Can we check serum lithium levels less often without compromising patient safety?

Background Lithium is viewed as the first-line long-term treatment for prevention of relapse in people with bipolar disorder. Aims This study examined factors associated with the likelihood of maintaining serum lithium levels within the recommended range and explored whether the monitoring interval could be extended in some cases. Method We included 46 555 lithium rest requests in 3371 individuals over 7 years from three UK centres. Using lithium results in four categories (<0.4 mmol/L; 0.40–0.79 mmol/L; 0.80–0.99 mmol/L; ≥1.0 mmol/L), we determined the proportion of instances where lithium results remained stable or switched category on subsequent testing, considering the effects of age, duration of lithium therapy and testing history. Results For tests within the recommended range (0.40–0.99 mmol/L categories), 84.5% of subsequent tests remained within this range. Overall, 3 monthly testing was associated with 90% of lithium results remaining within range, compared with 85% at 6 monthly intervals. In cases where the lithium level in the previous 12 months was on target (0.40–0.79 mmol/L; British National Formulary/National Institute for Health and Care Excellence criteria), 90% remained within the target range at 6 months. Neither age nor duration of lithium therapy had any significant effect on lithium level stability. Levels within the 0.80–0.99 mmol/L category were linked to a higher probability of moving to the ≥1.0 mmol/L category (10%) compared with those in the 0.4–0.79 mmol/L group (2%), irrespective of testing frequency. Conclusion We propose that for those who achieve 12 months of lithium tests within the 0.40–0.79 mmol/L range, the interval between tests could increase to 6 months, irrespective of age. Where lithium levels are 0.80–0.99 mmol/L, the test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.

402 - An audit of Lithium Prescribing Practices in an Old Age PsychiatryService highlighting renal impairment in this cohort

Aims:To compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West ofIreland among adults aged 65 years and over with best practice guidelines.Methods:Review of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary(2019) and Maudsley Prescribing Guidelines (2018). Data was collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past year.Results:At the time of audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n=9) had depression, 44% (n=8) had bipolar affective disorder (BPAD) and 6% (n=1) schizoaffective disorder.78% (n= 14) of patients met the NICE standard of 3-monthly lithium level. Lithium levels were checkedon average 4.5 times in past year, average lithium level was 0.61mmol/L across the group and 39% (n=7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% of patients (n=15) met the NICE standards of 3 monthly renal tests. Taking into consideration mostrecent blood test results, 100% (n=18) had abnormal renal function.Half (n=9) were initiated on lithium by POA service and of these, 56% (n=5) had documented renal impairment prior to initiation. Of patients on long term lithium at time of referral (n=9), almost half (n=4) had a documented history of lithium toxicity.Conclusions:The results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function. This is an important finding given the associations between those admitted to hospital with COVID-19 and co- morbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in elderly prescribed lithiumgiven the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

Audit of shared-care lithium monitoring in a large rural GP practice

AimsTo compare monitoring of lithium treatment with shared care lithium monitoring agreements in a large rural GP practice.BackgroundA ‘near miss’ event with a patient with drug induced long QT syndrome highlighted a need for an audit of lithium monitoring at a large rural GP practice.The practice had entered into shared-care monitoring agreements with the local mental health care trust. Under these agreements, responsibility for physical monitoring of lithium treatment was assumed by the practice.MethodUsing audit functions built into the IT system, all patients at the practice who were currently prescribed lithium-containing medications were identified (n = 28). Individual monitoring standards were determined for each patient based on the shared care agreement. These varied depending on age and comorbidity. Monitoring data obtained from medical records was compared against the individualised monitoring requirement.ResultThe key finding was that 26% of patients for whom annual ECGs were indicated according to the shared care agreement had received an ECG in the past year. 78% of patients had a lithium level recorded in the previous 3 months. 81% of patients had a renal function test within their monitoring requirements. 52% of patients had lipid measurement in the previous year.ConclusionThere is a great degree of heterogeneity in the extent to which shared care monitoring agreements are achieved. It is noted that those standards to which a Quality Outcome Framework incentive applied had a greater chance of being met. Worryingly, the QOF statements relating to lithium treatment have now been retired as of April 2019. It is suggested that psychiatrists are aware of the challenges primary care faces when monitoring lithium treatment.

