LITHIUM- Question Series (Check Your Basics)

**Admin** Thu Dec 15, 2011 2:00 am

LITHIUM- Question Series

This thread is dedicated to questions related to LITHIUM:

I would encourage all members on this Forum, Facebook & Twitter to participate.
This thread will cover all clinical and PRITE related facts on LITHIUM.

Thanks
Admin

**Answers with Explanation will be posted after member's have submitted there answers **
Banana3

LITHIUM- Question Series (Check Your Basics) Lithiu10

**Admin** Thu Dec 15, 2011 2:05 am

LITHIUM- Question Series (Check Your Basics) Pccc_q10

Which of the following statement is FALSE regarding LITHIUM:

(a) Lithium directly inhibits Glycogen Synthase Kinase 3B & Inositol monophosphate Phosphatase
(b) Lithium use in bipolar disorder can result in increase cortical gray matter & Hippocampal Volume.
(c) It takes at least 4-5 days for serum lithium levels to reach steady state after the dose is changed
(d) Food alters the Lithium absorption.
(e) Once daily lithium level of 1.0 meq/L is expected to drop to a level of 0.8 meq/L if the patient switches to a divided dose regimen

**Admin** Thu Dec 15, 2011 2:23 am

LITHIUM- Question Series (Check Your Basics) Pccc_q11

Which of the following condition is not a contraindication for Lithium use?

(a) Dehydration
(b) Psoriasis
(c) Significant renal impairment
(d) Sodium Depletion
(e) Significant cardiovascular disease
(f) All are contraindication for Lithium use
(g) None of them are contraindication for Lithium use

**Admin** Thu Dec 15, 2011 3:09 am

LITHIUM- Question Series (Check Your Basics) Pccc_q12

Select the FALSE statement regarding "Lithium levels"

(a) Levels ≥ 2.5 mEq/L constitute a medical emergency, even in patients who appear relatively asymptomatic.
(b) Thiazide diuretics increases, and potassium sparing diuretics decreases Lithium levels
(c) Concomitant use of Metronidazole can lower Lithium levels
(d) Thyroid Function Tests should be monitored every 2-3 months during the first six months of Lithium therapy, and every 6 to 12 months thereafter

**Admin** Fri Dec 16, 2011 3:07 am

LITHIUM- Question Series (Check Your Basics) Pccc_q13

Which of the following statement is incorrect regarding "Lithium Side Effects"?

(a) Clinicians should consult a nephrologist and discontinue lithium when the serum creatinine approaches or exceeds 1.6 mg/dL.
(b) Neither pretreatment hypothyroidism nor lithium-induced hypothyroidism is a contraindication to lithium therapy.
(c) ECG is recommended in patients > 40 yr age
(d) All the statements are correct
(e) All the statements are wrong

drrodrick Tue Dec 27, 2011 5:08 am

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USMLE

P450 Sun Jan 22, 2012 7:25 pm

I'll take a crack at these:

Q1: Which of the following statement is FALSE regarding LITHIUM:

(a) Lithium directly inhibits Glycogen Synthase Kinase 3B & Inositol monophosphate Phosphatase
(b) Lithium use in bipolar disorder can result in increase cortical gray matter & Hippocampal Volume.
(c) It takes at least 4-5 days for serum lithium levels to reach steady state after the dose is changed
(d) Food alters the Lithium absorption.
(e) Once daily lithium level of 1.0 meq/L is expected to drop to a level of 0.8 meq/L if the patient switches to a divided dose regimen

B: False --> I don't know of any data showing increase in brain volume

Q2: Which of the following condition is not a contraindication for Lithium use?

(a) Dehydration
(b) Psoriasis
(c) Significant renal impairment
(d) Sodium Depletion
(e) Significant cardiovascular disease
(f) All are contraindication for Lithium use
(g) None of them are contraindication for Lithium use

G: None --> Maybe a relative contraindication for a couple of these.

Q3: Select the FALSE statement regarding "Lithium levels"

(a) Levels ≥ 2.5 mEq/L constitute a medical emergency, even in patients who appear relatively asymptomatic.
(b) Thiazide diuretics increases, and potassium sparing diuretics decreases Lithium levels
(c) Concomitant use of Metronidazole can lower Lithium levels
(d) Thyroid Function Tests should be monitored every 2-3 months during the first six months of Lithium therapy, and every 6 to 12 months thereafter

C: Don't recall metronidazole having any effect on GFR or absorption.

