Lithium Carbonate

Aka: Lithium Carbonate, Lithium, Eskalith, Lithobid, Lithium Compound, Lithium Salt

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II. History

  1. Lithium has been used since the 1800s as a treatment for gout and Seizure Disorder and as of 1900s for mania

III. Indications

  1. Bipolar Disorder

IV. Contraindications

  1. Pregnancy
    1. Associated with Ebstein Anomaly when exposure in first trimester

V. Mechanism

  1. Lithium may increase CNS Serotonin levels
  2. Neuroprotective effect
  3. Decreases intracellular Inositol monophosphate concentrations
    1. Mood stabilization effect
  4. Inhibits Glycogen Synthase Kinase 3 (GSK3B)
    1. Enzyme involved in Neuronal development and Energy Metabolism
    2. GSK3B overexpression may be associated with Bipolar Disorder

VI. Pharmacokinetics

  1. Lithium Carbonate is a simple salt that is excreted and not metabolized
    1. Lithium is an alkali metal (the smallest metal, having atomic number 3)
  2. Steady state reached in 5 days
    1. Check Lithium levels 5 days after starting dose or changing dose
    2. Steady state will take >5 days to reach in the elderly or reduced Renal Function
  3. Blood levels peak
    1. Following immediate release dose: 1-2 hours
    2. Following sustained release dose: 4-6 hours
  4. Therapeutic Trough levels
    1. Narrow therapeutic window (low threshold for toxicity)
    2. Acute mania: 1.0 to 1.2 meq/L
    3. Maintenance Bipolar Disorder: 0.8 to 1.0 meq/liter
    4. Increasing dose 300 mg/day raises level 0.2 meq/L
  5. Excretion
    1. Renal excretion (and 60% reabsorbed at proximal tubules)
    2. Drug Clearance is directly proportional to GFR

VII. Medications

  1. Lithium Carbonate (immediate release)
    1. Capsules or Tablet: 150 mg, 300 mg, 600 mg
    2. Oral Solution: 8 mEq/5 ml (8 mEq = 300 mg)
    3. Syrup: 300 mg/ 5 ml
  2. Extended Release (Lithobid; Eskalith): 300 mg, 450 mg

VIII. Dosing: Adults

  1. Precautions
    1. Maintain oral hydration and avoid Salt Restriction
    2. Adverse effects are reduced by dividing doses 3-4 times daily and by using extended release forms
  2. Start: 300 mg orally twice daily
    1. May adjust dose every 2-3 days as tolerated
  3. Effective dose
    1. Target 900 to 1800 mg per day divided twice daily (or 3-4 times daily)
    2. Acute Mania: 1800 mg/day divided 2 to 3 times daily orally
    3. Bipolar Maintenance: 900 to 1200 mg/day divided 2 to 3 times daily
  4. Titration based on trough serum Lithium concentration
    1. Acute Therapy: 0.8 to 1.2 mEq/L
    2. Maintenance: 0.6 to 1 mEq/L

IX. Dosing: Children

  1. FDA approved for children ages 7 years and older
  2. Precautions
    1. Maintain oral hydration and avoid Salt Restriction
  3. Weight 20 to 30 kg
    1. Start 300 mg capsules (or 8 mEq of solution) orally twice daily
  4. Weight >30 kg
    1. Start 300 mg capsules (or 8 mEq of solution) orally three times daily
  5. Titration based on trough serum Lithium concentration
    1. Acute Therapy: 0.8 to 1.2 mEq/L
    2. Maintenance: 0.8 to 1 mEq/L

X. Adverse Effects: General

  1. Polyuria
  2. Hypothyroidism
    1. Often reversible on stopping Lithium
    2. Higher Prevalence in women and with increasing age
  3. Weight gain
  4. Fine Tremor
  5. Withdrawal symptoms on stopping
    1. More common than with Valproate or Lamotrigine

XI. Adverse Effects: Toxicity

  1. See Lithium Toxicity
  2. Precautions
    1. Toxicity is dose dependent and Overdose can be lethal
  3. Nausea and Vomiting
  4. Diarrhea
  5. Ataxia
  6. Coma
  7. Death
  8. Cerebellar Signs or symptoms

XII. Safety

  1. Avoid in Lactation
  2. Pregnancy Category D
    1. Highly Teratogenic
    2. Associated with Ebstein Anomaly when exposure in first trimester

XIII. Drug Interactions

  1. Drugs that increase Lithium levels
    1. Diuretics
    2. NSAIDs
      1. Aspirin and Sulindac do not increase Lithium levels
    3. ACE Inhibitors
    4. Angiotensin Receptor Blockers

XIV. Monitoring

  1. Serum Lithium level
    1. Day 5 after starting Lithium
    2. Then every 1-2 weeks initially
    3. Then every 3-6 months
    4. Also check serum levels before and 5 days after dose changes
  2. Other labs
    1. Schedule
      1. Baseline
      2. Month 3
      3. Month 6
      4. Every 6 to 12 months thereafter
    2. Thyroid Stimulating Hormone (TSH)
    3. Renal Function tests
      1. Serum Creatinine
      2. Blood Urea Nitrogen

XV. Resources

  1. Lithium Immediate Release
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=7dc9c6d2-6d9a-49e4-a8ab-437b0ed5f84e
  2. Lithium Extended Release
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=525a9d9b-cbb1-4644-a28a-8bba96f09348

XVI. References

  1. Perrone and Chatterjee (2018) UpToDate, accessed 8/20/2018

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Related Studies

Cost: Medications

lithium carbonate (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
LITHIUM CARBONATE 150 MG CAP Generic $0.08 each
LITHIUM CARBONATE 300 MG CAP Generic $0.06 each
LITHIUM CARBONATE 300 MG TAB Generic $0.13 each
LITHIUM CARBONATE 600 MG CAP Generic $0.15 each
LITHIUM CARBONATE ER 300 MG TB Generic $0.13 each
LITHIUM CARBONATE ER 450 MG TB Generic $0.19 each
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

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