Class: Antimanic Agents
VA Class: CN750
CAS Number: 554-13-2
Brands: Eskalith, Lithobid
Lithium toxicity is closely related to serum lithium concentrations and can occur at dosages close to therapeutic levels.404 428
Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy.404 428 (See Renal Effects under Cautions.)
Introduction
Antimanic agent.404 428
Uses for Lithium Salts
Bipolar Disorder
Management of bipolar disorder, 410 422 particularly acute manic or mixed episodes in patients with bipolar 1 or bipolar 2 disorder.401 403 404 405 406 407 409 410 411 412 421 422
A first-line agent in the initial treatment of depressive, manic, or mixed episodes in patients with bipolar disorder.401 421 a
Combination therapy with an atypical antipsychotic, another mood stabilizing agent, and/or antidepressant may be required to adequately treat rapid cycling and more severe depressive, manic, or mixed episodes.401 403 411 412 420 421 422 423
Maintenance therapy has been shown to prevent or diminish the intensity of subsequent manic episodes in patients with bipolar disorder with a history of mania.403 404 405 407 410 412 421 422 424
Major Depression†
Should be used only in patients who fail to respond to other antidepressants.a
Schizoaffective and Schizophrenic Disorders†
Limited effectiveness when used alone; should be used only after antipsychotic agents have failed.439 a
May be added to existing antipsychotic therapy, but efficacy of such combined therapy has varied in different clinical studies.439 Careful monitoring (e.g., serum lithium concentrations, adverse effects, possible adverse drug interactions) recommended.439 a
Disorders of Impulse Control†
Has reduced temper outbursts, impulsive antisocial behavior, and the number of assaultive acts in a small number of adults with disorders of impulse control†.a
Psychiatric Disorders in Children†
Treatment of children with apparent mixed bipolar disorder symptomatology†, hyperactivity with psychotic or neurotic components†, or aggressive behavior† or aggressive outbursts† associated with attention-deficit hyperactivity disorder (ADHD); should be used only after more conservative therapies have failed.a
Neutropenia and Anemia†
Treatment of neutropenia† or anemia† secondary to antineoplastic drugs.a
Routine use not recommended for congenital, idiopathic, or cyclic neutropenias†; Felty’s syndrome†; or aplastic anemia†.a
Hyperthyroidism†
Treatment of hyperthyroidism†; other treatments (e.g., radioactive iodine, surgery, propylthiouracil, methimazole) currently are preferred.a
SIADH†
No longer considered one of the therapies of choice; generally has been replaced with other more effective and/or less toxic therapies (e.g., demeclocycline).a
Lithium Salts Dosage and Administration
General
Careful monitoring of serum lithium concentrations and clinical status of the patient is mandatory and patients should be carefully instructed in the safe use of the drug.404 428
Carefully review the precautions and contraindications associated with lithium use before initiating therapy.404 428
Monitor serum lithium concentrations twice weekly during initiation of the acute phase of therapy and until serum concentration and clinical condition have stabilized;404 405 428 patient’s ability to tolerate high serum lithium concentrations usually decreases as initial manic symptoms begin to subside.a
After the patient has been stabilized, monitor serum concentrations at least every 2 months in most patients.404 405 428
Onset of acute antimanic effect of lithium usually occurs within 5–7 days; full therapeutic effect often requires 10–21 days.a
The manufacturers suggest that steady-state serum lithium concentrations be determined immediately before the next dose (i.e., 8–12 hours after the previous lithium dose).404 405 428 Total reliance must not be placed on serum lithium concentrations alone; accurate patient evaluation requires both careful clinical and laboratory evaluation.404 405 428
Serum lithium concentrations of 1–1.2 mEq/L usually are required during acute affective episodes.401 427 Serum concentration should not exceed 1.5 mEq/L during the acute treatment phase.401 427
If manifestations of lithium toxicity occur (see Lithium Toxicity under Cautions), temporarily discontinue for 24–48 hours, then resume at a lower dosage.404 405 428
Administration
Oral Administration
Administer orally, preferably with meals in divided doses.404 428
