Lithium intoxication and its implications, pertaining to a clinical case

A Quintão,H Simião

doi:10.1192/j.eurpsy.2021.1659

Abstract

IntroductionLithium is the most effective maintenance drug in Bipolar Disorder (BD), although it has a narrow therapeutic index, between 0.6 and 1.5 mEq/L; recommended doses for maintenance are 0.6-1.2 mEq/L.ObjectivesTo describe a clinical case of lithium intoxication and discuss relevant literature.MethodsClinical examination of a patient and her medical records; non-systematic PubMed review on “lithium intoxication”.ResultsA 73-year-old woman, diagnosed with BD, stabilized on lithium monotherapy for twenty-five years, was admitted to the Emergency Room (ER) with nausea, lethargy, drowsiness, confusion, cough, and fever. A respiratory tract infection is diagnosed, based on clinical presentation, x-ray and blood analysis. Blood tests also revealed a serum lithium concentration of 2.4 mEq/L and impairment of renal function, indicating lithium intoxication; hemodialysis was initiated, with lithium discontinuation. Over weeks, renal function and general state improved, and BD treatment was reinitiated, this time with valproic acid 800mg/day. Two weeks after discharge, she was admitted again at the ER, for an episode starting in the week prior, compatible with a manic episode; olanzapine 10mg was added to the prescription. A week after, the patient is admitted again in the ER, still in a manic episode.ConclusionsThere are no clear indications in the literature about reinitiating lithium on someone who had an intoxication. Given that lithium brings an unparalelled quality of life to BD patients, careful consideration about reintroduction, with close monitoring, should be made, but there is a critical need of more studies and guidelines to orient clinical practice.DisclosureNo significant relationships.

Highlights

Bipolar disorder, especially Bipolar II subtype, is a mental disorder that has one of the greatest risk of completed suicide (CS)
Determine the rate and the risk factors of CS in a cohort of Bipolar II patients followed after their first hospitalization Methods: We choose all Bipolar II patients (DSM-IV) who were hospitalized for first time in our Psychiatric unit between 1996 and 2016
We reviewed the charts of first hospitalization and recorded multiple baseline variables

Summary

Introduction

Bipolar Disorder (BD) is a severe recurrent disorder with a complex biogenetic and psychosocial etiology. The immune system cytokines in interaction with the CNS play a role in the pathophysiology. Objectives: To compare inflammatory cytokines between BD patients and controls during the manic episode; compare these cytokines with psychiatric symptoms and cognitive performance during follow-up. Methods: We recruited 25 BD patients in mania with paired controls. We measured baseline IL-2, IL-4, IL-8, IL-10, GM-CSG, TNF- α, and TNF- γ in plasma. We used U-Mann-Whitney for group comparison and Spearman correlation between sub-group follow-up assessments and cytokines. Results: We found a significant difference in IL-6 between subjects and controls (figure 1). During the follow-up, we found a correlation with psychiatric symptoms, cognition, and cytokines during manic episodes (Table 1). Follow-up Correlation with cytokines during a manic episode

Findings