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.

Electronic Health Record Nested Pragmatic Randomized Controlled Trial of a Reminder System for Serum Lithium Level Monitoring in Patients with Mood Disorder: KONOTORI study protocol

Background: The weaknesses of classical explanatory randomized controlled trials (RCTs) include limited generalizability, high cost, and time burden. Pragmatic RCTs nested within electronic health records (EHRs) can be useful to overcome such limitations. Serum lithium level monitoring has often been underutilized in real-world practice in Japan. This trial aims to evaluate the effectiveness of the EHR-nested reminder system for serum lithium level monitoring in the maintenance of therapeutic lithium concentration and in the improvement of the quality of care for patients on lithium maintenance therapy. Methods: The Kyoto tOyooka Nested cOntrolled Trial Of Reminders (KONOTORI trial) is an EHR-nested, parallel-group, stratified permuted block randomized controlled trial. Screening, random allocation, reminder output, and outcome collection will be conducted automatically by the EHR-nested trial program. Patients with a mood disorder taking lithium carbonate for maintenance therapy will be randomly allocated to the two-step reminder system for serum lithium level monitoring or to usual care. The primary outcome is achievement of therapeutic serum lithium concentration between 0.4 and 1.0 mEq/L after 18 months. Discussion: The KONOTORI trial uses EHRs to enable the efficient conduct of a pragmatic trial of the reminder system for lithium monitoring. This may contribute to improved quality of care for patients on lithium maintenance therapy.

Electronic Health Record Nested Pragmatic Randomized Controlled Trial of a Reminder System for Serum Lithium Level Monitoring in Patients with Mood Disorder: KONOTORI study protocol

Background: The weaknesses of classical explanatory randomized controlled trials (RCTs) include limited generalizability, high cost, and time burden. Pragmatic RCTs nested within electronic health records (EHRs) can be useful to overcome such limitations. Serum lithium level monitoring has often been underutilized in real-world practice in Japan. This trial aims to evaluate the effectiveness of the EHR-nested reminder system for serum lithium level monitoring in the maintenance of therapeutic lithium concentration and in the improvement of the quality of care for patients on lithium maintenance therapy. Methods: The Kyoto tOyooka Nested cOntrolled Trial Of Reminders (KONOTORI trial) is an EHR-nested, parallel-group, stratified permuted block randomized controlled trial. Screening, random allocation, reminder output, and outcome collection will be conducted automatically by the EHR-nested trial program. Patients with a mood disorder taking lithium carbonate for maintenance therapy will be randomly allocated to the two-step reminder system for serum lithium level monitoring or to usual care. The primary outcome is achievement of therapeutic serum lithium concentration between 0.4 and 1.0 mEq/L after 18 months. Discussion: The KONOTORI trial uses EHRs to enable the efficient conduct of a pragmatic trial of the reminder system for lithium monitoring. This may contribute to improved quality of care for patients on lithium maintenance therapy.

Electronic Health Record Nested Pragmatic Randomized Controlled Trial of a Reminder System for Serum Lithium Level Monitoring in Patients with Mood Disorder: KONOTORI study protocol

Background: The weaknesses of classical explanatory randomized controlled trials (RCTs) include limited generalizability, high cost, and time burden. Pragmatic RCTs nested within electronic health records (EHRs) can be useful to overcome such limitations. Serum lithium level monitoring has often been underutilized in real-world practice in Japan. This trial aims to evaluate the effectiveness of the EHR-nested reminder system for serum lithium level monitoring in the maintenance of therapeutic lithium concentration and in the improvement of the quality of care for patients on lithium maintenance therapy. Methods: The Kyoto tOyooka Nested cOntrolled Trial Of Reminders (KONOTORI trial) is an EHR-nested, parallel-group, stratified permuted block randomized controlled trial. Screening, random allocation, reminder output, and outcome collection will be conducted automatically by the EHR-nested trial program. Patients with a mood disorder taking lithium carbonate for maintenance therapy will be randomly allocated to the two-step reminder system for serum lithium level monitoring or to usual care. The primary outcome is achievement of therapeutic serum lithium concentration between 0.4 and 1.0 mEq/L after 18 months. Discussion: The KONOTORI trial uses EHRs to enable the efficient conduct of a pragmatic trial of the reminder system for lithium monitoring. This may contribute to improved quality of care for patients on lithium maintenance therapy.

Delirium associated with olanzapine therapy in a patient with Bipolar Affective Disorder: A Case Report

A patient of Bipolar Affective Disorder (BPAD) developed delirium after initiation and increment in the dosage of olanzapine. After hospital admission, we started olanzapine in combination with lithium. Olanzapine was gradually increased to 30 mg/day and lithium gradually increased to 1000 mg/day with serum lithium level at 0.85 mmol/L. After discontinuation of olanzapine, there was a complete resolution of delirium. We, hereby, report the case of delirium associated with olanzapine therapy.

Lithium Toxicity

Lithium is commonly prescribed for mood stabilization in bipolar disorder. Lithium has a narrow therapeutic range (0.8−1.2 mmol/L), and even chronic users may unexpectedly develop toxic levels. Toxicities manifest in various ways. The authors report the case of a patient who developed sinus bradycardia and asystolic arrest with an elevated serum lithium level.