Blood Lithium Levels Research Articles

Obstetric Outcomes in Women on Lithium: A Systematic Review and Meta-Analysis.

Background/Objectives: Lithium taken during pregnancy was linked in the past with increased risk for foetal/newborn malformations, but clinicians believe that it is worse for newborn children not to treat the mothers' underlying psychiatric illness. We set to review the available evidence of adverse foetal outcomes in women who received lithium treatment for some time during their pregnancy. Methods: We searched four databases and a register to seek papers reporting neonatal outcomes of women who took lithium during their pregnancy by using the appropriate terms. We adopted the PRISMA statement and used Delphi rounds among all the authors to assess eligibility and the Cochrane Risk-of-Bias tool to evaluate the RoB of the included studies. Results: We found 28 eligible studies, 10 of which met the criteria for inclusion in the meta-analysis. The studies regarded 1402 newborn babies and 2595 women exposed to lithium. Overall, the systematic review found slightly increased adverse pregnancy outcomes for women taking lithium for both the first trimester only and any time during pregnancy, while the meta-analysis found increased odds for cardiac or other malformations, preterm birth, and a large size for gestational age with lithium at any time during pregnancy. Conclusions: Women with BD planning a pregnancy should consider discontinuing lithium when euthymic; lithium use during the first trimester and at any time during pregnancy increases the odds for some adverse pregnancy outcomes. Once the pregnancy has started, there is no reason for discontinuing lithium; close foetal monitoring and regular blood lithium levels may obviate some disadvantages of lithium administration during pregnancy.

Rapid cycling bipolar disorder and atypical anorexia nervosa: changes in drug metabolism

IntroductionBipolar disorder (BD) is a complex mental illness described by recurrent episodes of mania and depression. One subtype of the illness is rapid cycling BD, characterized by experiencing four or more extreme mood swings within a year. Diagnosing and treating BD can be complicated by comorbid conditions, such as atypical anorexia nervosa (AAN), marked by disordered eating and disturbing weight-related thoughts.ObjectivesTo discuss the diagnosis and treatment plan of a patient with rapid cycling BD, who experienced adverse effects from prescribed medication and later was diagnosed with comorbid AAN.Methods We present a case of a 21 year-old man initially presenting with anxiety, low mood, and obsessive weight-related thoughts, ultimately diagnosed with major depression and mixed anxiety disorder.Results21 year-old man was diagnosed with major depression and mixed anxiety disorder, initially treated with mirtazapine and fluoxetine (limited success), later attempting escitalopram and bupropion combination (partial remission). After 2 years the patient discontinued the treatment due to feeling “euphoric”, subsequently experiencing depression and manic episodes – the initial diagnosis was rapid cycling BD. The treatment was changed to sodium valproate (up to 1500 mg/day) and aripiprazole (up to 10 mg/day), however extremely rare adverse medication effects (nosebleeds, diarrhea with blood admixture, “high-frequency sounds”) were reported. Throughout valproate treatment, the patient experienced persistent diarrhea. During hospitalization for treatment adjustment lithium carbonate was introduced at a starting dose of 900 mg/day, maintaining blood lithium levels between 0.4 mmol/l and 0.49 mmol/l. Later the dose was adjusted and a therapeutic lithium blood level was reached with 1575 mg/day of lithium carbonate. Additionally, risperidone was prescribed, however, the patient experienced an uncommon adverse reaction – nasal congestion. Subsequently, amisulpride was introduced, which provoked severe anxiety and fear, resulting in medication discontinuation. During the latest outpatient visit, fluoxetine was added to the treatment due to observed depressive symptoms. Throughout the treatment, the patient episodically intermittently starved, had persistent distressing thoughts about weight and was diagnosed with AAN. While planning further treatment it was hypothesized that comorbid AAN might affect drug metabolism and the patient was referred to a specialized inpatient facility for eating disorder management.ConclusionsThis case report highlights the complexity of psychiatric disorders and the importance of monitoring and adjusting treatment based on patient response and side effects. Additionally, it emphasizes comorbid conditions significance in influencing the primary disorder’s dynamics as well as the metabolism and effectiveness of psychiatric medications.Disclosure of InterestNone Declared

Lithium Intoxication with Therapeutic Doses Following Laparoscopic Sleeve Gastrectomy: A Case Report and Review of the Literature