Administer conventional tablets, capsules, or oral solution 3 or 4 times daily;404 428 twice daily administration may be associated with adverse GI or nervous system effects.a Administer extended-release tablets 2 or 3 times daily.404 405 a
Extended-release preparations should be swallowed intact and should not be chewed, crushed, or halved.405
Lithium citrate oral solutions may be useful in patients unable to swallow capsules or tablets; 5 mL of a commercially available solution contains about 8 mEq of lithium and is approximately equivalent to 300 mg of lithium carbonate.404 428
Dosage
Available as lithium carbonate and lithium citrate; dosages expressed in terms of the salts.404 428
Pediatric Patients
Bipolar Disorder
Acute Episodes†
Oral
Children ≤11 years of age: Usual dosages not established; lithium carbonate dosages of 15–20 mg/kg (about 0.4–0.5 mEq/kg) daily or equivalent lithium citrate dosages have been given in 2 or 3 divided doses.427 (Do not exceed usual adult dosages.a )
Children ≥12 years of age: Dosages usually are the same as those of adults.427
Maintenance Dosages†
Oral
Usual maintenance dosages have not been established; dosage should be adjusted according to serum lithium concentrations, patient tolerance, and clinical response.a
Adults
Bipolar Disorder
Acute Episodes
Oral
Initially, 1.8 g daily as conventional lithium carbonate capsules or tablets, given in 3 or 4 divided doses, or 30 mL (about 48 mEq of lithium) of lithium citrate oral solution daily, given in 3 divided doses.404 428
Alternatively, 900 mg twice daily (morning and evening) or 600 mg 3 times daily as extended-release lithium carbonate tablets.404 405
Maintenance Dosages
Oral
900 mg to 1.2 g daily as conventional lithium carbonate capsules or tablets, given in 3 or 4 divided doses, or 15–20 mL (about 24–32 mEq of lithium) of lithium citrate oral solution daily, given in 3 or 4 divided doses. This dosage generally provides serum lithium concentrations of 0.6–1.2 mEq/L.404 405 427 428
Alternatively, 900 mg to 1.2 g daily as extended-release lithium carbonate tablets, given in 2 or 3 divided doses.404 405
Prescribing Limits
Pediatric Patients
Bipolar Disorder
Oral
When calculating dosage based on weight, do not exceed usual adult dosage.a 428
Adults
Bipolar Disorder
Oral
Maintenance dosage usually should not exceed 2.4 g of lithium carbonate (65 mEq) daily.427
Special Populations
Geriatric Patients
Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.405 Lower initial dosages (e.g., ≤900 mg of lithium carbonate daily) and more gradual dosage titration recommended.401 405
May have decreased renal function; monitor renal function and adjust dosage accordingly.405
Dosages that produce serum lithium concentrations at the lower end of therapeutic range may be sufficient for maintenance.401 (See Geriatric Use under Cautions.)
Pregnant Women
Dosages generally need to be increased during pregnancy but should be reduced 1 week before parturition or when labor begins.a (See Fetal/Neonatal Morbidity and Mortality and also see Pregnancy under Cautions.)
Cautions for Lithium Salts
Contraindications
Significant renal or cardiovascular disease, severe debilitation, dehydration, sodium depletion, or concomitant therapy with diuretics; very high risk of lithium toxicity under such conditions.404 428
Only begin lithium in such patients if psychiatric indication is life-threatening, and other treatments have failed; however, must use with extreme caution, including daily serum lithium determinations and adjustment to usually low doses ordinarily tolerated by these individuals.404 428 In such instances, hospitalization is a necessity.404 428
Warnings/Precautions
Warnings
Fetal/Neonatal Morbidity and Mortality
May cause fetal toxicity (e.g., increase in cardiac and other anomalies, especially Ebstein’s anomaly) when administered to pregnant women, but potential benefits may be acceptable in certain conditions despite the possible risks to the fetus.a 428
If used in women of childbearing potential, during pregnancy, or if a patient becomes pregnant during treatment, the patient should be be informed of the potential hazard to the fetus.428
Whenever possible, lithium should be withdrawn for at least the first trimester unless it is determined that this would seriously endanger the mother.428 (See Pregnant Women under Dosage and Administration and see Pregnancy under Cautions.)
