and vomiting. Muscle weakness, lack of coordination, lethargy, progressing to ataxia, tinnitus, blurred vision,
dysarthria, coarse tremor and muscle twitching.
•
Above 2-3mmol/l large urine output, disorientation, seizure, coma,
cardiac arrhythmias, death.
Any signs of toxicity stop the lithium, urgent blood sample for serum
level measurement and seek an urgent medical review
•
.
Drugs may produce unwanted or unexpected adverse reactions. Detection
and recording of these is important.
Doctors, pharmacists and nurses should report adverse reactions to the
Medicines and Healthcare Products Regulatory Agency (MHRA).
Prepaid yellow cards for reporting are to be found at the back of the British
National Formulary or electronic submissions made on:
http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&nodeId=28
7
5.6 Communication
Reliable systems must be in place to ensure blood results are communicated
between laboratories and prescribers:
•
Close liaison must exist between the lithium prescriber, clinic/
community nurse, dispensing pharmacy (community or hospital) and
general practitioner (GP).
•
A clear written plan must exist defining arrangements for prescribing
medication.
•
Anyone suspecting non-compliance with lithium should notify the
lithium clinic and prescriber and appropriate action taken to follow this
up with the service user.
•
The lithium clinic staff or community psychiatric nurse are responsible
for following up non-attendance for blood tests and liaison with the
prescribing doctors.
10
Changes to lithium dosage
¾ Must be recorded in the service user’s notes and on RiO
¾ The clinic / community nurse and GP notified of the change in writing.
¾ The new lithium dosage must be written on the patient’s lithium card or
booklet.
Changes in lithium blood levels
¾ Lithium blood levels and relevant clinical tests must be recorded on the
service user’s lithium card or Therapy Record Book and the GP/nurse
informed if they are unable to access the ICE system.
¾ Prescribers must check that blood tests are monitored regularly and
that it is safe to issue a prescription.
¾ Pharmacists must check that blood tests are monitored regularly and
that it is safe to dispense the prescribed lithium.
6.
Training and Awareness
Staff involved with service users undertaking treatment with lithium should
have training in the use of the drug.
Phlebotomy training must be available for nursing staff who are required to
take blood. Training must include sufficient practice in taking blood to
enable the member of staff to feel confident that they can do this efficiently
and safely. Refresher courses should also be available when requested by
members of staff.
The instruction must include the transporting of blood samples to the
laboratory and infection control procedures.
7.
Legislation, supporting policies and guidance
Human Rights Act 1998
Race Relations Amendment Act 2000
HPT Medicines Policy
HPT Policy and guidance on the reporting and management of errors or
incidents in the prescribing, supply and administration of medicines
(Medication Errors) draft.
Mental Capacity Act 2005
8.
References and associated documents
The Maudsley Prescribing Guidelines 10th Edition
British National Formulary. No 60 Sept 2010 www.bnf.org
Medicines Compendium SPCs for Camcolit®, Priadel® and Li-Liquid
South West Yorkshire Area Prescribing Committee Lithium Shared Care
Guidelines.
National patient safety Alert NPSA/2009/PSA005 Safer Lithium Therapy
11
9.
Monitoring of policy
The policy will be monitored by the Lithium Safety Group. A review of the
policy will take place after one year.
Each lithium clinic must have an operational policy which should include the
following aims:
•
To facilitate regular blood sampling
•
To provide a safe and effective service
•
To provide a friendly environment to try and put service users at
ease
•
To liaise with prescribing doctors /GPs
•
To liaise with professionals and carers about the service provided
and how to access the service
Each lithium clinic must have a protocol for the running of the clinic
which should include information on:
Roles and responsibilities
Health and Safety issues e.g. number of staff required to run the clinic
Clinic environment
Referral and risk assessment
Nursing assessment, monitoring for side effects and adverse effects
Physical health checklist
Service user information
Haematological monitoring
Routine regular prescriptions
Change of medication
Procedures in the event of adverse events / physical symptoms
Out of hour’s policy
Identification and control of risk factors i.e. obesity, renal disease,
thyroid disease, service users holidays, pregnancy
Out of area issues
Input from other health professionals e.g. Dietician
Clear communication between relevant agencies (consultants, GP’s
and Lithium Clinics)
Audit – annually as a minimum
12
South West Yorkshire
Area Prescribing Committee
L
Liitth
hiiu
um
mS
Sh
haarreed
dC
Caarree G
Gu
uiid
deelliin
nee
IInnttrroodduuccttiioonn
General
Statements
• Patient is to receive supplies of drug from secondary care unit until shared care is agreed.
