Lithium side effects and toxicity: prevalence and management strategies

Despite its virtually universal acceptance as the gold standard in treating bipolar disorder, prescription rates for lithium have been decreasing recently. Although this observation is multifactorial, one obvious potential contributor is the side effect and toxicity burden associated with lithium. Additionally, side effect concerns assuredly play some role in lithium nonadherence. This paper summarizes the knowledge base on side effects and toxicity and suggests optimal management of these problems. Thirst and excessive urination, nausea and diarrhea and tremor are rather common side effects that are typically no more than annoying even though they are rather prevalent. A simple set of management strategies that involve the timing of the lithium dose, minimizing lithium levels within the therapeutic range and, in some situations, the prescription of side effect antidotes will minimize the side effect burden for patients. In contrast, weight gain and cognitive impairment from lithium tend to be more distressing to patients, more difficult to manage and more likely to be associated with lithium nonadherence. Lithium has adverse effects on the kidneys, thyroid gland and parathyroid glands, necessitating monitoring of these organ functions through periodic blood tests. In most cases, lithium-associated renal effects are relatively mild. A small but measurable percentage of lithium-treated patients will show progressive renal impairment. Infrequently, lithium will need to be discontinued because of the progressive renal insufficiency. Lithium-induced hypothyroidism is relatively common but easily diagnosed and treated. Hyperparathyroidism from lithium is a relatively more recently recognized phenomenon

Sudomotor dysfunction is associated with foot ulceration in diabetes

To examine the relationship between sudomotor dysfunction and foot ulceration (FU) in patients with diabetes. Ninety patients with either Type 1 or Type 2 diabetes [30 without peripheral sensorimotor neuropathy (PN), 30 with PN but without FU and 30 with FU] were recruited in this cross-sectional study. Assessment of PN was based on neuropathy symptom score (NSS), neuropathy disability score (NDS) and vibration perception threshold (VPT). Sudomotor dysfunction was assessed using the sympathetic skin response (SSR). Cardiac autonomic nervous system activity was assessed by the battery of the classical autonomic function tests. Patients with foot ulcers had longer duration of diabetes, higher values of VPT and NDS and lower values of the autonomic functions tests in comparison with the other study groups. Sudomotor dysfunction and cardiac autonomic neuropathy were significantly more common in the FU group. Multivariate logistic regression analysis after adjustment for gender, body mass index, duration of diabetes and glycated haemoglobin (HbA(1c)) demonstrated that the odds ratio (95% confidence intervals) of FU increased with measures of neuropathy such as NDS >= 6 (10.2, 6.2-17.3) and VPT >= 25 volts (19.8, 9.9-47.5), but was also significantly increased with absent SSR (15.3, 5.3-38.4). Sudomotor dysfunction is associated with increased risk of FU and should be included in the screening tests for identification of diabetic patients at risk of ulceration

Pharmacological treatment and risk of psychiatric hospital admission in bipolar disorder

Background Clinical trials have examined the efficacy of drugs to prevent relapse in patients with bipolar disorder, however their design often limits generalization to routine clinical practice. Aims To estimate the effectiveness of drugs used for maintenance treatment in bipolar disorder. Methods We used national registers to identify 35,022 individuals diagnosed with bipolar disorder and information on lithium, valproate, carbamazepine, lamotrigine, quetiapine, and olanzapine treatment from 2006-2009. The main outcome was psychiatric hospitalizations. We used stratified cox regression to compare periods on and off medication within the same individual. Results Medication with lithium, valproate, lamotrigine, olanzapine, and quetiapine was associated with reduced the rates of hospitalization. Lithium was more effective than quetiapine and olanzapine. The effects of specific drugs depended on the polarity of the mood episode. Conclusions Our findings complement results from RCTs, but suggest that lithium is more effective than both quetiapine and olanzapine in routine clinical practice. </p

Pharmacological treatment and risk of psychiatric hospital admission in bipolar disorder

Background Clinical trials have examined the efficacy of drugs to prevent relapse in patients with bipolar disorder, however their design often limits generalization to routine clinical practice. Aims To estimate the effectiveness of drugs used for maintenance treatment in bipolar disorder. Methods We used national registers to identify 35,022 individuals diagnosed with bipolar disorder and information on lithium, valproate, carbamazepine, lamotrigine, quetiapine, and olanzapine treatment from 2006-2009. The main outcome was psychiatric hospitalizations. We used stratified cox regression to compare periods on and off medication within the same individual. Results Medication with lithium, valproate, lamotrigine, olanzapine, and quetiapine was associated with reduced the rates of hospitalization. Lithium was more effective than quetiapine and olanzapine. The effects of specific drugs depended on the polarity of the mood episode. Conclusions Our findings complement results from RCTs, but suggest that lithium is more effective than both quetiapine and olanzapine in routine clinical practice. </p

Visual Hallucinations in a Patient with Adult Onset Acid Maltase Deficiency Disorder

A 66-year-old male presented with visual hallucinations. He had chronically elevated serum creatine kinase (CK) levels without muscle weakness. His hospital course was complicated by hypercapnic respiratory failure requiring mechanical ventilation. His hallucinations completely subsided on mechanical ventilation. Elevated CK levels prompted a muscle biopsy, which showed myopathy consistent with acid maltase deficiency disorder (AMDD). This is the first reported case of adult onset AMDD presenting with psychiatric symptoms. Our objective in reporting this case is to encourage early recognition of neuromuscular respiratory failure in AMDD and to reinforce that respiratory failure may develop without associated extremity muscle weakness