This site is intended for UK healthcare professionals
Medscape UK Univadis Logo
Medscape UK Univadis Logo

Lithium citrate oral

Updated 2 Feb 2023 | Lithium


Oral formulations of lithium citrate

Drugs List

  • LI-LIQUID 1.018g/5ml solution
  • LI-LIQUID 509mg/5ml solution
  • lithium citrate 1.018g/5ml oral solution
  • lithium citrate 509mg/5ml oral solution
  • lithium citrate 520mg/5ml oral solution sugar-free
  • PRIADEL 520mg/5ml liquid
  • Therapeutic Indications


    Aggressive or self mutilating behaviour
    Manic depression - prophylaxis
    Manic-depressive illness - treatment
    Prevention of relapse or recurrence of depressive illness


    Lithium levels should be checked before changing between lithium preparations.


    Body weight 50 kg or greater than
    Initial daily dose: 1018 mg to 3054 mg of lithium citrate, given in two divided doses, one in the morning and one in the evening (preferably at the same times each day).

    Body weight less than 50 kg
    Initial daily dose: 509 mg in two divided doses, one in the morning and one in the evening (preferably at the same times each day).


    Initial daily dose: 509 mg in two divided doses, one in the morning and one in the evening (preferably at the same times each day).

    Therapeutic Drug Monitoring

    Lithium has a narrow therapeutic/toxic ratio and therefore regular monitoring of serum lithium concentration is obligatory when lithium is used. Lithium therapy should not be initiated unless adequate facilities for routine monitoring of serum concentrations are available.

    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 every 3 months thereafter. Doses are adjusted to achieve serum lithium concentration of 0.5 to 1.5 mmol/L (lower end of the range for maintenance therapy and elderly patients).

    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 restabilisation is achieved.

    Blood samples for measurement of serum lithium concentration should be taken 12 hours after the preceding dose, concentration should be 0.5 to 0.8 mmol/L.

    Serum lithium concentration of over 1.5 mmol/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 redetermined, and steps taken to reverse lithium toxicity. Serum lithium concentration in excess of 2 mmol/L require urgent treatment.


    Family history of Brugada syndrome
    Restricted sodium intake
    Addison's disease
    Brugada syndrome
    Cardiac impairment
    Cardiovascular disorder
    Long QT syndrome
    Severe renal impairment
    Torsade de pointes
    Uncontrolled hypothyroidism

    Precautions and Warnings

    Children under 18 years
    Family history of long QT syndrome
    Family history of sudden death
    Females of childbearing potential
    Hot climates
    Major surgery
    Predisposition to epileptic disorder
    Predisposition to prolongation of QT interval
    Severe dieting
    Suicidal ideation
    Electrolyte imbalance
    Epileptic disorder
    Glucose-galactose malabsorption syndrome
    Hereditary fructose intolerance
    History of torsade de pointes
    Mild renal impairment
    Myasthenia gravis
    Reduced seizure threshold

    Advise ability to drive/operate machinery may be affected by side effects
    Renal impairment: Risk of renal tumour if treated for more than 10 years
    Presentations with sorbitol unsuitable in hereditary fructose intolerance
    Some brands contain Sunset Yellow (E110) - can trigger allergic reactions
    Some formulations contain glucose
    Some formulations contain hydroxybenzoate
    Some formulations contain propylene glycol
    Some formulations may contain alcohol
    Evaluate renal function before and during treatment
    Monitor cardiac function before and regularly during treatment
    Monitor thyroid function prior to and periodically during treatment
    Perform urine analysis before and periodically during treatment
    Evaluate benefit/risk in long term use ( > 5 years)
    Monitor lithium levels every three months when stabilized
    Monitor lithium levels weekly after initiation or dose change until stable
    Monitor renal function if polyuria or polydipsia occurs
    Monitor serum electrolytes
    Advise patient of signs of toxicity
    Advise patients/carers to seek medical advice if suicidal intent develops
    Discontinue if active infection develops
    Discontinue immediately on the first signs of toxicity
    Hypothyroidism may occur
    Patient to report nausea, vomiting or situations leading to salt/water loss
    Discontinue treatment 24 hours prior to surgery
    To discontinue, reduce dose gradually
    Bioavailability differs with preparations;caution on changing formulations
    Maintain treatment at the lowest effective dose
    Reduce dose in elderly
    Female: Ensure adequate contraception during treatment
    Advise patient to avoid strict low salt diet
    Lithium therapy record book to be issued

    Advise patient to report a persistent headache and/or visual disturbances.

    Pregnancy and Lactation


    Use lithium with caution in pregnancy.

    Lithium crosses the placenta. Animal studies have shown some teratogenic effects in foetal development including Ebstein's anomaly as well as some interference with gestation and fertility. Briggs (2015) states that if lithium is used within the first trimester, adequate screening tests such as an ultrasound and electrocardiogram of the foetus should be strongly advised.

    Lithium should be discontinued before a planned pregnancy, however if treatment is considered essential to maintain during pregnancy, Schaefer (2015) suggests serum levels should be monitored frequently due to the risk of foetal polyuria and toxicity and a daily intake of folic acid should be administered.

    Schaefer (2015) also recommends that treatment should be discontinued within the onset of labour, before delivery, and recommenced a few days after birth to avoid toxicity. The manufacturer suggests to avoid the use of lithium during pregnancy, especially in the first trimester, unless considered essential then serum levels should be monitored as necessary.

    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 ( ) or if this is unavailable at the backup site ( ).


    Lithium is contraindicated in breastfeeding.

    Lithium is excreted in breast milk. Studies have shown it is excreted in doses of up to 30% (Briggs et al, 2015). There have been some reports of toxicity in neonates, however Briggs (2015) states that there have been no adverse reactions found in infants when lithium has been administered during breastfeeding. Schaefer (2015) also states lithium can be administered during breastfeeding as long as the infant is closely monitored and the doses are as low as possible.

    There is limited published information on the long term use of lithium during breastfeeding. The manufacturer states lithium is contraindicated in breastfeeding, suggesting to analyse the importance of lithium treatment for the mother and the potential benefit of breastfeeding for the infant, and to discontinue either lithium treatment or breastfeeding.

    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

    Side Effects

    Abdominal discomfort
    Acneform changes
    Atrioventricular block
    Benign raised intracranial pressure
    Blurred vision
    Cardiac arrest
    Cardiac arrhythmias
    Circulatory collapse
    Collecting duct renal carcinoma
    Cutaneous ulcer
    Dazed feeling
    Decreased reflexes
    Diabetes insipidus
    Dry mouth
    ECG changes
    Exacerbation of psoriasis
    Extrapyramidal effects
    Histological renal changes
    Hyperactive deep tendon reflexes
    Impaired consciousness
    Impaired memory
    Interstitial fibrosis
    Maculopapular rash
    Muscle weakness
    Myasthenia gravis-like syndrome
    Nephrotic syndrome
    Papular eruption
    Prolongation of QT interval
    Pseudotumour cerebri
    Rash (allergic)
    Raynaud's phenomenon
    Reflex disorders
    Renal impairment
    Renal microcysts
    Renal oncocytoma
    Sensorimotor disorder
    Sexual dysfunction
    Sinus node dysfunction
    Slurred speech
    Speech disturbances
    T-wave changes
    Urinary dysfunction
    Ventricular fibrillation
    Ventricular tachycardia
    Weight gain


    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 ( ) or if this is unavailable at the backup site ( ).

    The MHRA have produced 'generic' overdose sections for the top ten drugs for which the NPIS received the greatest number of queries about management of overdose in 2002. This information is attached below:

    Any overdose in a patient who has been taking chronic lithium therapy should be regarded as potentially serious. A single acute overdose usually carries low risk and patients tend to show mild symptoms only, irrespective of their serum lithium concentration. However more severe symptoms may occur after a delay if lithium elimination is reduced because of renal impairment, particularly if a slow-release preparation has been taken. The fatal dose, in a single overdose, is probably over 5 g.

    If an acute overdose has been taken by a patient on chronic lithium therapy, this can lead to serious toxicity occurring even after a modest overdose as the extravascular tissues are already saturated with lithium.

    Lithium toxicity can also occur in chronic accumulation for the following reasons:
    Acute or chronic overdosage
    Dehydration e.g. due to intercurrent illness
    Deteriorating renal function
    Drug interactions, most commonly involving a thiazide diuretic or a non-steroidal anti-inflammatory drug (NSAID)

    In patients with a raised lithium concentration, the risk of toxicity is greater in those with the following underlying medical conditions: hypertension; diabetes; congestive heart failure; chronic renal failure; schizophrenia; Addison's disease.

    Signs and Symptoms

    The onset of symptoms may be delayed, with peak effects not occurring for as long as 24 hours, especially in patients who are not receiving chronic lithium therapy or following the use of a sustained release preparation.

    Mild: Nausea, diarrhoea, blurred vision, polyuria, light headedness, fine resting tremor, muscular weakness and drowsiness.
    Moderate: Increasing confusion, blackouts, fasciculation and increased deep tendon reflexes, myoclonic twitches and jerks, choreoathetoid movements, urinary or faecal incontinence, increasing restlessness followed by stupor. Hypernatraemia.
    Severe: Coma, convulsions, cerebellar signs, cardiac dysrhythmias including sino-atrial block, sinus and junctional bradycardia and first degree heart block. Hypotension or rarely hypertension, circulatory collapse and renal failure.


    Consider gastric lavage for non-sustained-release preparations if more than 4 g has been ingested by an adult within one hour or definite ingestion of a significant amount by a child. Slow-release tablets do not disintegrate in the stomach and most are too large to pass up a lavage tube. Gut decontamination is not useful for chronic accumulation. Whole bowel irrigation may be helpful in patients ingesting large quantities of a slow-release preparation.

    Note: Activated charcoal does not adsorb lithium.

    Haemodialysis is the treatment of choice for severe poisoning and should be considered in all patients with marked neurological features. It is the most efficient method of lowering lithium concentrations rapidly but substantial rebound increases can be expected when dialysis is stopped, and prolonged, or repeated treatments may be required. It should be considered also in acute overdose if the serum lithium concentration is >7.5 mmol/L. In cases of acute on chronic overdose or in cases of chronic lithium toxicity if the lithium concentration is >4.0 mmol/L, discuss with your local poisons service.

    Note: Clinical improvement generally takes longer than reduction of serum lithium concentrations regardless of the method used.

    Further Information

    Last Full Review Date: May 2017

    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.

    NICE Evidence Services Available at: Last accessed: 23 September 2017

    Summary of Product Characteristics: Priadel liquid. Sanofi-Aventis. Revised June 2015.

    Summary of Product Characteristics: Li-Liquid 509 mg/5 ml oral syrup. Rosemont Pharmaceuticals. Revised March 2017.

    Summary of Product Characteristics: Li-Liquid 1018 mg/5 ml oral syrup. Rosemont Pharmaceuticals. Revised March 2017.

    Access the full UK drug database with a FREE Medscape UK Account
    It takes just a few minutes, and you’ll get unlimited access to information on over 11,000 UK drugs.
    Register for Free

    Already a member? Log in

    Medscape UK | Univadis prescription drug monographs & interactions are based on FDB Multilex Content

    FDB Logo

    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.