• Patient’s clinical condition to be stable or predictable.
• Lithium salts should be initiated under specialist supervision. Stabilisation with lithium will
normally take at least three months. Once the patient’s mental state and medication have been
stabilised the patient may be considered for shared care between the psychiatrist, GP and
relevant community mental health teams.
• A full summary of product characteristics should be read before prescribing.
• Agreement of the GP must be sought before seeking patient agreement for shared care.
Service models vary across the area served by South West Yorkshire Area Prescribing
Committee. Where responsibility for prescribing and/or monitoring is not formally shared,
information on doses, serum levels and other results must be shared in a timely manner
across the interface in line with these recommendations.
Indication
Treatment and prophylaxis of mania, bipolar disorder and recurrent depression
IInnddiivviidduuaallss R
Reessppoonnssiibbiilliittiieess
Hospital
•
Specialist’s
•
Responsibilities •
•
•
•
•
•
Careful patient selection and discussion of risk, benefits and toxic effects with patient and carer.
Baseline monitoring and recording of cardiac, renal and thyroid function.
Prescribing (by brand name) until maintenance regimen established.
Monitoring and recording of results until maintenance regimen established.
Provide advice on dosage adjustments if level falls out of recommended range or other
medications are initiated or discontinued.
Communication to GP of established regimen, most recent monitoring details (including when
and results), when to refer back.
Assessment of continued appropriateness and need for treatment with lithium.
Provision and completion of the NPSA pack and booklet
Information to be received by the GP from the Consultant
•
•
•
•
•
•
•
•
General
•
Practitioner’s
•
Responsibilities •
•
•
•
•
•
•
Diagnosis and target lithium range.
Brand of Lithium prescribed.
Dose of lithium prescribed.
Concurrent medication prescribed via secondary care.
Details of patient follow up including care plan and monitoring.
Details of any identified problems e.g. compliance with treatment.
Details of mental health key worker if appropriate.
Copy of Shared Care Guidance.
Continued discussion of risks and benefits of medication with patients and carers as required.
Prescribing (by brand name) once maintenance regimen is established.
Dosage adjustments as advised by secondary care in response to changes in drug therapy or
serum lithium levels.
Continued monitoring including blood levels as per monitoring section.
Recording of results as agreed with secondary care, if there are any concerns regarding the level
contact secondary care urgently.
Refer back to secondary care if patient stops medication without medical advice, if mental state
starts to deteriorate or if there are concerns over patient compliance.
To respond to adverse reactions.
Maintain a practice lithium register.
To make entries in the NPSA booklet as appropriate relating to dosage, preparation and blood
results.
Information to be received by the consultant from the GP
•
Details of concurrent medication
Details of any identified problems e.g. compliance with treatment.
13
Monitoring
Required
When and
How to
Discontinue
Treatment
Information
given to the
patient by
initial
prescriber
Contact
Details
Parameter
Serum lithium
Standard care
3 monthly
Serum creatinine
and eGFR*
6 monthly
Serum calcium
12 monthly
Thyroid function
test
U&Es
BP
ECG
6 monthly
Special considerations
Over 65yr, significant cardiac or renal
disease or concomitant medication which
could affect lithium therapy (e.g. NSAID,
diuretics, ACE inhibitors); at least 2
monthly
Over 65yr, significant cardiac or renal
disease, or concomitant medication which
could affect lithium therapy (e.g.