Lithium Toxicity
Risk of toxicity increases with increasing serum lithium concentrations.428 Serum concentration should not exceed 1.5 mEq/L during the acute treatment phase.401 427
Serum lithium concentrations >1.5 mEq/L usually carry a greater risk than lower levels. (See General under Dosage and Administration.)428
Diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity, and can occur at lithium concentrations <2 mEq/L.428 At higher levels, giddiness, ataxia, blurred vision, tinnitus, and a large output of dilute urine may be seen.428
Serum lithium levels above 3 mEq/L may produce a complex clinical picture involving multiple organs and organ systems.428 (See General under Dosage and Administration.)
Renal Effects
Diminution of renal concentrating ability, occasionally presenting as nephrogenic diabetes insipidus, with polyuria and polydipsia, possible following chronic lithium therapy.428 Morphologic changes with glomerular and interstitial fibrosis and nephron atrophy also possible.428
Measurement of 24-hour Clcr, renal-concentrating ability, and a urinalysis recommended prior to initiating therapy.a Renal function should then be evaluated every 2–3 months for the first 6 months, then every 6–12 months during therapy or whenever clinically indicated.401 420
If progressive or sudden changes in renal function, even within the normal range, occur during lithium therapy, reevaluate need for therapy with the drug.a
Interactions
Encephalopathic syndrome reported with concomitant use with antipsychotic agents.404 405 428 May be similar to or same as neuroleptic malignant syndrome (NMS).404 405 (See Specific Drugs under Interactions.)
May prolong effects of neuromuscular blocking agents.404 405 428 (See Specific Drugs under Interactions.)
General Precautions
Concomitant Illnesses
Decreased tolerance to lithium has been reported to ensue from protracted sweating, diarrhea, or concomitant infection with elevated temperatures and may necessitate a temporary reduction or cessation of medication.404 428 a Patients should maintain their usual fluid (2.5–3 L/day) and sodium intake, and supplement these in the event of fever (e.g., during infections), vomiting, or diarrhea.404 428 a
Sodium-restricted Diet
Use with caution in patients whose sodium intake is restricted;a stabilize sodium intake and carefully titrate lithium dosage to avoid increased serum lithium concentrations that may occur with sodium depletion.a
Endocrine Effects
Hypothyroidism, with manifestations ranging from mild to severe myxedema, may occur within weeks to years after initiating lithium therapy; rarely, hypothyroidism may persist after discontinuance of the drug.a Geriatric patients and patients with antithyroglobulin antibody, a prior history of Graves’ disease or Hashimoto’s thyroiditis, or those receiving iodine appear most at risk.a Paradoxically, a few cases of hyperthyroidism also have been reported.
Preexisting thyroid disorders are not contraindications to lithium therapy.404 428 Patients with underlying hypothyroidism should have thyroid function (T3, T4, and TSH concentrations) evaluated yearly and be given supplemental thyroid therapy when needed.a
Specific Populations
Pregnancy
Category D.428 (See Fetal/Neonatal Morbidity and Mortality under Cautions.)
Women of childbearing age receiving lithium should be counseled about methods of birth control.a If used during pregnancy, carefully monitor serum lithium concentrations and adjust dosage accordingly.a (See Pregnant Women under Dosage and Administration.)
