Page 1 of 1: Lithium Counselling

junejo · Credits: 3915 My Scrapbook

Can anyone help me in Lithium counselling

Thanks

Kai1111 · Credits: 2036 My Scrapbook

I did some cursory research and was overwhelmed...side effects galor....and yet I see many people on lithium who are doing great....I've never been the person to start someone on lithium....don't know where to begin, so I fired off this question to a friend who is a seasoned psychiatrist...we'll see what he advises.....if I don't get a response, I'll find one, somehow....

bush5 · Credits: 1122 My Scrapbook

greet the patient

introduce

say why you wanted to quit? since how long you are taking this medications? Who did you put on Lithium? why what happened at that time? is there anytme when you are without lithium? then why did you started it again? enquire about regular blood work related to lithium? what were the results? ask about mania/ depression symptoms? enquire about symptoms of thyroid diseases? enquire about symptoms of diabetes insipidus? enquire about tremers? ask about possibility of pregnancy?

if there is no problem? then say that will keep you on lithium? benefits of being on lithium is more than discontinuing it? if still dissatisfied refer to psychiatrist?

Kai1111 · Credits: 2036 My Scrapbook

My friend wrote me back and all of this seems really important:

Close in size to the element Na (If I rember correctly)
3rd most abundant element in the earth.
exchange pump Na-K is effected by Li (and the pump has been proposed to have a problem in Bipolar disorder)
really deadly drug in overdose..... is dialysible
Is a model drug for therapeutic plasma monitoring..

Common side effects at therapeutic concentrations:

Polyuria (40%) ... rx is let them drink water, do not fluid restrict
tremor (fine tremor of the hands)
weight gain
rash
inhibition of thyroid function (in those predisposed by problems such as hashimotos, etc)- therefore monitor TSH every 3-6 months.
increases the plasma concentratiuon of WBC by mechanism of demargination od sequestered wbc's
Therapeutic plasma concentration range (trough level) .5- 1.2 Meq/L.

Earliest manifestation of toxicity (tremor of the tongue or diarrhea) present at or around 1.2 Meq/L
Toxicity at 2.0 Meq/L begins to involve changes in mental state - somnolence
Toxicity concentrations go up, risk of obtundation and seizures/cardiac arrhthymia, death increase
Fatal levels typically 3.5 -4.0 Meq/L.

Never underestimate this drugs ability to kill.
95% of Bipolar patients will attempt to harm themselves at some time during their life time.
Worst risk state is mixed bipolar, then depression.
Suicide risk is not related to severity of depression (perhaps greatest in moderately depressed who have the energy).
Risk period of suicide is highest 7-14 plus days after initiataion of anti-depression treatment (including lithium).

If a patient is at risk to become pregant lithium is the wrong drug for them. Lithium produces cardiac defects (tet of Fallot, etc.)

Then, he sent me anonther email.......

Whoops!!

Renal function - should do 24 hour creatinine clearance if possible prior to initiation of therapy.
Lithium levels are dependent upon lithium function (renally cleared).
Lithium does impair renal function in some patients so checking creatinine concentrations annually is a good practice.
Lithium overdose can wipe out kidney function.

vanjik · Credits: 371 My Scrapbook

3 opinions on this station until now....

as you all know, Lithium has very narrow therapheutic index.
so we need to FU very carefully of this drug level.

1) we have to ask about this part to the patient.

2) inquires for the detection of side effects

change in your peeing
any funny skin color or eczema
N/V
chest pain/tightness/heart pouding
joint pain or swelling
dizziness or sleepiness
energy level

3) inquiries about manic features

sleeping issue ( the patinet told me this stuff )
any plan or big project
spending spree
pressure to speech
grandious thought

4) inquires about doing harm/commiting a suicide

5) any stressful situations in the home environment/wrking place or any interpersonal relationship

somebody told me the possibility of
" hypothyroidism " and "recurrence of bipolar disorder"

Kai1111 · Credits: 2036 My Scrapbook

I have never started a patient on lithium (always discuss/refer to a psychiatrist) and because it carries potential, life-threatening toxicity I asked my friend, if family docs should start this medication and how. He wrote the following:

"Family physicians need to know how to initiate and follow this.
A consult with a psychiatrist is always a great idea but not always practical.
Therefore, for classical bipolar disorder (ie. clear cut ups and downs- the up and down and then up or down phases of the cycle spaced one year apart )-an FP can be certauin that Lithium is the way to go.

Initial dosing is something like 300mgs twice a day for a few days then increase to 300mg qam and 600 mg hs.
Leave it like that for 5 half-lives then do a trough blood level (usually done after 7 days but could be done after 3 or 4). Adjust up (or down ) according to the blood level. The target is the upper end of the therapeutic range.
I go for close to 1.0 Meq/L.

Don't have more than a seven day supply dispensed at the beginning. Have the patient pick up seven day supply at seven day intervals until the blood level is at steady state at the therapeutic level. If the patient's mood state is stable then go to once a month dispenseing and then after after three months go to despening without face to face contact every three month. Advise the patient to pay attention to their sleep and dreams. Dreams state changes (full color, technicolor dreams, etc) are a good predictor of a mood state switch in the three days after the onset of sleep changes."

Re the hypothyroidism....see my prior post:
"inhibition of thyroid function (in those predisposed by problems such as hashimotos, etc)- therefore monitor TSH every 3-6 months. "

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