Introduction Lithium is a mood stabilizer often used as a first-line treatment for bipolar disorder. Its narrow therapeutic window and changes in the absorption, distribution, and elimination of the drug following bariatric surgery have important implications regarding patient safety.ObjectivesWe present a 51-year-old female patient with bipolar disorder and a medical history of morbid obesity, type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and essential hypertension. She was mentally stable on lithium 1200 mg/day, valproate 500 mg/day, and quetiapine 400 mg/day. She had undergone laparoscopic sleeve gastrectomy. After a month, she showed up to the emergency room (ER) with nausea, vomiting, diarrhea, and fatigue. Gastroenteritis was suspected until the patient started showing neurological symptoms such as delirium, dysarthria, ataxia, chorea, and athetosis.MethodsThe patient was monitored and received aggressive intravenous hydration (3000 cc of 0.9% serum isotonic) in the intensive care unit (ICU). She was prescribed intramuscular biperiden injection of 5 mg/ml/day, pheniramine 45.5 mg/2 ml/day, and lorazepam 1 mg/day. Her lithium levels were checked every six hours. She was agitated and disoriented for the first five days despite lithium levels being in the therapeutic range. On day six, her blood lithium levels dropped to 0.399 mmol/L. Her psychiatric examination revealed that she resumed cooperation and orientation, her dysarthria subsided. However, her thought content and attitude were grandiose, and she had a labile affect. We prescribed 5 mg/day of olanzapine routinely and 1 mg/day of lorazepam on a needed basis. The next day, her labile affect became calmer, and her sleep improved so she was discharged from the ICU and admitted to general surgery inpatient service, and olanzapine was titrated to 10 mg per day since she had elevated mood symptoms.ResultsAfter 7 days of intravenous hydration and supportive treatment, her neurological symptoms completely subsided except for a fine tremor, which lasted for another 3 days and then ceased. She was clinically stabilized without further need for intervention. Her lithium level was 0.206 mmol/L before her discharge.Conclusions We believe it is of utmost importance to build a consensus in guidelines and inform physicians about lithium toxicity and its symptoms after bariatric surgeries. We recommend a careful follow-up of the patient pre-and postoperatively. Preoperative psychiatric intervention includes decreasing the lithium dose gradually and discontinuing it. After the operation, lithium can be started with a much lower dose and may be increased by checking lithium levels every week for at least 6 weeks after the operation until the patient can digest solid food again, and then every 2 weeks for 6 months, and thereafter every month for one year.Disclosure of InterestNone Declared

Management of Lithium Dosing Around Delivery: An Observational Study.

Recommendations on lithium dosing around delivery vary, with several guidelines suggesting that lithium should be discontinued prior to delivery. We aimed to evaluate the validity of these recommendations by investigating 1) maternal lithium blood level changes following delivery, and 2) the association between neonatal lithium blood levels at delivery and neonatal outcomes. In this retrospective observational cohort study, we included women with at least one lithium blood level measurement during the final week of pregnancy and the first postpartum week. For aim 2, we included a subcohort of women with neonates for whom neonatal lithium blood levels (obtained from the umbilical cord or a neonatal vein puncture within 24 hours of delivery) were available. There were a total of 233 maternal lithium blood level measurements; 55 (23.6%) in the week before delivery and 178 (76.4%) in the week after. There was no association between time and lithium blood level/dose ratio (Pearson correlation coefficient -0.03, P = .63). Additionally, we included a total of 29 neonates for whom a lithium measurement was performed within 24 hours postpartum. Maternal and neonatal lithium blood levels were strongly correlated. We observed no associations between neonatal lithium blood levels at delivery and neonatal outcomes. Based on our findings, we do not recommend lowering the dosage or discontinuation of lithium prior to delivery. Stable dosing can prevent subtherapeutic lithium serum levels, which is especially important in the postpartum period when relapse risks are highest.Appeared originally in Bipolar Disord 2021; 23:49-54.

Retrospective analysis of lithium treatment: examination of blood levels.