Lactation
Lithium is distributed into milk;428 discontinue nursing or the drug, taking into account the importance of the drug to the woman.428
Pediatric Use
Safety and efficacy have not been established in children <12 years of age;404 405 428 a however, the drug has been used in this age group when benefits were thought to outweigh risks.a
Transient acute dystonia and hyperreflexia occurred in a 15-kg child who ingested 300 mg of lithium carbonate.404 405 428
Geriatric Use
Insufficient experience with extended-release tablets in patients ≥65 years of age to determine whether geriatric patients respond differently than younger patients.405
Age-related differences in response to lithium generally not observed.405
Use with caution; geriatric patients appear more susceptible to adverse effects (e.g., adverse nervous system and neuromuscular effects), even at therapeutic serum concentrations, and more prone to developing lithium-induced goiter and clinical hypothyroidism.404 a Some clinicians recommend that thyroid function tests be performed every 6–12 months in these patients.a
Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and potential for concomitant disease and drug therapy; geriatric patients should receive initial lithium dosages in the lower end of the usual range (see Geriatric Patients under Dosage and Administration).405
Lithium is substantially excreted by the kidneys; consider monitoring renal function and adjust dosage if necessary since geriatric patients are more likely to have decreased renal function.405
Common Adverse Effects
Fine hand tremor, polyuria, mild thirst, transient and mild nausea, and general discomfort may appear during the first few days of lithium administration; usually subside with continued treatment, a temporary reduction of dosage, or temporary cessation.405 428 If persistent, a cessation of therapy is indicated.405 428
Interactions for Lithium Salts
Lithium is not metabolized.a
Electroconvulsive Therapy
Acute neurotoxicity with prominent delirium has occurred in patients receiving lithium and electroconvulsive therapy (ECT) concurrently.a Some clinicians recommend decreasing lithium dosage or withdrawing the drug 2 days prior to ECT.a
Specific Drugs
Drug | Interaction | Comments |
|---|---|---|
ACE inhibitors | Increased plasma lithium concentrations resulting in several cases of lithium intoxicationa | If used concomitantly, adjust lithium dosages and carefully monitor serum lithium concentrationsa Some clinicians advise against concomitant ACE inhibitor use in geriatric patients or those patients with CHF, renal insufficiency, or volume depletiona |
Alkalinizing agents (e.g., sodium bicarbonate) | May increase renal excretion of lithiuma | Higher lithium dosage may be requireda |
Anticonvulsants (e.g., carbamazepine, phenytoin) | Adverse neurologic effects following concomitant therapy with carbamazepine or phenytoina Concurrent use of lithium and phenytoin may increase serum lithium concentrationsa | Clinical importance not determineda |
Antidepressants, SSRIs (e.g., fluoxetine, paroxetine) | Possibly associated with increased serum lithium concentrations, lithium toxicity, and/or serotonin syndrome (e.g., absence seizures, agitation, ataxia, confusion, diarrhea, dizziness, dysarthria, stiffness of the extremities, tremor);404 405 a decreased serum lithium concentrations also reported405 | Use with caution and monitor closely404 405 |
Antipsychotic agents (e.g., haloperidol, phenothiazines) | Acute encephalopathic syndromes or extrapyramidal reactions (e.g., NMS or NMS-type reactions), possibly resulting in irreversible brain damage, parkinsonian movements, and dyskinesiasa 404 405 428 Nausea and vomiting, which are occasionally signs of lithium intoxication, may be masked by the antiemetic effect of some phenothiazines when used concurrentlya | Monitor patients for adverse neurologic effects, especially when large dosages of lithium and an antipsychotic agent are used; combined therapy should be promptly discontinued if such signs or symptoms appear404 405 428 a |
β-Adrenergic blocking agents | Absence of tremor may make lithium intoxication more difficult to diagnosea | Monitor for other signs and symptoms of lithium intoxicationa |
Baclofen | May cause hyperkinetic movementsa | |
Calcium-channel blocking agents (e.g., verapamil) | May potentiate the toxic effects of lithium; neurotoxicity (e.g., ataxia, choreoathetosis, tremors, tinnitus), adverse GI effects (e.g., nausea, vomiting, diarrhea), and bradycardia reporteda Decreased serum lithium concentrations following initiation of verapamil in patients stabilized on lithium therapya | Use with cautiona Monitor serum lithium concentrations and patient; adjust lithium dosage accordingly when verapamil is initiated or discontinued in patients receiving lithium therapya |
Diazepam | Profound hypothermia has been reported in at least one patienta | Widespread use usually without unusual adverse effects indicates that it is safe in most patientsa |
Diuretics (e.g., amiloride, aminophylline, furosemide, spironolactone, thiazides, urea) | Decreased lithium clearance resulting in increased serum lithium concentrations and several cases of lithium intoxication have occurred with concomitant thiazide usea Other diuretics (e.g., aminophylline, furosemide, spironolactone, urea) also may reduce renal clearance of lithiuma Amiloride does not appear to substantially affect lithium pharmacokinetics in most patientsa | Concomitant use usually is contraindicateda 428 If used in combination with thiazide diuretics, usual initial dosage of lithium should be reduced by about 50% and the patient and serum lithium concentrations should be monitored carefully;a subsequent lithium dosage should be adjusted as necessarya |
