Lithium carbonate oral
- Drugs List
- Therapeutic Indications
- Dosage
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Tablet formulations containing lithium carbonate.
Drugs List
Therapeutic Indications
Uses
Aggressive or self mutilating behaviour
Depressive illness
Hypomania
Mania
Manic depression - prophylaxis
Manic-depressive illness - treatment
Prevention of relapse or recurrence of depressive illness
Dosage
Adults
Liskonum:
Treatment of acute episodes of mania or hypomania.
Starting dose 450mg to 675mg twice daily, adjusted to achieve serum lithium level 0.8mmol/L to a maximum 1.5mmol/L.
Prophylaxis of manic depressive illness.
450mg twice a day, adjusted to achieve serum lithium level of 0.5mmol/l to 1.0mmol/L.
Priadel:
Treatment of acute episodes of mania or hypomania, episodes of recurrent depressive disorders, and prophylaxis of bipolar affective disorder and control of aggressive behaviour or intentional self harm.
Starting dose 400mg to 1200mg once daily or divided into two doses. Patients below 50kg, starting dose is 200mg to 400mg. Once daily dose, adjusted to achieve serum lithium level of 0.7mmol/l to 1.0mmol/l at 12 hours and 0.5mm/l to 0.8mm/l at 24 hours. Twice daily dose, adjusted to achieve serum lithium level of 0.5mmol/l to 0.8mmol/l at 12 hours.
Camcolit:
Treatment of mania, manic depressive illness, episodes of recurrent depressive disorders and treatment of aggressive or intentional self harm.
Starting dose 1g to 1.5g daily, adjusted to achieve serum lithium level of 0.6mmol/l to 1mmol/l.
Prophylaxis of recurrent affective disorders.
300mg to 400mg daily, adjusted to achieve serum lithium levels of 0.4mmol/l to 0.8mmol/L.
Elderly
Liskonum:
Treatment of acute episodes of mania or hypomania and prophylaxis of manic depressive illness.
Starting dose 225mg twice daily, adjusted to achieve serum lithium levels to lower range 0.4mmol/l to 0.7mmol/l.
Priadel:
Treatment of acute episodes of mania or hypomania, episodes of recurrent depressive disorders.
Starting dose 200mg to 400mg once daily, adjusted to achieve serum lithium levels of 0.8mmol/l to 1.0mmol/L.
Prophylaxis of bipolar affective disorder and control of aggressive behaviour or intentional self harm.
Starting dose 200mg to 400mg, adjusted to achieve serum lithium level of 0.4mmol/L to 0.8mmol/L.
Camcolit:
Treatment of mania, manic depressive illness, episodes of recurrent depressive disorders and treatment of aggressive or intentional self harm.
Reduce initial dose. Adjust to achieve serum lithium level of 0.4mmol/l to 0.7mmol/l.
Prophylaxis of recurrent affective disorders.
Reduce starting dose 300mg to 400mg, to aim to achieve serum lithium levels of 0.4mmol/l to 0.7mmol/L.
Children
Liskonum (licensed):
Treatment of acute episodes of mania or hypomania.
Starting dose 225mg to 675mg twice daily.
Prophylaxis of manic depressive illness.
Starting dose 225mg to 450mg twice daily.
Camcolit (unlicensed):
Treatment of mania, manic depressive illness, episodes of recurrent depressive disorders and treatment of aggressive or intentional self harm.
Starting dose 1g to 1.5g daily.
Prophylaxis of mania, manic depressive illness, episodes of recurrent depressive disorders and treatment of aggressive or intentional self harm.
Starting dose 300mg to 400mg daily.
Additional Dosage Information
As bioavailability varies from product to product (particularly with regard to retard or slow release preparations), a change of product should be regarded as initiation of new treatment. When changing between lithium preparations check serum lithium levels and commence therapy at a daily dose as close as possible to the dose of the other form of lithium.
Gradual withdrawal of lithium (over a period of at least 2 weeks) is recommended, as it may delay recurrence of the patient's underlying symptoms.
Therapeutic Drug Monitoring
On initiation of therapy, plasma concentrations should be measured after 4 to 7 days of treatment, then weekly until dosage has remained constant for 4 weeks and as minimum every 3 months thereafter. Doses are adjusted to achieve specific target serum lithium concentrations (see dosage section).