Q4:Which of the following statement is incorrect regarding "Lithium Side Effects"?

(a) Clinicians should consult a nephrologist and discontinue lithium when the serum creatinine approaches or exceeds 1.6 mg/dL.
(b) Neither pretreatment hypothyroidism nor lithium-induced hypothyroidism is a contraindication to lithium therapy.
(c) ECG is recommended in patients > 40 yr age
(d) All the statements are correct
(e) All the statements are wrong

A: You can simply lower the dose of lithium and of course monitor Li levels. The increase in Cr may have nothing to do with the lithium.

**Admin** Sun Jan 22, 2012 7:58 pm

Admin wrote:
Which of the following statement is FALSE regarding LITHIUM:

(a) Lithium directly inhibits Glycogen Synthase Kinase 3B & Inositol monophosphate Phosphatase
(b) Lithium use in bipolar disorder can result in increase cortical gray matter & Hippocampal Volume.
(c) It takes at least 4-5 days for serum lithium levels to reach steady state after the dose is changed
(d) Food alters the Lithium absorption.
(e) Once daily lithium level of 1.0 meq/L is expected to drop to a level of 0.8 meq/L if the patient switches to a divided dose regimen

Answer: C.
- Lithium is rapidly absorbed through the gastrointestinal tract; food does not alter lithium absorption.
(Source: UpToDate)

- Lithium directly inhibits Glycogen Synthase Kinase 3B & Inositol monophosphate Phosphatase
(Source: http://ajp.psychiatryonline.org/article.aspx?articleID=173733)

- Lithium also appears to increase neurogenesis and neuroprotective factors, and in patients with bipolar disorder, increase cortical gray matter and hippocampal volume.
(Source: Molecular actions and therapeutic potential of lithium in preclinical and clinical studies of CNS disorders.Pharmacol Ther. 2010;128(2):281.)
(Source: In search of the Holy Grail for the treatment of neurodegenerative disorders: has a simple cation been overlooked? Biol Psychiatry. 2007;62(1):4.)

- When lithium is taken once per day, serum levels are approximately 25 percent higher compared with levels when lithium is taken two or three times per day, due to changes in renal excretion. Therefore, a once daily lithium level of 1.0 meq/L is expected to drop to a level of 0.8 meq/L if the patient switches to a divided dose regimen. Virtually all studies examining optimal lithium levels have used divided dose regimens.
(Source: UpToDate)

Admin wrote:
Which of the following condition is not a contraindication for Lithium use?

(a) Dehydration
(b) Psoriasis
(c) Significant renal impairment
(d) Sodium Depletion
(e) Significant cardiovascular disease
(f) All are contraindication for Lithium use
(g) None of them are contraindication for Lithium use

Answer: F. All are contraindication for Lithium use

Contraindications —
- Significant renal impairment
- Sodium depletion
- Dehydration
- Significant cardiovascular disease (lithium can rarely cause sinus node dysfunction- eg, sinus bradycardia and sinoatrial block; atrioventricular node dissociation with atrioventricular block and junctional rhythms; and ventricular premature beats).
- Psoriasis, which lithium exacerbates, is a relative contraindication.

(Source: UpToDate)

Admin wrote:
Select the FALSE statement regarding "Lithium levels"

(a) Levels ≥ 2.5 mEq/L constitute a medical emergency, even in patients who appear relatively asymptomatic.
(b) Thiazide diuretics increases, and potassium sparing diuretics decreases Lithium levels
(c) Concomitant use of Metronidazole can lower Lithium levels
(d) Thyroid Function Tests should be monitored every 2-3 months during the first six months of Lithium therapy, and every 6 to 12 months thereafter

Answer: C.

- Concomitant use of Metronidazole can INCREASE Lithium levels

- Lithium toxicity is a clinical diagnosis that is confirmed by serum lithium levels.
Relatively mild toxicity usually does not occur until serum lithium reaches a level of 1.5 mEq/L (1.5 mmol/L).
Levels ≥ 2.5 mEq/L (2.5 mmol/L) constitute a medical emergency, even in patients who appear relatively asymptomatic.
The likelihood of lithium intoxication is increased when lithium excretion is impaired. This most commonly occurs with:
> Underlying renal insufficiency
> Effective volume depletion
> Elderly patients (low glomerular filtration rate)
(Source: UpToDate)

- Medications that Increases lithium level
> Thiazide diuretics
> Nonsteroidal antiinflammatory drugs (NSAIDS) except aspirin
> Angiotensin converting enzyme (ACE) inhibitors
> Antibiotics tetracyclines and metronidazole

- Medications that Decreases lithium level
> Potassium-sparing diuretics
> Theophylline
(Source: UpToDate)

Admin wrote:
Which of the following statement is incorrect regarding "Lithium Side Effects"?