Iodides | Additive or synergistic hypothyroid effect; may result in hypothyroidisma | Concomitant use is not recommended; if used concomitantly, monitor closely for signs and symptoms of hypothyroidisma |
Metronidazole | May increase serum lithium concentrations, resulting in signs of lithium toxicitya | Use with caution; monitor serum lithium concentrations frequentlya |
Neuromuscular blocking agents (e.g., pancuronium, succinylcholine) | May prolong the latency of neuromuscular blockadea | Use with caution and carefully monitor patients during concomitant use;a consider temporary discontinuance of lithiuma |
NSAIAs (e.g., celecoxib, indomethacin, piroxicam) | Decreased renal clearance of lithium, which may lead to increased serum or plasma lithium concentrations and lithium toxicity404 405 428 a | Monitor serum lithium concentrations and observe patient for signs and symptoms of lithium intoxication404 405 428 a Adjust lithium dosages as neededa |
Opiate agonists | Interferes with opiate-induced euphoria and diminishes the analgesic effect of opiates (narcotic analgesics)a | |
Sodium | Changes in sodium intake in patients receiving lithium may alter the renal elimination of lithiuma | Patients should be advised to avoid substantial changes in their sodium intakea When drugs with a high sodium content (e.g., antacids) are used concomitantly with lithium, serum lithium concentrations should be monitoreda |
Tetracycline | Increased serum lithium concentrationsa | The clinical importance of this effect has not been determineda |
Lithium Salts Pharmacokinetics
Absorption
Bioavailability
Conventional lithium carbonate capsules and tablets are 95–100% absorbed.a
Extended-release lithium carbonate tablets are 60–90% absorbed.a
Lithium citrate oral solutions are essentially 100% absorbed.a
Onset
Acute antimanic effect usually occurs within 5–7 days; full therapeutic effect often requires 10–21 days.a
Food
Food does not appear to affect the bioavailability of lithium.a
Plasma Concentrations
Therapeutic serum lithium concentrations usually range from 1–1.2 mEq/L during acute affective episodes.401 427 428
A 12-hour steady-state serum lithium concentration is used by most clinicians for monitoring serum concentrations; this concentration shows a high intraindividual (but not interindividual) reproducibility.a (See General under Dosage and Administration.)
Distribution
Extent
Widely distributed into most body tissues and fluids, including bone, brain tissue, erythrocytes, saliva, and thyroid.a
Lithium freely crosses the placenta; maternal and fetal serum concentrations are approximately equal.a The milk of nursing women contains lithium concentrations that are approximately 33–50% of those in serum.a
Plasma Protein Binding
Lithium is not bound to plasma proteins.a
Elimination
Metabolism
Lithium is not metabolized.a
Elimination Route
Principally renal.428
Half-life
Approximately 24 hours.428
Special Populations
In geriatric patients and patients with impaired renal function, serum half-lives of 36 and 40–50 hours, respectively, have been reported.a
Clearance and distribution into erythrocytes may be increased during pregnancy.a Immediately postpartum, renal clearance of lithium may decrease to pre-pregnancy levels.a
Lithium is readily removed by hemodialysis but not as readily removed by peritoneal dialysis.a Rebound increases in serum lithium concentration frequently occur 5–8 hours after dialysis.a
Stability
Storage
Oral
Capsules, Tablets, and Extended-release Tablets
Well-closed containers at 15–30°C.404 405 a Protect from moisture.405
Solution
Tight containers at 15–30°C.404 a
ActionsActions
Alters sodium transport in nerve and muscle cells and effects a shift toward intraneuronal metabolism of catecholamines, but the specific biochemical mechanism of lithium action in mania is unknown.404 405 428
Decreases renal-concentrating ability and water reabsorption and initially increases sodium and potassium excretion.a Some of these effects are overcome by counteracting physiologic mechanisms, while others may persist.a GFR may be slightly decreased in patients receiving prolonged lithium therapy.a
Various effects on the thyroid gland; principal effect is to block the release of thyroxine (T4) and triiodothyronine (T3) mediated by thyrotropin.a This results in a decrease in circulating T4 and T3 concentrations and a feedback increase in serum thyrotropin concentration.a Lithium also inhibits thyrotropin-stimulated adenylate cyclase activity and thyrotropin-induced release of thyroidal iodine 131, decreases intrathyroidal iodothyronine-iodotyrosine ratios, and inhibits colloid droplet formation.a
Advice to Patients
Importance of avoiding dehydration and maintaining usual sodium and fluid intake; importance of reporting polyuria and any prolonged vomiting, diarrhea, or fever to clinician.404 428
Importance of immediately discontinuing lithium therapy and consulting a clinician if signs of lithium intoxication (e.g., muscle twitching, tremor, mild ataxia, drowsiness, muscle weakness, diarrhea, vomiting) occur.404 428
Importance of advising patients that lithium may impair their ability to perform activities requiring mental alertness or physical coordination (e.g., operating machinery, driving a motor vehicle).404 428
Importance of informing clinician of existing or contemplated concomitant therapy, including prescription and OTC drugs.404 428
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.404 428
Importance of informing patients of other important precautionary information.404 405 428 (See Cautions.)