NSAIDS, diuretics, ACE inhibitors); 4
monthly
eGFR less than 60ml/min; with every
serum lithium test
Over 65yr or cardiac disorder; at least
every 6 monthly
6 monthly
Over 65yr; 4 monthly
12 monthly
Initially and if
clinically indicated
Weight
At start and when
needed if weight
gain is rapid
Where renal impairment is present, FBC is recommended.
*if eGFR falls below 60ml/min, consider referring to Consultant Psychiatrist for review
of the ongoing need for lithium
Specialist advice should be sought. Gradual discontinuation is generally recommended
over at least four weeks and preferably longer to reduce the risk of relapse*. The risk of
relapse remains even after years of remission. Early relapse to mania is an early risk of
abrupt lithium discontinuation.
*(3-4 months is recommended).
•
•
•
•
The patient will be involved in the choice of medication and verbal information given.
The NPSA pack & booklet will be issued initially be secondary care.
A lithium card and details of the brand will be provided.
Signs and symptoms of toxicity will be emphasised.
Including telephone, bleep, email and fax numbers, out of hours and contact details of
hospital medicines information department to be included in specialist’s letter.
14
P
Prroodduucctt IInnffoorrm
maattiioonn
The information in this Shared Care Guideline should be used in conjunction
with the latest edition of the BNF and Summary of Product Characteristics
•
In patients of average weight (70kg) an initial dose of 400 – 1200mg may be given as a single
Dosage
dose at night for slow release preparations or twice daily for normal release tablets or
liquid.
•
Different preparations and salts are not bioequivalent and should not be interchanged.
•
Four to five days after starting treatment, or changing the dose (and never longer than one
week) a blood sample should be taken for the estimation of serum lithium level.
•
Dosage should then be adjusted to maintain the serum lithium concentration at the desired
levels.
•
Blood samples should be taken at least 12 hours post dose.
Target serum lithium concentration
(mmol/l)
Prophylaxis of bipolar affective
0.4 – 0.8
disorder
(aiming for 0.6 to 0.8 where possible)
Treatment of acute manic or
0.6 – 1.0
hypomanic episode or recurrent
depressive disorders
Elderly, or eGFR <60ml/min
0.4 – 0.8
(aiming for the lower end of this range where possible)
Lithium has linear pharmacokinetics therefore, assuming stable renal function, an increase in dose of
25% will increase the serum lithium concentration by 25%.
The recommended starting dose for the elderly or those below 50kg is 400mg. Lower doses
may be required to maintain therapeutic levels. Dose reductions may be required over a
period of years.
Adverse
Effects
•
•
•
Nausea, vertigo, muscle weakness, dazed feeling (frequently disappear on stabilisation).
Fine hand tremor, polyuria and polydipsia may persist.
Long-term effects can include weight gain and oedema, hypercalcaemia, hypermagnesaemia and
hyperparathyroidism, rash acne and other skin disorders, disturbance of thyroid function,
memory impairment and nephrotoxicity
Toxic Effects
•
•
Anorexia, diarrhoea and vomiting.
Muscle weakness, lack of co-ordination, lethargy, progressing to ataxia, tinnitus, blurred vision,
dysarthria, coarse tremor and muscle twitching.
•
Above 2-3mmol/l large urine output, disorientation, seizure, coma, cardiac arrhythmias, death.
Any signs of toxicity stop the lithium, urgent blood sample for serum level measurement.
Precautions
and Contraindications
•
•
•
•
•
•
Clinically
relevant
Drug
Interactions
and their
management
•
•
•
•
Prior to commencement of treatment, ensure the service user agrees to routine monitoring for the
length of treatment and that facilities for monitoring are available.
Contra-indicated in cardiac failure, significant renal impairment, Addison’s Disease and
untreated hypothyroidism.
Pre-treatment assess renal, thyroid and cardiac function.
Diet and fluid intake should remain normal to maintain stable electrolyte balance. Hot weather /
environments and infectious diseases may alter fluid balance and thus serum lithium levels.
Diarrhoea and vomiting may require dose reduction or discontinuation.