Lithium is a key medication for treating various neuropsychiatric disorders, with a narrow therapeutic index and significant drug interactions. Monitoring lithium blood levels is crucial. This study aims to investigate the relationship between lithium blood levels and demographic characteristics such as age and gender, as well as possible drug interactions, in patients with a history of lithium use who applied to various services and outpatient clinics. The files of 438 patients who were admitted to various services and outpatient clinics of Kırklareli Training and Research Hospital between January 1 and December 31, 2023, were retrospectively reviewed. Patients' blood lithium levels, gender, age, service/outpatient clinic they admitted to, other medications used, urea, creatinine, and eGFR values were recorded. When the demographic characteristics of 438 patients were examined, 62% were female (270), 38% were male (168), and the average age was 46.3 ± 14.8 years, showing a normal distribution. It was found that 192 patients (71 males, 121 females) had therapeutic lithium blood levels, while 244 patients (97 males, 147 females) had levels below 0.6 mmol/L. Two female patients had blood levels above the therapeutic range (1.23 and 1.43 mmol/L). Among the clinics and services, the four most frequented were the psychiatry clinic (314 patients), internal medicine clinic (36 patients), emergency service (27 patients), and medical oncology clinic (17 patients). Of the 314 patients admitted to the psychiatry clinic, 168 had therapeutic drug levels; only 7 of the 36 admitted to internal medicine had therapeutic levels; 12 of the 27 patients in the emergency service had therapeutic levels; and all 17 patients in medical oncology had levels below therapeutic limits. The data emphasize the importance of regular blood level monitoring to ensure lithium treatment's efficacy and patient safety. It is noteworthy that most patients in the psychiatry clinic had therapeutic drug levels, while those in other clinics had lower levels. In conclusion, this study highlights the importance of regular blood level monitoring to ensure the efficacy and safety of lithium treatment.

Ciddi Nörolojik Bulgularla Birlikte Giden Lityum Zehirlenmesi Olgusu

Lithium is used for the treatment of bipolar disorder and some other psychiatric disorders. Due to the narrow therapeutic range, intoxications are common. In this case, chronic lithium intoxication with severe neurological symptoms was discussed in light of the literature. A 72-year-old female patient. The patient had been receiving psychiatric treatment for 7 years with the diagnosis of unipolar depression. In the 6th month of lithium use, she was brought by her relatives with complaints of drowsiness, tremor, muscle twitching, and difficulty walking. On examination, consciousness was confused, there was no cooperation orientation and there was general rigidity, tremor, fasciculations, and ataxic gait. Vital signs; blood pressure 147/92 mmHg, heart rate 69 bpm, SpO2: 94%. The laboratory tests: lithium 2.98 mEq/L, potassium 5.8 mmol/l, sodium 129 mmol/l, creatinine 1.66 mg/dl, urea 166 mg/dl. The patient was transferred to the internal medicine clinic with the diagnosis of lithium intoxication. Lithium treatment was discontinued. On the 7th day, her neurological symptoms improved with supportive treatment, and biochemical parameters returned to normal. A lithium concentration of more than 3.5 mEq/L was defined as severe poisoning. Neurological findings are prominent in severe poisonings. Especially, geriatric population is at greater risk. In our case; age, use of three different groups of diuretics as antihypertensive treatment, and urinary tract infection were defined as factors that predispose to poisoning. In this case, it's emphasized that although the lithium blood level isn't very high, severe neurological symptoms can be seen clinically in the presence of risk factors.

