Evaluation of the utilization of extracorporeal toxin removal in lithium poisoning patients in Hong Kong

Background: Extracorporeal toxin removal is used for enhanced elimination in severe lithium poisoning. The Extracorporeal TReatments In Poisoning workgroup provides recommendations on the use of extracorporeal toxin removal in poisoning. Objectives: Our aim was to identify the pattern for using extracorporeal toxin removal in managing lithium poisoning in Hong Kong and compare the outcomes in extracorporeal toxin removal-treated patients and non-extracorporeal toxin removal-treated patients if indicated for treatment as defined by The Extracorporeal TReatments In Poisoning criteria. Methods: Lithium poisoning presented between year 2009 and 2019 in Hong Kong Poison Information Centre (HKPIC) database was categorized into extracorporeal toxin removal-treated group and non-extracorporeal toxin removal-treated group. Comparative analyses were performed. Results: Among 112 lithium-poisoned patients, 21% were treated with extracorporeal toxin removal. Larger proportion of patients had fulfilled at least one Extracorporeal TReatments In Poisoning criteria for extracorporeal toxin removal in the extracorporeal toxin removal-treated group (87% vs 18%, p < 0.005). The extracorporeal toxin removal-treat group patients were more commonly presented with impaired consciousness, seizure and dysrhythmia ( p < 0.05). They also got higher admission (3.62 mmol/L vs 2.18 mmol/L, p < 0.05) and peak (4.15 mmol/L vs 2.28 mmol/L, p < 0.05) serum lithium concentrations, as well as a significantly higher serum creatinine concentration upon presentation (263.74 µmol/L vs 98.66 µmol/L, p < 0.05). Extracorporeal toxin removal-treat group patients more frequently had a severe poisoning outcome (91.3% vs 9%, p < 0.05) and developed complications (69.6% vs 13.5%, p < 0.05). Logistic regression identified seizure, peak serum lithium concentration, and serum creatinine concentration upon presentation as risk factors for severe poisoning outcome. In subgroup analysis on patients with at least one indication for extracorporeal toxin removal as defined by Extracorporeal TReatments In Poisoning criteria, the proportion of severe poisoning remained higher in the extracorporeal toxin removal-treated group (90% vs 43.7%, p < 0.05). Complication rate was not significantly different between the two groups. Conclusion: Clinically severe lithium poisoning patients were treated with extracorporeal toxin removal in Hong Kong. Extracorporeal TReatments In Poisoning criteria can serve as a reference in considering extracorporeal toxin removal treatment for lithium poisoning patients. Nevertheless, Extracorporeal TReatments In Poisoning criteria recommend more extracorporeal toxin removal treatment than it was actually done. Lithium poisoning patients with positive Extracorporeal TReatments In Poisoning criteria have been managed without extracorporeal toxin removal. No statistically significant adverse outcome was observed in these cases.

Undetectable serum lithium concentrations after coadministration of liquid lithium citrate and apple juice: A case report

Lithium is a mood-stabilizing medication approved by the FDA for the treatment of acute manic or mixed episodes of bipolar disorder as well as maintenance treatment. Lithium citrate is an oral solution, and the carbonate salt is available as oral capsules or extended-release tablets. A patient with a psychiatric history of PTSD and schizoaffective disorder–bipolar type, maintained on lithium and olanzapine prior to admission, was admitted to an inpatient psychiatric unit due to destabilization, paranoia, and mania. He was started on lithium citrate, administered with apple juice, while admitted due to nonadherence. An initial serum lithium concentration was found to be undetectable. Lithium was then administered with an alternative non–apple juice liquid, at which point serum lithium concentration became detectable and patient clinically improved. Lithium concentrations may be impacted by a number of causes, such as underlying medical conditions, drug interactions, and diet. As the majority of these factors remained stable during the patient's admission and the serum lithium concentration became detectable after switching from apple juice to an alternative non–apple juice liquid, it led to the identification of a possible incompatibility.