Pregnancy – is a contra-indication as lithium is a known teratogen. Women of childbearing
age should be advised to use reliable contraception.
Breastfeeding- is a contra-indication as lithium is excreted in the breast milk and can lead
to toxicity in the infant.
Diuretics, especially thiazides, (bendroflumethiazide), reduce lithium clearance and increase
serum levels leading to toxicity. Refer to secondary care for specialist advice and dose
reduction prior to initiating a diuretic. Restabilisation will be required.
Other psychotropic medication can require lower doses as lithium can potentiate their side
effects.
NSAIDS can increase lithium serum levels leading to toxicity. More frequent monitoring is
required. Avoid prn use of NSAIDS.
ACE inhibitors can increase lithium levels leading to toxicity
It is advisable to check the Lithium levels 1-2 weeks after initiation of an NSAID or ACE inhibitor.
15
Appendix 2
CAUTIONS WHILE TAKING
LITHIUM
• LITHIUM MAY CAUSE DROWSINESS THEREFORE
TAKE CARE WHEN DRIVING OR OPERATING
MACHINERY.
• BEWARE WHEN BUYING ANTI-INFLAMMATORY
MEDICATION (e.g. Ibuprofren/Nurofen, Naproxen)
ask your pharmacist for advice
• As lithium is a salt, try to maintain an adequate
fluid intake. Dehydration can lead to Lithium
toxicity.
• Avoid changes to your salt intake.
• Sickness, diarrhoea and excessive sweating may
all affect lithium levels.
SIDE EFFECTS OF LITHIUM
Dry mouth
Thirst
Passing more urine
Tiredness
Muscle ache
Confusion
Swollen feet or hands
Skin rashes
Dizziness
Mild diarrhoea
Tremor
Nausea or feeling sick
Stomach pain
Drowsiness
Weight gain
• These effects often wear off. If they do not tell
your doctor, nurse or pharmacist as the dose
• If these side effects become more severe and
interfere with normal functioning this may
indicate LITHIUM TOXICITY - omit the next dose
and contact your doctor or nurse as soon as
possible.
• If you are a woman of childbearing age use reliable
contraception.
• If you are pregnant or planning to become pregnant
you must discuss this with your Doctor, Nurse or
pharmacist.
LITHIUM SHOULD NOT BE STOPPED SUDDENLY AS
THIS COULD LEAD TO RELAPSE. IF FOR ANY
REASON YOU ARE THINKING OF STOPPING
LITHIUM SPEAK TO YOUR DOCTOR, NURSE OR
PHARMACIST
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BLOOD TESTS
Regular blood tests will be done to check that the amount of
Lithium in your blood is within the normal range
(0.4-1.0mmol/l).
DATE
DOSE
LEVEL
NEXT
APPOINTMENT
INITIALS
WHAT YOU NEED TO KNOW WHEN
TAKING LITHIUM
• Lithium is a mineral salt.
• Lithium helps to level your mood.
• It is a preventative medicine and should be taken
even when you feel well.
• Initially it may take a few weeks to work properly.
• It is not addictive.
HOW TO TAKE LITHIUM
• Always take your tablet at the same time every daypreferably last thing at night.
• Always swallow your tablets whole or break in half.
• Do not crush, chew or dissolve your tablets.
• Always take the same brand of lithium
(eg Camcolit or Priadel)
FORGETTING A DOSE
Produced by:
Pharmacy Dept, Fieldhead Hospital, Ouchthorpe
Lane, Wakefield, WF1 3SP
Tel: 01924 328691/95
•
•
•
•
If you forget to take your lithium:
Take it as soon as you remember.
If three hours overdue miss out that dose, and take
your next dose at the usual time.
DO NOT DOUBLE THE DOSE UNDER ANY
CIRCUMSTANCES.
If you miss several doses start again when you
remember, tell your doctor, nurse or pharmacist,
you may need an extra blood test.
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http://www.nrls.npsa.nhs.uk/alerts/?entryid45=65426
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