B-313 Aberrant Lithium Results After HDL Assay on Roche Cobas c503 Instrument

Abstract Background Lithium is prescribed clinically to manage mania in patients with bipolar disorder. However, blood levels higher than 1.5 mmol/L (12 h post administration) indicate toxicity accompanied by severe nausea and vomiting, severe hand tremors, confusion, and vision changes. If neglected, lithium toxicity can lead to coma, brain damage, or even death. Diligent monitoring of blood lithium levels periodically is critical to preventing lithium toxicity. Case Presentation: A 37 y/o female with schizophrenia and bipolar disorder on lithium since 2019 visited the outpatient clinic for her routing biannual lithium check. The patient’s plasma lithium levels were detected at 3.9 mmol/L (previously 0.4 mmol/L; Therapeutic range: 0.60–1.20 mmol/L; Toxic: >2.00 mmol/L). The cause for elevated lithium level was unclear; EKG and vital sign were unremarkable and patient was asymptomatic for toxicity. Nevertheless, patient was then managed with IV infusions and admitted to emergency room for follow up. A redrawn lithium sample ∼22 h later was 0.3 mmol/L, suggesting no toxicity. We then investigated the discrepancy in lithium levels reported by the laboratory. Retesting of the original sample detected lithium at 0.5 mmol/L, a value significantly less than the previously reported 3.9 mmol/L. Our laboratory had recently introduced the Roche Cobas® pro integrated solutions into the lab and chemistry testing (including Lithium) are performed on the Roche Cobas c503 analyzers (an arm of the Roche pro integrated solutions). Our goal was to investigate the observed phenomenon and find potential solutions, especially as it had significant implications to patient care. Method We reviewed all high lithium levels recently tested our new instrument within a week of this incident. Seven samples (lithium values >1.2 mmol/L) were identified and lithium measurements repeated. We also investigated and ruled out the possibility of carry over contamination by rerunning a low lithium sample before and after a high lithium sample. Results Retesting all seven samples resulted in lower lithium level with an average % change of 365%. Further investigations and discussions with manufacturers alluded to interference after HDL testing on the same instrument. To investigate this hypothesis, we reran two previously reported low samples (0.3 and 0.6 mmol/L) immediately after running the HDL cholesterol assay on the Roche Cobas c503 analyzer. Retesting resulted in lithium levels of 7.32 and 1.36 mmol/L (2313.3% and 126.7% change) respectively. Conclusion Our investigation suggests that running the HDL cholesterol assay prior to the lithium assay on the Roche Cobas c503 analyzer results in positive interference. As oppose to other Roche chemistry analyzers (such as the Roche c501), the Roche Cobas c503 analyzer has no wash step between the HDL cholesterol and the lithium assays. Detergents in buffers and reactive byproducts (like peroxide) of the HDL cholesterol assay, may leave behind salts in the instrument probe that can interfere with the lithium assay. We are currently working on adding a wash step between the HDL cholesterol and lithium assays. In the interim, we are repeating lithium testing on high lithium samples.

Antisuicidal effect of lithum in bipolar disorder: is there an age-specific effect?

ObjectiveOur group reported previously a comparable overall antisuicidal effect of lithium and valproate in bipolar patients. We investigated factors associated with higher antisuicidal efficacy of lithium in older individuals. MethodsThe age-related antisuicidal effect of lithium and valproate was compared in ninety-four (n = 94) high-risk bipolar suicide attempters who participated in a 2.5-year randomized, double-blind trial. ResultsAge significantly moderated the effect of lithium vs. valproate on the risk of suicide event during the study (z = −1.98, p = 0.049). We found that those who were 42 years or older (above the 75th percentile), and on lithium had significantly lower risk of suicidal behavior than older patients on valproate (>42y) or younger (<42 y) patients on either medication (interaction HR = 0.09, 95%CI: 0.01–0.89, z = −2.07, p = 0.039). This difference in risk differences was not explained away by age-related differences in the proportion of participants with bipolar II disorder (Fisher's test p = 0.020) or higher lethality of past suicide attempts in younger participants (Wilcoxon test p = 0.024); neither was there any correlation with age in the longitudinally measured blood lithium levels (t = 1.04, df = 36, p = 0.307) or valproate levels (t = −0.50, df = 41, p = 0.621). LimitationsBesides the fact that this is a secondary analysis, a limitation is that the study is not powered to detect suicide deaths or suicide attempts. ConclusionBipolar patients randomized to lithium and older than 42 years had less suicidal behavior compared to same aged patients on valproate or younger patients (<42 y) on either medication. This effect was independent of clinical and sociodemographic characteristics.