An audit of lithium prescribing practices in an old age psychiatry service highlighting renal impairment in this cohort

AimsTo compare Lithium prescribing practices in a Psychiatry of Old Age (POA) Service in the North-West of Ireland among adults aged 65 years and over with best practice guidelines.MethodReview of the literature informed development of audit standards for Lithium prescribing. These included National Institute for Clinical Excellent (NICE) 2014 guidelines, The British National Formulary (2019) and Maudsley Prescribing Guidelines (2018). Data were collected retrospectively, using an audit-specific data collection tool, from clinical files of POA team caseload, aged 65 years or more and prescribed Lithium over the past one year.ResultAt the time of the audit in February 2020, 18 patients were prescribed lithium, 67% female, average age 74.6 years. Of those prescribed Lithium; 50% (n = 9) had a depression diagnosis, 44% (n = 8) had bipolar affective disorder (BPAD) and 6% (n = 1) had schizoaffective disorder.78% (n = 14) of patients were on track to meet, or had already met, the NICE standard of 3-monthly serum lithium level. Lithium levels were checked on average 4.5 times in past one year, average lithium level was 0.61mmol/L across the group and 39% (n = 7) had lithium level within recommended therapeutic range (0.6-0.8mmol/L).83% (n = 15) of patients met the NICE standards of 3 monthly renal tests, thyroid function test was performed in 89% (n = 16) and at least one serum calcium level was documented in 63% (n = 15). Taking into consideration most recent blood test results, 100% (n = 18) had abnormal renal function, 78% (n = 7) had abnormal thyroid function and 60% (n = 9) had abnormal serum calcium.Half (n = 9) were initiated on lithium by POA service and of these, 56% (n = 5) had documented renal impairment prior to initiation. Of patients on long term lithium therapy at time of referral (n = 9), almost half (n = 4) had a documented history of lithium toxicity.ConclusionThe results of this audit highlight room for improvement in lithium monitoring of older adults attending POA service. Furthermore, all patients prescribed lithium had impaired renal function, half had abnormal calcium and two fifths had abnormal thyroid function. This is an important finding given the associations between those admitted to hospital with COVID-19 and comorbid kidney disease and increased risk of inpatient death.Our findings highlight the need for three monthly renal function monitoring in older adults prescribed lithium given the additive adverse effects of increasing age and lithium on the kidney. Close working with specialised renal services to provide timely advice on renal management for those with renal impairment prescribed lithium is important to minimise adverse patient outcomes.

We can check serum lithium levels less often without compromising patient safety: evidence from a multi-centre study

AimsLithium was first found to have an acute antimanic effect in 1948 with further corroboration in the early 1950s. It took some time for lithium to become the standard treatment for relapse prevention in bipolar affective disorder. In this study, our aims were to examine the factors associated wtih the likelihood of maintaining lithium levels within the recommended therapeutic range and to look at the stability of lithium levels between blood tests. We examined this relation using clinical laboratory serum lithium test requesting data collected from three large UK centres, where the approach to managing patients with bipolar disorder and ordering lithium testing varied.Method46,555 lithium rest requests in 3,371 individuals over 7 years were included from three UK centres. Using lithium results in four categories (<0.4 mmol/L; 0.40–0.79 mmol/L; 0.80–0.99 mmol/L; ≥1.0 mmol/L), we determined the proportion of instances where, on subsequent testing, lithium results remained in the same category or switched category. We then examined the association between testing interval and proportion remaining within target, and the effect of age, duration of lithium therapy and testing history.ResultFor tests within the recommended range (0.40–0.99 mmol/L categories), 84.5% of subsequent tests remained within this range. Overall 3-monthly testing was associated with 90% of lithium results remaining within range compared with 85% at 6-monthly intervals. At all test intervals, lithium test result history in the previous 12-months was associated with the proportion of next test results on target (BNF/NICE criteria), with 90% remaining within range target after 6-months if all tests in the previous 12-months were on target. Age/duration of lithium therapy had no significant effect on lithium level stability. Levels within the 0.80–0.99 mmol/L category were linked to a higher probability of moving to the ≥1.0 mmol/L category (10%) than those in the 0.40–0.79 mmolL group (2%), irrespective of testing frequency. Thus prior history in relation to stability of lithium level in the previous 12 months is a predictor of future stability of lithium level.ConclusionWe propose that, for those who achieve 12-months of lithium tests within the 0.40–0.79mmol/L range, it would be reasonable to increase the interval between tests to 6 months, irrespective of age, freeing up resource to focus on those less concordant with their lithium monitoring. Where lithium level is 0.80–0.99mmol/L test interval should remain at 3 months. This could reduce lithium test numbers by 15% and costs by ~$0.4 m p.a.

