Lithium is one of the most complex medications one of your patients can be on. Between drug interactions, monitoring parameters, and managing bipolar disorder, it is easy to get overwhelmed by the complexity. Here are a few lithium clinical pearls I always think about when I see an order for the medication.

Some of the most commonly used medications can interact with lithium. First I look and see if they have hypertension and are taking any medications to manage this condition. The likelihood that they are on an ACE or an ARB is high if they have high blood pressure. If they aren’t, diuretics can also interact and potentially raise concentrations of lithium. Either way, a patient on an ACE, ARB, or a diuretic is more at risk for toxicity.

Another really common interaction that is more difficult to control is NSAIDs (case study from the past). If a patient has generalized aches and pains or a headache, they can go find their over the counter NSAID of choice without consulting a healthcare professional. It is critical to educate patients on lithium that there is a risk in doing this. I discuss lithium interactions in much greater detail in my latest book which you can find here.

Lab monitoring is critical with lithium. In addition to the drug level, I always take a look at their renal function and TSH. Both can impact lithium or be impacted by lithium.

Dietary changes are also a challenge with lithium. Large increases in sodium may cause levels to go down, while strict limitations for a period of time may cause lithium levels to rise. Consistency is key and if the patient is going to make a change in salt intake, we better make sure that we are monitoring the patient for lithium toxicity or treatment failure.

Tremor is an adverse effect that doesn’t happen with a ton of medication. If I ever hear that a patient is going to be placed on propranolol or primidone for tremor, I always take a look and ensure that the patient isn’t experiencing signs and symptoms of lithium toxicity.

These are a few lithium clinical pearls that I hope can help you take care of your patients on lithium. What else would you add to this list?

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