Lithium intoxication due to furosemide interaction – a case report

IntroductionLithium has been used for the management of psychiatric illnesses over the years and it continues to be the first-line mood stabilizer used in treatment and prevention of bipolar disorder. Due to its narrow therapeutic index, other prescribed medications can increase lithium levels and potentiate its toxic effects. Among the most described drugs, non-steroid anti-inflammatory drugs and diuretics (mainly thiazides and loop diuretics) are the most commonly implicated. Risk factors for developing lithium toxicity include old age, polypharmacy, renal impairment, hyponatremic and hypovolemic conditions. Although there is interindividual susceptibility, older patients are at particularly higher risk.ObjectivesTo summarize the latest literature about this field and to present a case report as a basis for discussion.MethodsA brief review of the latest literature was performed, using PubMed and the keywords “lithium” and “acute renal injury”. Also, a case report about a 73 year-old man who suffer from lithium intoxication due to lithium-furosemide interaction is presented.ResultsIn the presented case, Mr. F, 73 years old, independent for activities of daily living, was admitted to the Internal Medicine ward due to acute renal injury and lithium intoxication. Initially he was non-collaborative, sleepy, disoriented in all references and speechless. The creatinine was 1.28 mg/dL, urea 63 mg/dL, unspecific leucocitosis 17000/mm3, C-Reactive Protein 8 mg/dL, lithium 2.22 mEq/L. The psychiatrist was called to approach the psychiatric status, but as the patient awareness was impaired, the mental state examination was not possible. The patient’s daughter was interviewed. The patient had bipolar disorder (BD) type 1 and was diagnosed with mild cognitive impairment (MCI) a year ago. He had been stable for BD and MCI until the last month. He began to present nocturia, so he went to a urologist who prescribed him furosemide 40 mg daily for benign prostatic hyperplasia (BPH). Since that moment, he started being confused and progressively went to the state that was previously described at the admission of internment. Furosemide, quetiapine and lithium were stopped. He got better, to his previous state, and then started quetiapine 200 mg/day and tansulosine 0.4 mg/day.ConclusionsInitiating diuretics in patients under lithium should be carefully considered and lithium blood levels must be monitored more regularly when new drugs are prescribed. Other medications must be regarded as alternatives but, if it is not possible, they should be used in the lowest dose and shortest duration as possible. With this case report, we highlight the importance of considering patients as a whole, taking both their physical and mental well-being into account. Healthcare professionals are invited to coordinate their efforts to deliver the best standard of care.Disclosure of InterestNone Declared

The Various Methods to Prevent Lithium Toxicity in Treatment for Patients with Bipolar Disorder

Bipolar disorder (BD) is a serious mental illness that leads to considerable shifts in mood, energy, and physical activity levels, impairing a person’s ability to complete day-to-day tasks. About 4.4% of adults in the US report having experienced an episode of BD at least once in their life, and approximately 82.9% of people with BD are left severely impaired. To combat this, doctors prescribe lithium, which is an effective mood stabilizer that can regulate the extreme highs and lows of BD. However, lithium is a toxic substance when it exceeds the therapeutic range, requiring frequent trips to the hospital to evaluate blood lithium levels Such monitoring may not always be effectively feasible, especially for patients experiencing a mental health crisis or patients in rural areas without local medical facilities. &#x0D; Research studies have been conducted to provide patients with alternative methods to avoid lithium toxicity including ways to check the lithium levels on their own Additionally, studies investigate the ideal dosing regimen to prevent toxic side effects, while others aim to prevent toxicity before it happens.

Long-term lithium therapy and risk of chronic kidney disease, hyperparathyroidism and hypercalcemia: a cohort study

BackgroundLithium is well recognized as the first-line maintenance treatment for bipolar disorder (BD). However, besides therapeutic benefits attributed to lithium therapy, the associated side effects including endocrinological and renal disorders constitute important parameters in prescribing patterns and patient adherence. The objectives of this study is to (i) determine whether long-term lithium therapy is associated with a decrease in renal function, hyperparathyroidism and hypercalcemia and (ii) identify risk factors for lithium-induced chronic kidney disease (CKD).MethodsWe conducted a single-centered cohort study of adult patients (≥ 18 years) treated with lithium, who were enrolled at Rennes University Hospital in France between January 1, 2018 and June 1, 2020. Required data were collected from the patient’s medical records: demographics characteristics (age, sex, body mass index), biologic parameters (GFR, lithium blood level, PTH and calcium), medical comorbidities (hypertension and diabetes), lithium treatment duration and dosage, and length of hospitalization.ResultsA total of 248 patients were included (mean age: 60.2 ± 16.5 years). Duration of lithium treatment correlated with (i) deterioration of renal function estimated at − 2.9 mL/min/year (p < 0.0001) and (ii) the development of hyperparathyroidism (p < 0.01) and hypercalcemia (p < 0.01). We also noted that patients with lithium blood level > 0.8 mEq/mL had significantly lower GFR than patients with lithium blood level < 0.8 mEq/mL (61.8 mL/min versus 77.6 mL/min, respectively, p = 0.0134). Neither diabetes mellitus nor hypertension was associated with more rapid deterioration of renal function.ConclusionThis study suggests that the duration of lithium treatment contribute to the deterioration of renal function, raising the question of reducing dosages in patients with a GFR < 60 mL/min. Overdoses has been identified as a risk factor for CKD, emphasizing the importance of regular re-evaluation of the lithium dose regimen. Also, long-term lithium therapy was associated with hyperparathyroidism and hypercalcemia. Particular vigilance is required on these points in order to limit the occurrence of endocrinological and renal lithium adverse effects.

Optical determination of lithium therapeutic levels in micro-volumes of interstitial fluid.

