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Lithium Toxicity

Lithium Toxicity. Robert Nashat, Pharm.D, CDE Medical Place Pharmacy 20 Emma St, Chatham, On. Roadmap . Lithium Background Pharmokinetics of Lithium Lithium Toxicity Lithium Side-effects Acute and Long Term Lithium Toxicity Factors leading to Toxicity Drug Interactions

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Lithium Toxicity

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  1. Lithium Toxicity Robert Nashat, Pharm.D, CDE Medical Place Pharmacy 20 Emma St, Chatham, On

  2. Roadmap • Lithium Background • Pharmokinetics of Lithium • Lithium Toxicity • Lithium Side-effects • Acute and Long Term • Lithium Toxicity • Factors leading to Toxicity • Drug Interactions • Treating Lithium Toxicity • Case • Conclusion

  3. Background on Lithium • Has been used since the 1870s. • Initially used to gout • Also used in the treatment of symptoms associated with depression independent of gout. • Fell out of favor because of side effects. • Banned by FDA in 1940s because of fatalities John Cade

  4. Lithium • Considered Standard of Therapy For Bipolar Disease

  5. Lithium Pharmokinetics • Taken Orally ( Liquid and Capsule) • Absorption • Complete Absorption from the GI Tract • 2-4 Hours Post-ingestion • Long Half-life • 12-27 Hours • Elimination • Excreted from the Kidney but undergoes a lot of reabsorption (80%) • Works very similar to Sodium in the body and is linked to sodium concentrations. • Levels between 0.6-1.2 meq/L • Narrow Therapeutic Index

  6. Lithium Toxicity Severe Toxicity- Seizures, loss of consciousness, coma, death Mild Toxicity- Nausea, vomiting, Tremor, Slurred Speech, Confusion We have to be very careful of Drug Interactions and other Influencing factors ( Salt Intake, Caffeine, Hydration Status)

  7. Factors Predisposing To Lithium Toxicity • Renal failure • Volume depletion • CHF • Caffeine Intake • Decreased Na intake • Dehydration

  8. Drug Interactions and Lithium Levels • ACE Inhibitors/ARB • Increase lithium levels • Diuretics • Especially HCTZ, triamterene, spironolactone • Caffeine • NSAIDs • Advil, Aleve • Increase lithium levels • Serotonergic agents

  9. Drug Interactions and Lithium Levels • ACE Inhibitors/ARB • Increase lithium levels • Diuretics • Especially HCTZ, Lasix • Caffeine • NSAIDs • Advil, Aleve • Increase lithium levels • Serotonergic agents

  10. Diuretics and the Kidney Direutics Increase

  11. Lithium Toxicity(chronic Ingestion)

  12. What Else Should Be Done? • Consult Renal Service • Consult psychiatric Service • Consult poison control/toxicology service

  13. Lithium Side Effects • Long Term Side Effects • Hypothyroidism • Cardiac Effects • Weight Gain • Leukocytosis • Dermatological Effects • Acne, Psoriasis • Acute effects • Nausea, Diarrhea • Lethargy • Impaired Cognitive Functioning • Hand Tremor

  14. Putting It All Together- Case 1 • The Patient Mr. X 53 years old Presented to the ER with • Loose Stools from the last 2 days • Nausea • Loss of Energy • Fatigue Known Patient of Bipolar Disorder and under treatment by Psychiatry Care. Patient is on Lithium Carbonate

  15. Examination • Pulse: 108 • Bp 100/70 • Dehydrated • CNS: Irritable, Confused, Mild Tremor, Ataxia • CVS: Tachycardia • Lithium Levels: 3.17 mmol/L ( Ref:0.50-1.2 mmol/L)

  16. Diagnosis

  17. Management • Admit in ward • I/V Fluids • Stop the Lithium • Supportive Care • Lithium repeated after 4 days is 0.68 mmol/L • Discharged via psychiatry after one week.

  18. Conclusion • Important to be educated about the side effects of Lithium. • Mortality rate • Approximately 25 percent with an acute overdose • 9 percent in patients intoxicated during maintenance therapy. • Presentation is available on our website • www.medicalplacepharmacy.com • Online Medication Reconciliation Program Available

  19. Questions? Thank you

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