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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 16 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. 17 http://www.nrls.npsa.nhs.uk/alerts/?entryid45=65426 18