Additional measurements should be made if signs of lithium toxicity occur, on dosage alteration, development of significant intercurrent disease, signs of manic or depressive relapse and if significant changes in sodium or fluid intake occurs. More frequent monitoring is required if patients are receiving any drug treatment that affects renal clearance of lithium e.g. diuretics and NSAIDs.
As bioavailability may vary between formulations, should a change of preparation be made, blood levels should be monitored weekly until re-stabilisation is achieved.
Blood samples for measurement of serum lithium concentration should be taken just before a dose is due and not less than 12 hours after the previous dose.
Contraindications
Children under 12 years
Family history of Brugada syndrome
Restricted sodium intake
Addison's disease
Breastfeeding
Brugada syndrome
Cardiac disorder
Dehydration
Hyponatraemia
Long QT syndrome
Severe renal impairment
Torsade de pointes
Uncontrolled hypothyroidism
Precautions and Warnings
Elderly
Electroconvulsive therapy
Family history of long QT syndrome
Females of childbearing potential
Hyperhidrosis
Infection
Electrolyte imbalance
Galactosaemia
Glucose-galactose malabsorption syndrome
History of torsade de pointes
Lactose intolerance
Mild renal impairment
Moderate renal impairment
Myasthenia gravis
Pregnancy
Psoriasis
Seizures
Correct electrolyte disorders before treatment
May exacerbate myasthenia gravis
Advise ability to drive/operate machinery may be affected by side effects
May reduce seizure threshold
Not all available brands are licensed for all age groups
Not all available brands are licensed for all indications
Some formulations contain lactose
Different oral formulations are not interchangeable (not bioequivalent)
Consider ECG before treatment
Monitor cardiac function before and periodically during treatment
Monitor renal function before and at 6 monthly intervals during treatment
Monitor serum electrolytes before & at 6 monthly intervals during treatment
Monitor thyroid function before and at 6 monthly intervals during treatment
Monitor weight or BMI before and at 6 monthly intervals during treatment
Perform full blood count before treatment
Check lithium levels and suspend treatment following signs of toxicity
Consider monitoring ECG in patients at risk of QT prolongation
Evaluate benefit/risk in long term use ( > 5 years)
Measure lithium levels where risk of fluid or electrolyte imbalance
Monitor lithium levels every three months when stabilized
Monitor lithium levels weekly after initiation or dose change until stable
Monitor patients for signs and symptoms of Neuroleptic Malignant Syndrome
Monitor renal function if polyuria or polydipsia occurs
Monitor serum calcium levels on prolonged use
Monitor serum electrolytes
Advise patient of signs of toxicity
Advise patients/carers to seek medical advice if changes in behaviour/mood
May exacerbate psoriasis
Patient to report nausea, vomiting or situations leading to salt/water loss
Seek specialist advice if lithium level greater than 1.5 mmol/L
Avoid abrupt withdrawal
Interrupt treatment in patients undergoing major surgery
Maintain treatment at the lowest effective dose
Reduce dose in elderly
Advise patient to maintain usual salt and fluid intake
Female: Ensure adequate contraception during treatment
Lithium therapy record book to be issued
Cases of microcysts, oncocytomas and collecting duct renal carcinoma have been reported in patients with severe renal impairment who received lithium for more than 10 years.
Serum lithium concentration of over 1.5mmol/l may be fatal and toxic effects include tremor, ataxia, dysarthria, nystagmus, renal impairment and convulsions. If these potentially hazardous signs occur, treatment should be stopped, serum lithium concentrations re-determined, and specialist advice should be sought. Serum lithium concentration in excess of 2mmol/l require urgent treatment.
Patients should only be maintained on lithium after 3 to 5 years if, on assessment, benefit persists.
Perform an ECG prior to treatment as a baseline and periodically through treatment in patients with cardiovascular disease.
Interruption of treatment should be considered during any intercurrent infection.
Pregnancy and Lactation
Pregnancy
Use lithium carbonate with caution in pregnancy.
Lithium crosses the placental barrier. There is epidemiological evidence to suggest that lithium may be harmful during human pregnancy. Lithium treatment has been associated with congenital defects (particularly cardiovascular malformations) including Ebstein's anomaly. If the use of lithium is unavoidable, close monitoring of serum concentrations should be made throughout pregnancy, due to renal function changes associated with pregnancy and parturition. Pre-natal screening should be available including echocardiography and level II ultrasound.
It is recommended that lithium be discontinued shortly before delivery and reinitiated post partum. During delivery, the renal clearance of lithium decreases considerably, which may result in toxicity in mother and infant. Thyroid function in both the mother and neonate should be well controlled.
