LithiumLithium Carbonate/Citrate

About Lithium

How lithium works is unknown. Capsules, tablets and oral solution are labeled as sole treatment of bipolar I disorder, for acute manic and mixed episodes and maintenance, from age 7; Lithobid is labeled for manic episodes and maintenance, with safety and effectiveness under 12 not determined. On the capsule, tablet and solution labels, adults and children over 30 kg start at 300 mg (5 mL of solution) three times a day, rising by 300 mg every three days, and children of 20 to 30 kg start twice a day, rising weekly. Blood levels, drawn 12 hours after the last dose (8 to 12 hours on the Lithobid label), set the dose: first after three days, then regularly until stable, and after any dose change, change in other medicines, strenuous exercise or illness. Target levels differ between labels; the prescriber sets them. Older adults usually start at the low end of the range, and lithium is not recommended in severe kidney impairment.

The boxed warning says toxicity is closely tied to blood levels and can occur at doses close to therapeutic ones, so level testing must be available before treatment starts. The label grades toxicity from fine tremor, lightheadedness, poor coordination and weakness, through drowsiness, muscle twitching, unsteadiness and blurred vision, to confusion, seizures, coma and death; because lithium can take up to 24 hours to reach the brain, symptoms can be delayed. Fever, dehydration, heavy sweating or diarrhea, kidney impairment, heart disease and some medicines raise the risk. Other warnings cover passing large amounts of urine (nephrogenic diabetes insipidus), low sodium, long-term kidney damage, a brain syndrome with antipsychotics, serotonin syndrome, thyroid problems, high calcium with overactive parathyroid glands, unmasking of Brugada syndrome (a heart rhythm disorder, in which lithium is avoided) and pseudotumor cerebri. Hand tremor, frequent urination, mild thirst and nausea are common early on.

Kidney function, vital signs, electrolytes and thyroid function are checked before starting; thyroid tests are repeated at three months and every six to twelve months, calcium regularly, and kidney function during treatment. Extended-release tablets are designed to give lower peak levels than capsules and tablets and are swallowed whole, never chewed or crushed; 5 mL of solution holds 8 mEq of lithium, the amount in 300 mg of lithium carbonate. Lithium may harm a fetus: early reports linked first-trimester use to heart defects, especially Ebstein’s anomaly, though later studies suggest the added risk is likely small, and the dose is lowered or stopped two to three days before delivery. Breastfeeding is not recommended. Use for depression is not FDA-approved; the prescriber decides.

Taking Lithium

How to take it

At the same times each day, usually two to four times a day depending on the form; swallow extended-release tablets whole. Keep a normal diet with the right amounts of salt and fluids, and ask the prescriber about caffeine drinks. Keep taking it even if you feel well, and do not stop it on your own.

If you miss a dose

Take it as soon as you remember, unless it is almost time for the next dose; then skip the missed dose and carry on as usual. Do not take a double dose.

Storage

At room temperature in the original, tightly closed container, away from excess heat and moisture (not in the bathroom), out of reach of children. Use a take-back program rather than flushing.

Interactions to know about

Diuretics, NSAIDs such as ibuprofen and naproxen, ACE inhibitors, angiotensin receptor blockers and metronidazole can raise lithium to toxic levels; acetazolamide, theophylline and sodium bicarbonate lower it. Antipsychotics and calcium channel blockers add to the risk of nervous system toxicity, serotonin-affecting antidepressants to the risk of serotonin syndrome, and iodide to the risk of an underactive thyroid.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Lithium differs from pharmacy to pharmacy

Capsules and 300 mg extended-release tablets each come from several makers; the solution, the 450 mg extended-release tablets and the immediate-release tablets come from fewer. A prescription that names Lithobid and blocks substitution is priced as a brand.

No form can be exchanged for another at the counter, so each quote is for the form and strength written; because doses are set by blood levels, the strengths and count written shape each quote.

Ways to pay less for Lithium without insurance

• Ask for generic lithium, and check that the prescription does not name Lithobid only.
• If you are thinking of switching between immediate-release and extended-release forms, ask the prescriber first; they release lithium at different rates.
• Once your level and dose are stable, ask for a ninety-day supply.
• Ask whether lithium is on the pharmacy’s flat-price generic list, and compare more than one pharmacy.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Lithium

1. 1.Which pain relievers, blood pressure medicines or water pills could raise my lithium level?
2. 2.What should I do if I have vomiting, diarrhea, a fever or heavy sweating?
3. 3.When should my blood be drawn in relation to my last dose?
4. 4.Which symptoms mean my level may be too high?

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