Calcium of 19mg/dL and Yet Asymptomatic

Lithium is a commonly used medication for Bipolar disorder. Lithium induced hyperparathyroidism is a rare disorder but leading cause of hypercalcemia in patients receiving Lithium treatment. Lithium may lead to exacerbation of pre-existing hyperparathyroidism or it may increase set point for calcium for PTH suppression. We present a case of 65 year old female presented with hypercalcemia of 19mg/dl. She was sent by PCP office for hypercalcemia. She did not have any complains and was completely asymptomatic. Her history includes hypertension, Bipolar disorder and Diabetes mellitus type 2. She has not been able to get her labs drawn because of COVID-19. She was only having Tele visits with Psychiatrist. Her mood and bipolar symptoms were under controlled. She denies any abdominal pain, headache, visual problems, polyuria, polydipsia, numbness or tingling. She was given IV fluids and calcium was monitored. Her PTH was 65mg/dl, CBC and metabolic panel normal otherwise. Her Sestamibi scan was negative for parathyroid adenoma. Her lithium level was 4mg/dl. Lithium was discontinued after Psychiatry consultation. Her calcium came down to 9mg/dl after aggressive fluid resuscitation. Her calcium, parathyroid and lithium levels were monitored for next 6 months. Given her asymptomatic course she was not started on any calcium lowering medication. Her lithium level normalizes after one year of abstinence. A patient who is started on Lithium therapy should be monitored for hypercalcemia, hyperparathyroidism and nephrogenic diabetes.

A case of unsuspected chronic lithium toxicity presenting with neurological symptoms

Lithium Carbonate is the first line treatment for bipolar depressive disorder. It also has beneficial effects on prophylactic use in Acute manic episodes to prevent recurrence and reduces rate of suicide associated with affective disorder. Low therapeutic index of Lithium (0.8-1.2meq/l) mandates regular and frequent measurement of Serum lithium level in patients taking this drug. Here we present a 59 years Indian male who is a known diabetic, chronic alcoholic and a case of bipolar disorder. He was on Lithium tablet off and on for last 4 years and was also on oral antidiabetic agent. He was admitted in ICU through emergency with complaints of altered level of consciousness for 2 days with H/O recurrent hypoglycemia associated with nausea, reduced food intake, vertigo, tremor of all four limbs with weakness of both lower limbs for approximately last 2 months. Admission serum lithium level was 2.24meq/l. Hemodialysis was started. Neurological symptoms improved and serum Lithium level returned to normal (0.79meq/l) after 2 session of hemodialysis. Bangladesh Crit Care J March 2021; 9(1): 46-48

Serum Lithium in Patients in Remission of Bipolar Disorder

Introduction: Bipolar affective disorder a chronic, and highly disabling psychiatric disorder is one of the leading causes of disability and is estimated to affect more than 1% of the global population irrespective of origin, ethnicity, nationality or socioeconomic status. The effectiveness of lithium in mania and psychotic excitement was proven first proven in 1960 and since then lithium is considered to be a gold standard treatment for bipolar disorder. Material and Method: A total of one hundred thirty five patients with bipolar disorder were enrolled in a prospective study to analyze the serum lithium levels on maintenance dose of lithium. After ethical clearance data was collected from patients attending BG Hospital and Research Centre from July 2013 to July 2019. The patients who were on maintenance treatment with different doses of lithium only were included. These patients were tested for serum lithium concentration as per lithium monitoring guidelines. Serum Lithium, serum electrolytes, height and weight of the patients were recorded. The psychiatric diagnosis was made according to the ICD-10 criteria. Data were computed and analyzed by using SPSS version 21. Parametric and non-parametric statistical technique was applied wherever appropriate. Results: The minimum efficacious serum lithium level in the long-term treatment of bipolar disorder was found at 0.16 mmol/l and maximum serum levels was 1.51 mmol/l. The mean serum lithium level was 0.596 mmol/l with standard deviation of 0.237 mmol/l. Conclusion: There is substantial variation in between the serum lithium levels of patients in remission on long term treatment. The uncertainty about the most efficacious serum lithium level for the long-term treatment of bipolar disorder leads to the suggestion of the treatment of individual patients to be based on clinical response rather than on serum lithium levels.