Long-term management of bipolar disorder (BD), characterized by mood fluctuating between episodes of mania and depression, involves the regular taking of lithium preparations as the most reliable mood stabilizer for bipolar patients. However, despite its effectiveness in preventing and reducing mood swings and suicidality, lithium has a very narrow therapeutic index and it is crucial to carefully monitor lithium plasma levels as concentrations >1.2 mmol/L are potentially toxic and can be fatal. Current methods of lithium therapeutic monitoring involve frequent blood tests, which have several drawbacks related to the invasiveness of the technique, comfort, cost and reliability. Dermal interstitial fluid (ISF) is an accessible and information-rich biofluid, and correlations have been found between blood and ISF levels of lithium medication. In the current study, we sought to investigate the optical determination of lithium therapeutic concentrations in samples of ISF extracted from porcine skin utilizing a microneedle-based approach. Monitoring of lithium levels in porcine ISF was achieved by employing a spectrophotometric method based on the reaction between the chromogenic agent Quinizarin and lithium. The resulting spectra show spectral variations which relate to lithium concentrations of lithium in samples of porcine ISF with a coefficient of determination (R2 ) of 0.9. This study has demonstrated successfully that therapeutic levels of lithium in micro-volumes of porcine ISF can be measured with a high level of accuracy utilizing spectroscopic techniques. The results support the future development of a miniaturized and minimally-invasive device for lithium monitoring in bipolar patients.

A case of lithium intoxication with reversible parkinsonism

A 73-year-old man, who had been treated for bipolar disorder since he was 39 years old, was admitted because he had developed difficulty in walking and moving his hands for the past 2 months. He was suspected of having Parkinson's syndrome. On admission, his blood lithium level was at the upper limit of normal (1.34mEq/l), but his food intake gradually decreased and his communication difficulties worsened. On the sixth day of hospitalization, his blood lithium level was in the toxic range (2.44mEq/l). His general condition, including motor symptoms, improved after lithium medication was discontinued and infusions (normal saline) were started. On the 24th day of admission, he was transferred to the psychiatry department for a psychotropic medication adjustment. It is important to note that chronic intoxication can occur even at the upper limit of the therapeutic range and that salt reduction at the start of the inpatient diet may be a trigger for intoxication.

Effect of Hypertension on Blood Lithium Level and its Concentration to Dose Ratio in Manic Episode Patients

Effect of Hypertension on Blood Lithium Level and its Concentration to Dose Ratio in Manic Episode Patients

Lithium placental passage at delivery: an observational study

IntroductionLithium is used as a first-line treatment for bipolar disorder during perinatal period. Dosing of lithium can be challenging as a result of pharmacokinetic changes in renal physiology. Frequent monitoring of lithium blood levels during pregnancy is recommended in order remain within the therapeutic window (0.5 to 1.2 mEq/L). Lower neonatal lithium blood level (&lt;0.64 mEq/L) at time of delivery reduces the risk of lithium side effects in the neonate.ObjectivesThe aim of the present study was to quantify the rate of lithium placental passage in real word.MethodsWe included a total of 68 mother-infant pairs for which a lithium measurement was performed intrapartum. Lithium serum concentrations were determined by means of an AVL 9180 electrolyte analyzer. The limit of quantification (LoQ) was 0.20 mEq/L and detection limit was 0.10 mEq/L. Pearson analyse was performer to assess the correlation between mother and umbilical cord lithium serum concentrations.ResultsThe mean of umbilical cord serum concentration at delivery was 0.57 mEq/L (SD=0.26, range 0,20-1,42). The mean infant-mother lithium ratio at delivery for the 68 pairs was 1.12 (SD=0.24) across a wide range of maternal concentrations (range 0.14-1,40 mEq/L). There was a strong positive correlation between maternal and umbilical cord lithium blood levels (Peearson correlation coefficient 0.948, p&lt;0.001).ConclusionsLithium demostrates complete placental passage. This finding is consistent with the results of others studies (Newport 2005; Molenaar 2021).DisclosureNo significant relationships.