Careful clinical observation of neonates exposed to lithium during pregnancy is recommended and lithium levels may need to be monitored. Neonates may show signs of lithium toxicity including symptoms such as lethargy, flaccid muscle tone, or hypotonia necessitating fluid therapy in the neonatal period. Neonates born with low serum lithium concentrations may have a flaccid appearance that returns to normal without any treatment
The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Lactation
Lithium is contraindicated in breastfeeding.
Lithium is excreted in breast milk, some studies have reported lithium levels in breast milk to be 40% to 45% of maternal serum level. There are limited reports of toxicity in breast fed infants during breastfeeding but the long term effects from exposure during early development have not been studied.
If breastfeeding continues, close monitoring of lithium levels in the infant and clinical observation including assessment of thyroid function is necessary. A decision should be made whether to discontinue lithium therapy or to discontinue breastfeeding, taking into account the importance of the drug to the mother and the importance of breastfeeding to the infant.
Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1
Side Effects
Abdominal discomfort
Acne
Acneform changes
Alopecia
Anorexia
Arthralgia
Asthenia
Ataxia
Benign raised intracranial pressure
Blurred vision
Bradycardia
Cardiac arrest
Cardiac arrhythmias
Cardiomyopathy
Circulatory collapse
Cognitive impairment
Collecting duct renal carcinoma
Coma
Confusion
Cutaneous ulcer
Dazed feeling
Decreased reflexes
Delirium
Diabetes insipidus
Diarrhoea
Dizziness
Dry mouth
Dysgeusia
ECG changes
Encephalopathy
Exacerbation of psoriasis
Extrapyramidal effects
Fatigue
Folliculitis
Gastritis
Giddiness
Goitre
Hallucinations
Hyperactive deep tendon reflexes
Hypercalcaemia
Hyperglycaemia
Hypermagnesaemia
Hyperparathyroidism
Hyperreflexia
Hypersalivation
Hyperthyroidism
Hypotension
Hypothyroidism
Impaired consciousness
Impaired memory
Increase in antinuclear antibodies (ANA)
Interstitial fibrosis
Intraventricular block
Lethargy
Leucocytosis
Maculopapular rash
Malaise
Muscle weakness
Myalgia
Myasthenia gravis-like syndrome
Myoclonus
Nausea
Nephrotic syndrome
Neuroleptic malignant syndrome
Neurotoxicity
Nystagmus
Oedema
Parkinsonism
Polydipsia
Polyuria
Prolongation of QT interval
Pruritus
Rash (allergic)
Raynaud's phenomenon
Renal damage
Renal microcysts
Renal oncocytoma
Rhabdomyolysis
Scotoma
Seizures
Serotonin syndrome
Sexual dysfunction
Sinus node disease
Slurred speech
Somnolence
Stupor
T-wave changes
Taste disturbances
Thirst
Thyrotoxicosis
Torsades de pointes
Tremor
Ventricular fibrillation
Ventricular tachycardia
Vertigo
Vomiting
Weight gain
Overdosage
It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.
The following number will direct the caller to the relevant local centre (0844) 892 0111
Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).
Further Information
Last Full Review Date: February 2018.
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.
Martindale: The Complete Drug Reference. 39th Edition. London: Brayfield A (ed). Pharmaceutical Press; 2017.
The Maudsley Prescribing Guidelines in Psychiatry. 11th Edition (2012) Taylor, D., Paton, C. and Kapur, S. Wiley Blackwell, West Sussex.
Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.
Summary of Product Characteristics: Priadel. Sanofi-Aventis. Revised June 2015.
Summary of Product Characteristics: Camcolit 250. Norgine Ltd. Revised April 2015.
Summary of Product Characteristics: Camcolit 400. Norgine Ltd. Revised April 2015.
Summary of Product Characteristics: Liskonum tabs. GlaxoSmithKline UK. Revised June 2016.
NPSA December 2009 - Safer lithium therapy alert.
Available at: https://www.nrls.npsa.nhs.uk/resources/?entryid45=65426
Last accessed: 6 February 2018.
US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Lithium Last revised: March 10, 2015.
Last accessed: 6 February 2018.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 6 February 2018.
Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content
FDB Disclaimer : FDB Multilex is intended for the use of healthcare professionals and is provided on the basis that the healthcare professionals will retain FULL and SOLE responsibility for deciding what treatment to prescribe or dispense for any particular patient or circumstance.