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Lithium pioneered mood stabilization and continues to be the preferred first-line treatment choice despite the availability of newer mood stabilizers. Although lithium is approved by the U.S. Food and Drug Administration (FDA) for treating bipolar I disorder, it is often underutilized due to concerns about potential adverse effects and its status as an older drug. Lithium is prescribed for managing acute manic and mixed episodes and maintenance treatment in patients aged 7 or older. In addition, lithium is prescribed off-label for treating major depressive disorder as an adjunct therapy, managing bipolar disorder without a history of mania, addressing vascular headaches, and alleviating neutropenia. This activity outlines the indications and contraindications for lithium use, furnishes guidelines for its administration and monitoring, assesses lithium toxicity, and highlights the role of the interprofessional team in caring for patients undergoing or potentially undergoing lithium therapy. Objectives: Differentiate between the indications and contraindications for lithium use in bipolar disorder and other conditions. Implement proper dosing strategies for initiating and titrating lithium therapy, considering patient-specific factors. Apply knowledge of drug interactions to select appropriate concomitant medications and maintain therapeutic lithium levels within the therapeutic range while prescribing lithium. Collaborate with other healthcare professionals to optimize comprehensive patient care and address concerns for patients on lithium therapy. Access free multiple choice questions on this topic.

Due to its narrow therapeutic index, serum levels of lithium exceeding 2 mEq/L are considered toxic, which falls within its therapeutic range. Lithium toxicity can result in interstitial nephritis, arrhythmia, sick sinus syndrome, hypotension, T-wave abnormalities, and bradycardia. In rare instances, toxicity can lead to pseudotumor cerebri and seizures. Notably, there exists no antidote for lithium toxicity. The primary approach to treating lithium toxicity involves hydration and discontinuation of the drug. Administering hydration through normal saline concurrently facilitates lithium excretion. Close monitoring is essential to prevent hypernatremia in patients receiving normal saline. Diuretic use should be avoided for patients on lithium treatment. For mitigating tremors, administering 20 to 30 mg of propranolol twice or thrice daily is recommended. Recommendations The guidelines established by EXtracorporeal TReatments In Poisoning (EXTRIP) are listed below. Initiate extracorporeal treatment for patients with severe lithium poisoning presenting with coma, myoclonus, convulsions, or cardiopulmonary collapse. Initiate extracorporeal treatment when impaired kidney function is evident, and the lithium concentration surpasses 4 mEq/L. Hemodialysis is also indicated in patients with altered consciousness, seizures, or life-threatening dysrhythmias, regardless of the lithium concentration. Consider extracorporeal treatment if the lithium concentration exceeds 5 mEq/L, significant confusion is evident, or the projected duration for reducing the lithium concentration below 1 mEq/L extends beyond 36 hours. Continue extracorporeal treatment until clinical improvement or lithium concentration drops below 1 mEq/L. In cases where lithium concentration measurement is unattainable, maintain extracorporeal therapies for at least 6 hours. Hemodialysis is the preferred extracorporeal treatment option, although continuous renal replacement therapy is also acceptable.[32] Please see the StatPearls' companion topic "Lithium Toxicity" for an in-depth discussion regarding the toxic effects of Lithium.

Although psychiatrists typically initiate lithium prescriptions, primary care providers, mental health nurses, pharmacists, and internists collaborate as an interprofessional healthcare team to monitor drug levels. Lithium continues to be a first-line treatment option for mood stabilization in individuals. Pharmacists are critical in conducting medication reconciliation, assessing drug interactions, and emphasizing the significance of consistent adherence to lithium therapy to caregivers, thus improving compliance. Mental health nurses should maintain vigilance for signs and symptoms of lithium toxicity and promptly communicate these findings to the prescriber. Due to its narrow therapeutic index and the potential for adverse effects and toxicity, interprofessional team members must collaborate to manage lithium therapy in patients, thereby ensuring coordinated care.[33] In cases of lithium poisoning, it is advisable to contact toxicologists or poison control centers to obtain the latest information. A psychiatrist consultation is essential if an overdose is suspected to be intentional. A nephrologist consultation is necessary to initiate hemodialysis in case of severe poisoning. In addition, an interprofessional team approach coupled with open communication among physicians, specialists, advanced practice practitioners, pharmacists, nurses, and toxicologists is indispensable for enhancing patient outcomes associated with lithium therapy and mitigating the likelihood of toxicity.