Point-of-care test for rapid assessment of blood lithium levels in women with bipolar disorder during perinatal period

IntroductionDetermination of lithium levels in serum has become a standard of care due to its narrow therapeutic rang, thus an immediate test for determination of blood lithium may contribute to minimize toxicit, to avoid relapse and to ensure treatment adherence. This is particularly relevant during pregnancy and early postpartum because pharmaokinetic changes in renal physiology.ObjectivesThe aim of this study is verify Medimate point-of-care method performance and systematically compare it with the routine laboratory measurement of lithium.MethodsThis cross-sectional method comparison study was conductec in the Unit of Perinatal Mental Health in the Hospital Clinic of Barcelona. Pearson and Bland-Altman analyses were performed to assess the accuracy, precision and correlation between the capillary electrophoresis technology (Medimate MiniLab) and the ion selective electrode (ISE) potentiometry method (AVL 9180).ResultsTwenty-five women with bipolar disorder in treatment with lithium during perinatal period were enrolled, corresponding to 75 blood specimens for analyses. Correlation (r), mean difference (bias), and 95% limit of agreement (LOA) of the point-of-care method [r=0.917; bias 0.0021 (95% LOA; 0.440, 0.619) mEq/L], showed that difference between ISE method and capillary electrophoresis technology was not statistically significant.ConclusionsConsidering the practicality, the microchip capillary electrophoresis technology provides a simple and highly affordable way of measuring lithium levels in a single drop of blood outside the clinical laboratory. The Medimate point-of-care system (POC) appears well adapted for the rapid and specific detection of lithium as an alternative to the current ISE procedure.DisclosureNo significant relationships.

A novel approach to monitoring lithium blood levels and renal function in patients receiving lithium during the COVID-19 pandemic

IntroductionLithium is commonly administered to patients in an outpatient department (OPD) setting. Regular monitoring of lithium levels and renal function in accordance with published guidelines is required. In our unit, this is usually performed at OPD review. During the COVID-19 pandemic, reviews were either postponed or done remotely.Objectives1. To devise a system to ensure that patients receiving lithium had appropriate blood test monitoring in the absence of traditional OPD appointments. 2. To assess the efficacy of this intervention by recording blood test dates and comparing with pre-COVID compliance.MethodsAll outpatients receiving lithium, identified from the hospital database, received (1) a letter summarising the monitoring guidelines and (2) prospectively dated blood request forms. Patients at higher risk of contracting COVID-19 were advised to attend their primary care setting. Others were encouraged to attend primary care or our phlebotomy department. Compliance was measured by accessing the hospital’s laboratory enquiry computer based system and compared with pre-COVID-19 figures. Information was anonymised, as per General Data Protection Regulations.Results57 patients receiving lithium were identified. Prior to the first Irish lockdown in March 2020, 16 (28%) were overdue testing. Three months into the pandemic, 15 patients (26%) were overdue testing.ConclusionsIn the absence of routine outpatient appointments during the COVID-19 pandemic, the provision of written guidelines and completed blood request forms for patients receiving lithium was effective in ensuring monitoring of lithium levels and renal function. This system can be utilised as an alternative/adjunct to OPD review benefitting patients and health service delivery.DisclosureNo significant relationships.

A Case of Parkinsonism and Encephalopathy with Combined Lithium-Risperidone Therapy: Treatment with Pramipexole

Lithium is a drug that has been used in the treatment of bipolar disorder for many years. Due to its narrow therapeutic range, systemic side effects can be seen frequently. Serious side effects can occur even in non-toxic doses. We present a case of parkinsonism and encephalopathy developed in a patient with normal lithium blood level who used lithium and risperidone combination therapy for bipolar disease.

Long-Term Effects of Lithium Use on Children and Adolescents: A Retrospective Study from Turkey.