Seasonal and temperature effect on serum lithium concentrations

Background: Lithium remains the gold standard treatment for bipolar disorder. However, it has a very narrow therapeutic index (0.6–0.8 mmol/L). It has been suggested that high environmental temperature can lead to dehydration, elevated plasma lithium concentration and then lithium toxicity. Objectives: We aimed to investigate the effect of seasonal and short-term changes in temperature on serum lithium concentrations in Sydney, Australia. Methods: We retrospectively analysed data from all patients who had serum lithium concentrations taken from the Prince of Wales and Sutherland Hospitals between 2008 and 2018. Temperature data came from the Bureau of Meteorology. We examined correlations between lithium concentrations and the preceding 5 days maximum temperatures, month and season. We also performed a longitudinal analysis of the effect of temperature and seasons within selected patients who had repeated levels. Results: A total of 11,912 serum lithium concentrations from 2493 patients were analysed. There was no significant association between higher lithium concentration and preceding higher temperatures ( r = –0.008, p = 0.399). There was also no important seasonal or monthly variation, across all patients or in the smaller cohort with longitudinal data ( n = 123, r = 0.008, 95% confidence interval: [–0.04, 0.06]). Conclusion: There were no clinically important differences in serum lithium concentration related to seasons, months or temperatures, which suggests that patients on lithium are able to adequately maintain hydration during hot weather in Sydney.

Lithium-related medication problems on nonpsychiatric inpatient medical units

Purpose Results of a study of medication-related problems (MRPs) associated with lithium use on nonpsychiatric inpatient medical units are reported. Methods In a single-center, retrospective study, the records of all patients hospitalized over a 21-month period who received lithium or had a documented serum lithium concentration during hospitalization were evaluated. The primary objective was to identify patient-specific factors associated with lithium MRPs on nonpsychiatric inpatient medical units. Secondary objectives included characterization of lithium MRPs. Identified MRP occurrences were further evaluated to determine if an intervention was necessary to resolve the MRP and whether or not an intervention was made. Results A total of 150 patients were included in the study sample. One or more lithium MRPs were identified in 85% of the patients, with a total of 255 lithium MRPs identified. None of the patient-specific factors analyzed were significantly associated with MRP occurrence. Of the 128 patients in whom a lithium MRP occurred, 92.2% (n = 118) were judged to be appropriate candidates for interventions as defined per the study definitions; among those 118 patients, such interventions were documented for only 40.7% (n = 48). Conclusion Lithium MRPs were found to have occurred frequently on nonpsychiatric inpatient medical units at 1 hospital. Laboratory test– related MRPs and drug–drug interactions were the most commonly identified types of MRPs. Interventions to address MRPs were not made in the majority of patients; however, interventions were more frequently made when psychiatry consultation was involved.

Validation of the Sinhala version of the Morisky Medication Adherence Scale to determine medication adherence in patients with bipolar affective disorder on lithium therapy

Rationale, aims and objectives: The Morisky Medication Adherence Scale (MMAS-8) is a self-reported scale used in assessing medication adherence in patients on chronic therapy. Medication adherence is a neglected area of research in Sri Lanka and in this study we have attempted to validate the Sinhala translation of the MMAS-8 to determine medication adherence among patients stabilized on lithium therapy for bipolar disorder (BD).Methods: The MMAS-8 was translated to Sinhala with standard forward and backward translations from English to Sinhala. Patients with BD on stable doses of lithium were administered the Sinhala version of the MMAS-8. During the same visit, the serum lithium concentration was measured. Criterion validity was assessed using therapeutic serum lithium concentrations as the gold standard. Internal consistency was assessed using Cronbach’s alpha and Spearman’s rank correlation was used to assess test-retest reliability.Results: From a sample of 240 patients, 82.1% were considered adherent, with serum lithium concentration >0.4 mmol/L. The mean MMAS-8 score was 6.95±1.3. According to the MMAS-8 scale, 13.3% reported low adherence while 43.3% reported medium and high adherence equally using MMAS cut offs <6, 6 to<8 and 8 respectively. The scale sensitivity to identify adherence at a cut-off score of 6 was 86.3%. The test–retest reliability value was 0.708 (p<0.001). Internal consistency was found with a Cronbach’s alpha value of 0.608 for the 8 items of the scale.Conclusion: The Sinhala version of MMAS-8 can be used as a sensitive instrument to identify medication adherence in patients with bipolar disorders.

