88
(ACEI) Angiotensin Receptor Blockers (ARBs)
Lithium Management
Up to fourfold increase in lithium level.
Most likely to cause lithium toxicity within a month of starting.
the elderly
Consider alternative anti-hypertensive
If combination necessary, increased monitoring of lithium level and renal function required.
Lithium Therapy: a national patient safety and quality N: improvement initiative Non- Steroidal
Diclofenac: up to 23% increase in lithium level From 10% to Ibuprofen: up to 25% increase in Antimore than lithium level inflammatories four-fold Patients should be advised Product: Formulation: Recommended Lithium levelto avoid (NSAIDs) increase in OTC NSAIDs and use Paracetamol if dosing: sampling time: lithium level. OTC analgesic required. Lithium Carbonate. Once daily: 12 hours post-dose Priadel Tablets: at night-time 200mg+400mg Unpredictable Thiazides Thiazide diuretics should only be used T: 400mg tablet contains (acceptable 10-14 hours) reduce renal where unavoidable and with strict Thiazide 10.8mmol/L Lithium. (Prolonged Release) (200mg tablet may be halved to clearance of monitoring Up to fourDiuretics facilitate 100mg dose ) lithium and fold increase levels can rise in lithium Loop diuretics may be safer. Once daily: 12ishours post-dose Camcolit tablet EMP level. Lithium Carbonatewithin a few Furosemide probably the safest at night-time diuretic to use with lithium but days 400mg (acceptable 10-14 hours) Usually frequent monitoring required. (Prolonged Release) EMP: Exempt Medicinal Product apparent in the
Priadel Liquid EMP Written by Audrey Purcell B(Sc) Pharm. MPSI. MSc. Psych Pharm. Chief 2 Pharmacist, Saint John of God Hospital, Stillorgan, Co Dublin.
Sodium
Honorary Senior Clinical Lecturer,
Switching lithium products: Royal College of Surgeons in Ireland.
Variable: a few days to several months.
first 10 days Twice daily: Pre-morning dose Any effect will morning and night be apparent in 520mg/5ml : equivalent the first month. to Lithium Carbonate (Immediate Release) Excess Sodium Consider high Sodium content OTC 204mg/5ml can reduce preparations and recommend suitable lithium levels alternatives (calculate as 200mg/5ml)
Lithium Citrate
520mg/5ml
S:
Unpredictable
Sodium Care with Sodium content in restriction can effervescent formulation lead to lithium Priadel tablets are recommended for routine use. The tabletstoxicity. have score- lines therefore they can be divided Pharmacy NHS Lithium Citrate Twice daily: Refer to SPS Pre-morning dose Li-Liquid EMP 509mg/5ml “Considering Sodium content of accurately to provide smaller dosage requirements. If a patient is unable to swallow tablets a liquid may be morning and night medicines”; particular care with 509mg/ml:by equivalent to prescribed. It is essential that a switch from tablets to liquid is prescribed their Doctor, and calculation confirmed products > 17mmol Sodium in 1. BACKGROUND AND Lithium Carbonate (Immediate Release) maximum daily dose CLINICAL INFORMATION: by Pharmacist. 200mg/5ml https://www.sps.nhs.uk/articles/consi Lithium Indications: dering-sodium-content-of-medicines/ 200mg/5ml) Example: Switching patient from Priadel tablet (Carbonate) 800mg(calculate nocte toasPriadel liquid (Citrate) = 400mg (10ml) • Bipolar Disorder: mania, hypomania prophylaxis Example: Sodium Bicarbonate in antacids BD morning and and night. Lithium of level to be checked 5-7 days post- switch. Bipolar Disorder (Gaviscon); recommend Maalox instead.
• Recurrent Depressive Baseline work-up: Disorder: used to augment antidepressants
Example: patient from concomitant • Serum Creatinine+/-estimated Prescribing: •• Reduction ECG : if of cardiac history, forSwitching QTc prolongation, medicines that prolong QTc intentional self- risk factors Priadel tablet (Carbonate) 800mg Glomerular Filtration Rate (eGFR) harm and suicidality. • Weight and height Starting dose may usually range nocte to Priadel liquid (Citrate) = • Adjusted Calcium Switching lithium products: from 400mg-800mg OD (nocte) in 400mg (10ml) BD morning and • Urea and Electrolytes adults, depending on indication. night. Lithium level to be checked Priadel tablets are recommended • Thyroid Function Tests (TFTs): •for routine Serumuse. Creatinine+/-estimated Glomerular Filtration Rate (eGFR) Elderly patients, those with renal 5-7 days postswitch. The tablets have include Free T4 and Thyroid impairment or those below 50kg lines therefore they can •scoreAdjusted Calcium Baseline work-up: Stimulating Hormone (TSH). in weight, often require lower be divided accurately to provide Patient should be euthyroid starting •smaller Thyroid Function Tests (TFTs): include Free T4 and Thyroid Stimulating Hormone (TSH).Patient should dose be (eg 200mg), and • ECG : if cardiac history, risk dosage requirements. If a before initiation maintenance doses. factors for QTc prolongation, patient is unable to swallow tablets euthyroid before initiation concomitant medicines that a liquid may be prescribed. It is • Full Blood Count Plasma levels: •essential Full Blood Countfrom tablets prolong QTc that a switch • Pregnancy test and review of to liquid is prescribed by their • Pregnancy test and review of •contraception (in women of childbearing age). Weight and height Lithium plasma level should be contraception (in women of Doctor, and calculation confirmed by Pharmacist.
• Urea and Electrolytes
childbearing age).
checked 5-7 days after starting, after every dose change, and after addition/discontinuation of medication that can affect level. Target levels:
The minimum effective plasma level for prophylaxis in adults is 0.4mmol/L; optimal range is 0.60.8 mmol/L. A level of 0.4mmol/L may be effective in unipolar depression; 0.6 -1 mmol/L in Bipolar Disorder, and levels at the higher end of the range in mania (0.8-1mmol/L).
PHARMACYNEWSIRELAND.COM
Prescribing:
