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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 25 of 28. This is the beginning of the thread.
Posted by Phillipa on January 23, 2012, at 19:01:09
Looks like lithium is safer than though but calcium should be monitored also and does raise risk for thyroid disorder Phillipa
From Medscape Medical News > Psychiatry
Lithium's Safety Examined
Findings Reaffirm Drug's Role as First-Line Therapy for Bipolar Disorder
Fran LowryAuthors and Disclosures
January 19, 2012 Lithium is linked to thyroid and parathyroid abnormalities, weight gain, and an increased risk for reduced urinary concentrating ability, but the jury is still out on whether it causes birth defects, new research suggests.
The systematic review and meta-analysis of 385 randomized, controlled trials and observational studies also found scant evidence that lithium produced a clinically significant reduction in renal function in most patients and that the risk of end-stage renal failure among users of the drug is low.
"Lithium is the most effective long-term therapy for bipolar disorder, protecting against both depression and mania and reducing the risk of suicide and short-term mortality," Professor John R. Geddes, MD, University of Oxford and Warneford Hospital, Oxford, United Kingdom, and colleagues write.
"Because lithium has always been an unpatented, cheap drug, it is not commercially promoted and the potential for adverse effects has been a substantial deterrent to use," they write.
There have been concerns about lithiums effect on renal function and its purported teratogenicity. Despite these concerns, there has not been an "adequate synthesis of the evidence for adverse effects," the authors note.
With first author Rebecca F. McKnight, BMBCh, the study is published online January 20 in the Lancet.
Small Risk of Renal Failure
The investigators assessed 385 studies investigating the association between lithium and all major adverse effects that have been reported to obtain a "clinically informative" toxicity profile.
The analysis showed that lithium reduced glomerular filtration rate by an average of −6.22 mL/min (95% confidence interval [CI], −14.65 to 2.20, P = 0.148) and urinary concentrating ability by 15% of normal maximum (weighted mean difference, −158.43 mOsm/kg, 95% CI, −229.78 to −87.07, P < 0.0001).
The absolute risk of renal failure was small, the authors report. A few patients (18 of 3369, or 0.5%) receiving lithium also underwent renal replacement therapy.
There was an increase in the prevalence of clinical hypothyroidism in patients taking lithium compared with patients who did not (odds ratio [OR], 5.78; 95% CI, 2.00 to 16.67; P = 0.001).
Additionally, lithium increased thyroid stimulating hormone by an average of 4.00 iU/mL (95% CI 3.90 to 4.10, P < 0.0001).
Lithium was also linked to increased blood calcium (+0.09 mmol/L, 95% CI, 0.02 to 0.17; P = 0.009) and increased parathyroid hormone (+7.32 pg/mL, 95% CI, 3.42 to 11.23; P < 0.0001).
Weight gain was also associated with lithium use. Patients receiving lithium gained more weight compared with those not receiving lithium (OR, 1.89; 95% CI, 1.27 to 2.82; P = 0.002). However, weight gain was lower with lithium than with olanzapine (OR, 0.32; 95% CI, 0.21 to 0.49; P < 0.0001).
Evidence of Teratogenicity "Weak"
The researchers note that they were unable to find any significant increased risk for congenital abnormalities, hair loss, or skin disorders.
"The evidence that exposure to lithium is teratogenic is quite weak, and our findings accord with the notion that the risk has been overestimated," they write.
Currently, it is recommended that lithium be avoided during pregnancy, but the authors suggest that a "sounder approach" would be to explain the uncertainty about the risk to women of childbearing age.
They also recommend that calcium levels be checked before and during treatment with lithium because of the high prevalence of hyperparathyroidism.
They conclude that lithium has long been recommended as a first-line treatment for bipolar disorder, but its use has decreased, owing to concerns about its safety.
"This review provides a comprehensive synthesis of the evidence of harm that should inform clinical decisions and draw attention to key questions in urgent need of further clarification," the investigators write.
"This is a synthesis of data on harms, and as such is less of an exciting new result," Dr. Geddes told Medscape Medical News.
"There were not too many surprises in the results, although the need to monitor calcium is a change from some guidelines. Also, the risk of harm to the kidney and during pregnancy that we found is probably less than is often thought," he said.
"Hopefully, this analysis will help patients and clinicians make informed decisions about care," Dr. Geddes said.
Still Treatment of Choice
In an accompanying editorial, Australian researchers Gin S. Mahli, MD, from the University of Sydney, and Michael Berk, MD, from the University of Melbourne, write that correctly judging the treatment options for bipolar disorder "has never been more crucial."
They congratulate the investigators for their systematic quantification of lithiums potential risks, but they also caution that there are caveats to be considered when interpreting the findings.
Among these are the heterogeneity of the studies in the meta-analysis and the absence of key information, such as the timing of the onset of side effects in relation to the start of lithium treatment.
Despite these limitations, "this study provides timely clarification of the toxicity associated with lithium therapy and, on balance, reaffirms its role as a treatment of choice for bipolar disorder," they conclude.
This study was funded by the National Institute for Health Research Programme Grant for Applied Research. Dr. McKnight reports no relevant financial relationships. Dr. Mahli reports financial relationships with AstraZeneca, Eli Lilly, Organon, Pfizer, Servier, Wyeth, Janssen-Cilag, Lundbeck, and Ranbaxy. Dr. Berk reports financial relationships with Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Organon, Novartis, Mayne Pharma, Servier, Janssen-Cilag, Lundbeck, Merck, Sanofi-Synthelabo, Solvay, and Wyeth. The editorialists have disclosed no relevant financial relationships.
Lancet. Published online January 20, 2012
Posted by Raisinb on January 23, 2012, at 19:12:42
In reply to Lithium's Safety Evaluated Safer Than Thought, posted by Phillipa on January 23, 2012, at 19:01:09
Man, lithium was tough on me. Severe acne and constipation and I couldn't read or think. If only they could do something about that.
Posted by crazyjoe on January 23, 2012, at 21:10:26
In reply to Lithium's Safety Evaluated Safer Than Thought, posted by Phillipa on January 23, 2012, at 19:01:09
after approx. 8 years on lithium ...doses between 900-1800 ...my nephrologist suggested i discontinue lithium....and his report was backed up by a second opinion....especially if i' could do as well on others... this case i was and on tegretol/lamictal so i think there is some controversy surrounding lithium and long term use...only my 2
Posted by Phillipa on January 23, 2012, at 21:18:36
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by crazyjoe on January 23, 2012, at 21:10:26
Hi these are the nursing bulletins I receive. I did know the thyroid controversy didn't know the kidneys. Also knew weight gain. Great to learn some new things. Phillipa
Posted by SLS on January 24, 2012, at 3:41:02
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by Raisinb on January 23, 2012, at 19:12:42
> Man, lithium was tough on me. Severe acne and constipation and I couldn't read or think. If only they could do something about that.
Have there been any other drugs that affected the way you read and think in a similar way?
- Scott
Posted by Raisinb on January 24, 2012, at 7:41:54
In reply to Re: Lithium's Safety Evaluated Safer Than Thought » Raisinb, posted by SLS on January 24, 2012, at 3:41:02
Hi Scott,
No, to my knowledge lithium is the only one that had such a dramatic effect on my cognition. I do remember that after I took ambien at night, I would read a chapter or two of a book and literally remember nothing (I'd have a bookmark but have to move it and start over). That was only at night, though.
Posted by SLS on January 24, 2012, at 8:15:29
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by Raisinb on January 24, 2012, at 7:41:54
> Hi Scott,
> No, to my knowledge lithium is the only one that had such a dramatic effect on my cognition. I do remember that after I took ambien at night, I would read a chapter or two of a book and literally remember nothing (I'd have a bookmark but have to move it and start over). That was only at night, though.Yeah. Ambien is well known to produce amnestic effects, including sleep-walking and sleep-eating.
I was just curious if any serotonergic drugs affected you the same way that lithium did. Lithium has some pro-serotonergic properties. Klonopin acts somewhat like lithium in this regard. You might want to be aware of this should you choose to try it at some point.
- Scott
Posted by Toph on January 24, 2012, at 11:08:05
In reply to Lithium's Safety Evaluated Safer Than Thought, posted by Phillipa on January 23, 2012, at 19:01:09
30 years on lithium. No significant side effects. One manic relapse (when I was careless with my med).
Posted by raisinb on January 24, 2012, at 11:32:50
In reply to Re: Lithium's Safety Evaluated Safer Than Thought » Raisinb, posted by SLS on January 24, 2012, at 8:15:29
I have never tried Klonopin, but I will keep it in mind, since it is a possibility for the future.
I have been on several SSRIs and the effect is noticeably different. On the former I can definitely experience emotional flattening, but it's a circumscribed experience. On Lithium I wouldn't even remember the word "circumscribed," nor how to use it. I remember reading pages and paragraphs over and over again--I read all the words--but the content refused to enter my brain, as if there was a wall between me and my thoughts or understanding.
Posted by SLS on January 24, 2012, at 13:46:20
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 24, 2012, at 11:32:50
> I have never tried Klonopin, but I will keep it in mind, since it is a possibility for the future.
Klonopin can be a great match for some people, so I wouldn't reject it as an alternative. Just be aware that it can produce a mild to moderate depression sometimes.
- Scott
Posted by papillon2 on January 25, 2012, at 6:46:04
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 24, 2012, at 11:32:50
> I remember reading pages and paragraphs over and over again--I read all the words--but the content refused to enter my brain, as if there was a wall between me and my thoughts or understanding.
This is exactly what I experience when my lithium level is too 'high' (high for me is ridiculously low for most people). Great description - I think I might borrow it when trying to explain it to others. Thanks.
Posted by Raisinb on January 25, 2012, at 9:25:48
In reply to Re: Lithium's Safety Evaluated Safer Than Thought » raisinb, posted by papillon2 on January 25, 2012, at 6:46:04
Interesting--did you have the blood tests? That is what I was like on a level of .8, which pdoc said was normal. After three months of it I told her I was going off, and she nearly jumped out of her seat. Are you on lithium now?
Posted by papillon2 on January 25, 2012, at 20:24:43
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by Raisinb on January 25, 2012, at 9:25:48
I am currently on 125mg (level .12) but I'm taking a little hiatus from Lithium until I speak with my psychiatrist in 2 weeks (reasons below).
On 500mg (level .8) I experienced:
- severe cognitive problems (the "wall") - confusion; difficulty thinking, talking and understanding others when spoken to; word find problems and occasionally saying the wrong words in sentences.
- nausea from even just moving my head
- dizziness
- stumbling around
- trembling
- massive headache and eye pain
- slowed movements in addition to the slowed thinkingOn 250mg (level .2) I had occasions where I experience the above, as opposed to a constant presentation. These were usually preceeded by slight dehydration and a marked increase in that horrible Lithium metallic taste. On one instance I also had a freaky experience where my eyes were constantly and uncontrollably darting from side to side even when my eyelids were closed. I think it's called nystagmus.
So, the reason for my hiatus? Three nights ago I had cognitive problems again (though not to the same degree), the massive headache and eye pain that comes with the cognition problems, and a full colour visual hallucination that was terrifying.
I'm not sure if the hallucination was related to Lithium. There's a small chance I may have had a seizure due to a sudden spike in my Lamictal level (an interaction with the contraceptive pill). The hallucination that I had, which was of being attacked by a purple/blue geometric shape with a bright light, is apparently frequent with ocipital seizures. But I'd rather not risk it.
I am mainly terrified that I am developing psychotic features but hoping it's just something called hypnopompic and hypnocogic hallucinations.
Wow, I've rambled. Anyway, I wish I weren't so sensitive to Lithium because the low dose I have as an adjunct to my anti-depressant would otherwise be quite safe, it is proven to reduce suicide rates* and has neuroprotective features. If someone had a choice between Lithium and an atypical anti-psychotic as a mood stabilizer, I would definitely suggest first trying Lithium.
*For example, there's one study where they found that towns in... I think it was Sweden or Switzerland... with higher levels of Lithium in the drinking water had less suicide attempts and deaths than towns with lower Lithium levels. They made adjustments for other factors like population and mental illness rates.
Posted by raisinb on January 28, 2012, at 21:09:20
In reply to Re: Lithium's Safety Evaluated Safer Than Thought » Raisinb, posted by papillon2 on January 25, 2012, at 20:24:43
I have heard of hypnagogic hallucinations--sometimes I get the auditory kind. I read on Wikipedia that they are actually fairly common. Still a scary, scary experience.
But the side effects were more than enough to worry about the Lithium before your hallucination.
From all the studies I read about Lithium, it ought to be the perfect drug for me--I have bipolar II, depressed--that is, until I actually take it. Worst side effects I've ever had from anything.
Posted by SLS on January 29, 2012, at 6:51:06
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 28, 2012, at 21:09:20
> From all the studies I read about Lithium, it ought to be the perfect drug for me--I have bipolar II, depressed--that is, until I actually take it. Worst side effects I've ever had from anything.
That totally sucks. Sorry.
I thought that lithium was not very effective for treating BPII. Maybe this is an old idea. Valproate had been the drug of choice for this indication before the AAPs came to market.
What were the side effects that you had with lithium?
- Scott
Posted by raisinb on January 29, 2012, at 11:50:03
In reply to Re: Lithium's Safety Evaluated Safer Than Thought » raisinb, posted by SLS on January 29, 2012, at 6:51:06
I was hospitalized in the fall, and both the pdocs there and my regular pdoc thought Lithium should be my drug of choice. I guess it's the reducing suicidality piece.
I had bad cystic acne I couldn't get rid of, despite all the topical, antibiotic, and natural remedies I tried. I even had some accutane from sources I won't mention, and that only helped a bit.
I also had severe constipation. Again, no mild remedies helped; despite water, exercise, fiber, and stool softeners, I had to take stimulant laxatives a few times a week. Not to provide TMI, but safe to say, that's no way to live!
I also had the cognitive effects I mentioned above. Felt like my brain was encased in cement.
It stabilized my moods, but did it to the point of anhedonia. I just felt nothing all the time.
I gave it three months; I don't know if that's an adequate trial, but I got fed up. The blood level was .8, which was not too high. The pdoc was strongly against me ditching it, but agreed to put me on Trileptal. It seems to be going okay, but not ideal. When I get severely stressed, I need to attack my moods with extra therapy, hard exercise, and total social withdrawal. I guess I'd rather spend several days in my apartment playing video games than deal with Lithium.
Posted by Toph on January 30, 2012, at 10:08:42
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 29, 2012, at 11:50:03
Almost half a million Americans are treated with lithium. I imagine that probably at least that many have tried it and found it ineffective or the side effects unacceptable.
Posted by papillon2 on January 30, 2012, at 18:02:31
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 28, 2012, at 21:09:20
> I have heard of hypnagogic hallucinations--sometimes I get the auditory kind. I read on Wikipedia that they are actually fairly common. Still a scary, scary experience.
>
> But the side effects were more than enough to worry about the Lithium before your hallucination.
>
> From all the studies I read about Lithium, it ought to be the perfect drug for me--I have bipolar II, depressed--that is, until I actually take it. Worst side effects I've ever had from anything.Yeah, you're right. I just... I really wanted Lithium to work, you know? I can tell you know. It took me ages to garner up the courage to try it, and that was only because I was in hospital (4 months!) with three docs wanting to give me ECT and they said if I couldn't make a decision - augment with Lithium or ECT or both - then they would have me declared legally unfit and they'd make the decision for me.
I hate anti-psychotics, they make me feel worse. All the fat meds make me feel worse, too much anxiety. I don't want ECT messing with my brain, I've already lost my brain to depression as it is. And all the meds just keep getting worse and worse and more and more intolerable.
Sh*t, everything is freaking hopeless.
Posted by raisinb on January 30, 2012, at 19:45:28
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by papillon2 on January 30, 2012, at 18:02:31
WTF, can they legally do that? Are you in the US?
Yeah, I know how you feel--I desperately needed something to work, too. Finally a combo of things did, just not Lithium. I'm in remission now and have been for a few months, but suicidal depression has been a regular part of most of my life.
Posted by papillon2 on January 30, 2012, at 20:33:02
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 30, 2012, at 19:45:28
> WTF, can they legally do that? Are you in the US?
I'm from Australia, relevant legislation here: http://www.legislation.nsw.gov.au/fullhtml/inforce/act+8+2007+FIRST+0+N refer to section 3.
I know you can be forcibly admitted and treated against your wishes in the US, but I'm not sure if such treatment extends to ECT.
Posted by papillon2 on January 30, 2012, at 20:39:40
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by raisinb on January 30, 2012, at 19:45:28
Sorry, that should be Chapter 3 (section 12 onwards) and for ECT, see Divison 3 (section 87 onwards)
Posted by Raisinb on January 31, 2012, at 16:59:45
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by papillon2 on January 30, 2012, at 20:39:40
I didn't know that. Sobering. Glad you were able to avoid the ECT.
Posted by crazyjoe on February 1, 2012, at 21:28:07
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by Raisinb on January 31, 2012, at 16:59:45
why does know one ever discuss lithiums effects on the kidneys
Posted by ed_uk2010 on February 2, 2012, at 6:26:49
In reply to Re: Lithium's Safety Evaluated Safer Than Thought, posted by crazyjoe on February 1, 2012, at 21:28:07
>why does no one ever discuss lithium's effects on the kidneys
Lithium is now generally used at lower doses than previously, which may be less toxic to the kidneys. Rather than using very high doses of lithium, it is usual to combine a moderate dose of lithium with another medication (eg. Depakote or Zyprexa) if the response is not sufficient.
Regular blood tests are recommended to assess lithium level, renal (kidney) function, thyroid function and according to this article, calcium levels. The dose is adjusted based on patient response, tolerability and lithium level. Additional treatment with thyroid hormones may be needed if hypothyroidism occurs. If there was a large decrease in renal function, lithium would have to be stopped. Fortunately, it's much more common to see small changes in renal function which would be monitored with further blood tests.
Posted by papillon2 on February 8, 2012, at 20:30:08
In reply to Re: Lithium's Safety Evaluated -Safer Than Thought » crazyjoe, posted by ed_uk2010 on February 2, 2012, at 6:26:49
So I saw my psychiatrist yesterday who agreed with me on the likelihood of Lithium being responsible for my confusion, hallucination, etc two weeks ago. She also agreed that I made the right call in discontinuing Lithium. But she wants me to resume taking it (and have weekly appointments) as I have a stressful 2 months ahead of me. So back I go.
This could get interesting. :/S
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