Background: The aim of this study was to evaluate the long-term effects of lithium treatment on white blood cell (WBC) count, serum creatinine, and thyroid-stimulating hormone (TSH) levels in children and adolescents with bipolar disorder (BD) and non-BD in a Turkish children and adolescent sample. Methods: The study is based on retrospective chart review. Children and adolescent patients with BD and non-BD prescribed lithium in a mental health and neurological disorders hospital between 2012 and 2017 were included in the study. Data were collected from the electronic medical files. Laboratory values for WBC count, serum creatinine, and TSH levels at baseline within the week before the onset of lithium, and at 1st, 3rd, 6th, and 12th month of treatment were recorded. Results: A total of 143 patients (82 females, 61 males; 100 BD, 43 non-BD) aged 9-18 were included. Non-BD diagnoses were psychotic and schizoaffective disorders, unipolar depression, attention-deficit/hyperactivity disorder, conduct disorder, severe mood dysregulation syndrome, borderline personality disorder, and autism. Mean age of the participants were 15.90 ± 1.16 years for the bipolar group and 14.88 ± 1.79 years for the nonbipolar group. Patients with BD reported more adverse effects. There was a statistically significant increase in WBC counts and TSH levels at any time point. A statistically significant elevation in serum creatinine was found at 3rd and 12th month of treatment. During the course of lithium treatment, WBC counts exceeded 13,000 in 14 (9.8%) patients, and TSH levels exceeded 5.5 mU/L in 41 patients (28.6%). Twenty-one (14.68%) patients were started on thyroxin replacement. Basal TSH levels and duration of the lithium treatment were higher in the participants with TSH levels exceeding 5.5 mU/L. Lithium maximum dose, lithium blood level, basal TSH level, and duration of treatment were higher in the participants receiving thyroxin replacement. No patients had serum creatinine levels exceeding the normal reference values. Conclusion: Our study suggests that lithium is a generally safe and tolerable agent for children and adolescents with BD and non-BD; however, close monitoring of thyroid functions particularly in patients with a higher basal TSH level and longer duration of lithium use is important.

Drug-induced arrhythmia: Are we cautious enough?

Dear Editor, Many drugs, like antiarrhythmic agents, psychotropic medications, neurological drugs, and even antimicrobial agents, may trigger multiple types of arrhythmias.[1] Some arrhythmias may cause serious consequences, including death. We report a rare incident where psychotropic medications not only precipitated a life-threatening arrhythmia but also a stroke! A 64-year-old man with a history of bipolar disorder had no other comorbidity. He presented to the ER (emergency room) with hypotension and bradycardia. His GCS (Glasgow Coma Scale) score was 15/15 and had no neuro-deficit. We detected idioventricular rhythm, and a temporary pacemaker was implanted. His hypotension improved, and it stabilized him. We planned a permanent pacemaker the next morning. The family gave a history that he was on 400 mg of lithium and 400 mg of carbamazepine for more than a year. Considering their arrhythmogenic potential, they were withheld. (Blood lithium level was in the normal range.) The next morning we detected him to have right gaze deviation and left-sided complete hemiplegia (NIHSS of 17). He had established an infarct at the right frontal–temporal region with hemorrhagic conversion in the MRI (magnetic resonance imaging) brain [Figure 1a]. MRA (magnetic resonance angiography) brain revealed right M2 occlusion [Figure 1b]. Conservative stroke treatment along with rehabilitation was executed. TEE (transesophageal echocardiography) ruled out intracardiac clot and other cardiac pathology. Details of stroke workup were also not contributory. Since his sinus rhythm persisted even after removal of the temporary pacemaker, we canceled a permanent pacemaker implantation. We withdrew his offending drugs permanently. Henceforth, the cardiology team monitored the cardiac rhythm and until 2 years of follow-up, he had no further event. His Modified Rankin Scale (mRS), however, remained 5 (with no significant improvement).Figure 1: (a) Acute infarct with hemorrhagic conversion in the right frontal and temporal region. (b) Right M2 division of middle cerebra artery occludedThey associated junctional bradycardia with ischemic stroke, particularly in the absence of an identifiable retrograde P-wave.[2] He had the stroke just after his rhythm got converted to sinus rhythm from junctional bradycardia (like thromboembolism as happens in AF (atrial fibrillation) patients shortly after they get cardioverter).[3] Carbamazepine and lithium both can precipitate bradyarrhythmia.[45] Although we found his lithium level to be within range, there are reports where lithium has precipitated bradyarrhythmia even when the drug level was within therapeutic range.[5] The drugs might have had a synergistic action in our case causing precipitation of the bradyarrhythmia. Interesting learning points in our case are as follows: Arrhythmogenic drugs can precipitate stroke. While on these types of drugs, caregivers should monitor the heart rate and blood pressure regularly. Careful selection of drugs in psychiatric patients is important because they may have a synergistic action in causing arrhythmogenic insults. Before opting for a permanent pacemaker, careful history taking is important to isolate culprit drugs if any which might have precipitated arrhythmia. The status of the arrhythmia needs to be observed after their withdrawal before taking further action. In cardioversion, conversion to sinus rhythm may cause sudden dislodgement of clots from the heart, leading to systemic embolization. Similarly, the stoppage of the arrhythmogenic drugs may precipitate a similar event. So, we need to be more cautious during this time. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgement We acknowledge the faith the patient and family kept on us during difficult times.