29.19 Lithium
985
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,
Table 29.19-2
Nonpsychiatric Uses of Lithium
a
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)
Movement disorders
Huntington’s disease
l
-Dopa–induced hyperkinesias
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
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.
Table 29.19-3
Adverse Effects of Lithium
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
GFR, glomerular filtration rate.