Interference in Serum Lithium Estimation by Silica Clot Activator and Silicone Surfactant in ISE Principle: a Cross-Sectional Study

Serum lithium concentration is monitored to ensure patient's compliance and to avoid intoxication and thus it is a prerequisite for an individual's dose adjustment. An unavoidable error during lithium estimation in blood collected in 'red-top plastic vacutainer plus tube containing silica clot activator and silicone surfactant' by ISE appeared as a reality for a standard laboratory like AFIP. The error could not be detected even by proven internal and external QC. This cross-sectional study was carried out at AFIP Chemical Pathology Department from May' 2015 to July'2015 to find out the interference causing falsely elevated serum lithium concentration by ISE principle. Blood were collected from the 40 study subjects including 30 healthy volunteers, who never took Tab Lithium and 10 patients, who used to take Tab Lithium for bipolar mood disorder in both 'plain red-top plastic vacutainer tubes without additive' as well as 'plain red-top plastic vacutainer plus tube containing silica clot activator and silicone surfactant'. Lithium concentrations were estimated in both types of tubes by Ion-Selective Electrode (ISE) principle employing world class, USA manufactured analyzer NOVA-4 as well as by colorimetric method using Dade Dimension, Siemens. Serum lithium concentrations were undetectable for the 'lithium-free normal volunteers' in both types of tubes measured by colorimetry but in ISE principle it was undetectable when collected in plain test tube without additives but when collected in 'vacutainer plus tube containing silica clot activator and silicone surfactant' and measured by ISE technique, the mean serum lithium concentration was found to be 1.78 ±0.40 mmol/l. Besides, mean serum lithium concentration of 10 individuals taking Tab Lithium had no statistically significant difference while measured by ISE or colorimetry in 'vacutainer tubes without additive' and also in 'vacutainer plus tubes containing silica clot activator and silicone surfactant' measured by colorimetry. But, vacutainer plus tubes containing silica clot activator and silicone surfactant' while measured serum lithium concentration by ISE principle had significant (p <0.001) increase in mean concentration than others, as determined by one-way ANOVA and Post-hoc tests. This study demonstrates that positive interference; caused by silica clot activator and silicone surfactant of the collection tubes; increases measured concentration of lithium. This interference; being in the pre-analytic phase, cannot be detected by routinely performed laboratory quality control.Bangladesh J Med Biochem 2015; 8(2): 60-65

NON PITTING TYPE PEDAL EDEMA WITH LITHIUM: A CASE REPORT

<p><strong>Objective: </strong>To report a case of lithium induced bilateral nonpitting pedal edema.</p><p><strong>Methods: </strong>The clinical data of a bipolar affective disorder patient with current episode of mania and psychotic symptoms who experienced bilateral non pitting pedal edema with lithium.</p><p><strong>Results: </strong>The patient was a 29 yr old female who developed bilateral non-pitting type pedal edema with lithium therapy with normal plasma lithium level (0.72mEq/l). She is a known case of bipolar affective disorder (BPAD) was admitted to psychiatry department with episode of mania with psychotic symptoms. She had history of drug induced hypersensitivity reaction with eosinophilia and systemic symptoms (DRESS) with oxcarbazepine and so the drug was discontinued and was started on tablet lithium 400 mg twice daily. On admission here, the dose of lithium was increased to 1200 mg/day. The patient gradually improved but she developed bilateral non-pitting pedal edema. Serum lithium concentration was normal and there were no other early symptoms of lithium toxicity. But as the patient's distress further increased with increasing pedal edema, it was decided to stop lithium altogether and to maintain the patient on tablet quetiapine 800 mg therapy for BPAD. Within one week of stopping lithium the edema on both her feet decreased significantly. Causality was assessed by naranjo causality assessment scale and a probable relationship was obtained between lithium and pedal edema with a score of 6.</p><p><strong>Conclusion: </strong>This case emphasises that regular physical examination and laboratory investigations are important for patients who are on lithium therapy. Clinicians should always be careful while initiating lithium treatment in a patient with respect to the initial dose and dose escalation even after a period of successful therapy with lithium, as minor dose escalation can cause major changes in the serum lithium concentration and thereby the patient’s tolerability to lithium.</p>