Kaplan + Sadock's Synopsis of Psychiatry, 11e

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29.19 Lithium

Table 29.19-2 Nonpsychiatric Uses of Lithium a

from its effects on mood. Aggressive outbursts in persons with schizophrenia, violent prison inmates, and children with con- duct disorder and aggression, or self-mutilation in persons with mental retardation can sometimes be controlled with lithium. Precautions and Adverse Effects More than 80 percent of patients taking lithium experience side effects. It is important to minimize the risk of adverse events through monitoring of lithium blood levels and to use appro- priate pharmacological interventions to counteract unwanted effects when they occur. The most common adverse effects are summarized in Table 29.19-3. Patient education can play an important role in reducing the incidence and severity of side effects. Patients taking lithium should be advised that changes in the body’s water and salt content can affect the amount of lith- ium excreted, resulting in either increases or decreases in lith- ium concentrations. Excessive sodium intake (e.g., a dramatic dietary change) lowers lithium concentrations. Conversely, too little sodium (e.g., fad diets) can lead to potentially toxic con- centrations of lithium. Decreases in body fluid (e.g., excessive perspiration) can lead to dehydration and lithium intoxication. Patients should report whenever medications are prescribed by another clinician because many commonly used agents can affect lithium concentrations. Cardiac Effects Lithium can cause diffuse slowing, widening of frequency spectrum, and potentiation and disorganization of background rhythm on electrocardiography (ECG). Bradycardia and cardiac arrhythmias may occur, especially in people with cardiovascu- lar disease. Lithium infrequently reveals Brugada syndrome, Neurological Benign, nontoxic: dysphoria, lack of spontaneity, slowed reaction time, memory difficulties Tremor: postural, occasional extrapyramidal Toxic: coarse tremor, dysarthria, ataxia, neuromuscular irritability, seizures, coma, death Miscellaneous: peripheral neuropathy, benign intracranial hypertension, myasthenia gravis–like syndrome, altered creativity, lowered seizure threshold Endocrine Thyroid: goiter, hypothyroidism, exophthalmos, hyperthyroidism (rare) Parathyroid: hyperparathyroidism, adenoma Cardiovascular Benign T-wave changes, sinus node dysfunction Renal Concentrating defect, morphologic changes, polyuria (nephrogenic diabetes insipidus), reduced GFR, nephrotic syndrome, renal tubular acidosis Dermatological Acne, hair loss, psoriasis, rash Gastrointestinal Appetite loss, nausea, vomiting, diarrhea Miscellaneous Altered carbohydrate metabolism, weight gain, fluid retention Table 29.19-3 Adverse Effects of Lithium

Historical Gout and other uric acid diatheses Lithium bromide as anticonvulsant Neurological Epilepsy Headache (chronic cluster, hypnic, migraine, particularly cyclic) Ménière’s disease (not supported by controlled studies) On–off phenomenon in Parkinson’s disease (controlled study found decreased akinesia but development of dyskinesia in a few cases) Spasmodic torticollis Tardive dyskinesia (not supported by controlled studies, and pseudoparkinsonism has been reported) Tourette’s disorder Pain (facial pain syndrome, painful shoulder syndrome, fibromyalgia) Periodic paralysis (hypokalemic and hypermagnesic but not hyperkalemic) Hematological Aplastic anemia Cancer—chemotherapy induced, radiotherapy induced Neutropenia (one study found increased risk of sudden death in patients with pre-existing cardiovascular disorder) Drug-induced neutropenia (e.g., from carbamazepine, antipsychotics, immunosuppressives, and zidovudine) Felty’s syndrome Leukemia Endocrine Thyroid cancer as an adjunct to radioactive iodine Thyrotoxicosis Syndrome of inappropriate antidiuretic hormone secretion Cardiovascular Antiarrhythmic agent (animal data only) Dermatological Genital herpes (controlled studies support topical and oral use) Eczematoid dermatitis Seborrheic dermatitis (controlled study supports) Gastrointestinal Cyclic vomiting Gastric ulcers Movement disorders Huntington’s disease l -Dopa–induced hyperkinesias

Pancreatic cholera Ulcerative colitis

Respiratory Asthma (controlled study did not support) Cystic fibrosis Other Bovine spastic paresis

a All the uses listed here are experimental and do not have Food and Drug Administration(FDA)–approved labeling. There are conflicting reports about many of these uses—some have negative findings in controlled studies, and a few involve reports of possible adverse effects. l -Dopa, levodopa.

GFR, glomerular filtration rate.