(a) Clinicians should consult a nephrologist and discontinue lithium when the serum creatinine approaches or exceeds 1.6 mg/dL.
(b) Neither pretreatment hypothyroidism nor lithium-induced hypothyroidism is a contraindication to lithium therapy.
(c) ECG is recommended in patients > 40 yr age
(d) All the statements are correct
(e) All the statements are wrong

Even I thought answer is A.
But correct answer= (d) All the statements are correct

- Lithium has a deleterious effect on renal tubular function. Initially, lithium reduces the ability of the kidney to concentrate urine, leading to dilute urine and polyuria (nephrogenic diabetes insipidus). Over months and years, this functional deficit becomes structural. Biopsy specimens from patients chronically treated with lithium show interstitial fibrosis that is consistent with chronic interstitial nephritis in more severe cases. If patients drink enough when they are thirsty, this is not dangerous. However, this process can lead to increased serum creatinine and, rarely, to progressive renal failure. Thus, monitoring renal function by serial serum creatinine is an essential part of ongoing lithium therapy. Clinicians should consult a nephrologist and discontinue lithium when the serum creatinine approaches or exceeds 1.6 mg/dL (140 mmol/L). The most important risk factor for renal damage from lithium is repeated episodes of lithium intoxication.
(Source: UpToDate)

- Lithium interferes with function of the thyroid gland and can cause goiter, hypothyroidism, chronic autoimmune thyroiditis, and possibly hyperthyroidism. Neither pretreatment hypothyroidism (presumably treated adequately with T4) nor lithium-induced hypothyroidism is a contraindication to lithium therapy. Reasonable recommendations are to monitor serum TSH and if it rises much above the upper value of normal, to start T4 while continuing the lithium.
(Source: UpToDate)

Thanks again for participating P450.
Regards

P450 Sun Jan 22, 2012 9:05 pm

Good to know! Thanks Harvinder.

**Admin** Sun Jan 22, 2012 9:14 pm

Thanks buddy Smile

Do try rest of the questions from Psychopharmacology thread:
https://psychiatry.forumotion.com/t197-psychopharmacology-discussion-thread

I like this discussion.

adisuper Mon Oct 15, 2012 12:56 pm

in question 3 option b it's written that potassium sparing diuretics decrease lithium levels but as per ctp table 31.19-4 they could possibly increase lithium level by causing lithium retention. Which one is correct...

**Admin** Mon Oct 15, 2012 9:01 pm

Hi Adisuper.
This is confusing for me too.

Check the following information from UpToDate:

LITHIUM- Question Series (Check Your Basics) Lithiu11

Source used by UpToDate:
Labbate, LA, Fava, M, Rosenbaum, JF, et al. Drugs for treatment of bipolar disorders. In: Handbook of Psychiatric Drug Therapy, 6th ed, Lippincott Williams & Wilkins, Philadelphia 2010. p.110.

Can anyone Explain the mechanism of interaction between Lithium and Diuretics.

adisuper Tue Oct 16, 2012 9:24 am

Documentation Level:
Limited - Few reports of this interaction exist. These few reports usually consist of limited case reports where clinically sound justification of the interaction is found.
Probable Mechanism:
Generally, diuretics may reduce lithium clearance, resulting in increased lithium levels and possible toxicity. Spironolactone has been reported to increase lithium levels in one report
This is as per MIMS website which quotes following references
Reference:
MedicinesComplete: Sweetman S (ed). Spironolactone: Martindale: The Complete Drug Reference. RPS Publishing, London, UK, Available from URL: http://www.medicinescomplete.com/mc [Accessed on 22/07/2010]
MedicinesComplete: Baxter K (ed). Lithium + Diuretics; Potassium-sparing: Stockleys Drug Interactions. RPS Publishing, London, UK, Available from URL: http://www.medicinescomplete.com/mc [Accessed on 22/07/2010]

Loop diuretics e.g. Furosemide (frusemide), bumetanide, and Potassium Sparing Diuretics e.g.
amiloride, spironolatone are safer than thiazide diuretics but not without risks of Lithium toxicity
References
BNF No 48 September 2004
Psychotropic Drug Directory 2003/04. Stephen Bazire.

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