Preparations
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Oral | Capsules | 150 mg (4.06 mEq of lithium) | Lithium Carbonate Capsules | Roxane |
300 mg (8.12 mEq of lithium)* | Eskalith (with benzyl alcohol and povidone) | GlaxoSmithKline | ||
600 mg (16.24 mEq of lithium) | Lithium Carbonate Capsules | Roxane | ||
Tablets | 300 mg (8.12 mEq of lithium) | Lithium Carbonate Tablets (with povidone; scored) | Roxane, Rugby | |
Tablets, extended-release | 450 mg (12.18 mEq of lithium) | Eskalith CR (scored) | GlaxoSmithKline | |
Tablets, extended-release, film-coated | 300 mg (8.12 mEq of lithium) | Lithobid Slow-release (with povidone and propylene glycol) | JDS Pharma |
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Oral | Solution | 8 mEq (of lithium) per 5 mL | Lithium Citrate Syrup (with alcohol 0.3%) | Major, Morton Grove, Roxane |
Comparative Pricing
This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 04/2011. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.
Lithium Carbonate 150MG Capsules (ROXANE): 90/$18.99 or 270/$56.97
Lithium Carbonate 300MG Capsules (ROXANE): 90/$25.99 or 180/$42.97
Lithium Carbonate 300MG Controlled-release Tablets (ROXANE): 30/$17.99 or 90/$35.97
Lithium Carbonate 300MG Tablets (ROXANE): 90/$25.99 or 270/$59.97
Lithium Carbonate 450MG Controlled-release Tablets (ROXANE): 60/$28.99 or 180/$81.97
Lithium Carbonate 600MG Capsules (ROXANE): 90/$39.99 or 270/$119.97
Lithium Citrate 8MEQ/5ML Syrup (ROXANE): 500/$59.99 or 1500/$150.96
Lithobid 300MG Controlled-release Tablets (NOVEN THERAPEUTICS): 90/$222 or 270/$625.95
Disclaimer
This report on medications is for your information only, and is not considered individual patient advice. Because of the changing nature of drug information, please consult your physician or pharmacist about specific clinical use.
The American Society of Health-System Pharmacists, Inc. and Drugs.com represent that the information provided hereunder was formulated with a reasonable standard of care, and in conformity with professional standards in the field. The American Society of Health-System Pharmacists, Inc. and Drugs.com make no representations or warranties, express or implied, including, but not limited to, any implied warranty of merchantability and/or fitness for a particular purpose, with respect to such information and specifically disclaims all such warranties. Users are advised that decisions regarding drug therapy are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and the information is provided for informational purposes only. The entire monograph for a drug should be reviewed for a thorough understanding of the drug's actions, uses and side effects. The American Society of Health-System Pharmacists, Inc. and Drugs.com do not endorse or recommend the use of any drug. The information is not a substitute for medical care.
AHFS Drug Information. © Copyright, 1959-2011, Selected Revisions June 01, 2006. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.
† Use is not currently included in the labeling approved by the US Food and Drug Administration.
References
Only references cited for selected revisions after 1984 are available electronically.
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