Prescribing and monitoring lithium therapy: summary of a safety report from the National Patient Safety Agency
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6258 (Published 19 November 2010) Cite this as: BMJ 2010;341:c6258
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The National Patient Safety Agency report on prescribing and
monitoring of lithium (1) provides a valuable tool for practitioners
wishing to avoid adverse events with the prescription of lithium.
Unfortunately in common with NICE Guidelines (2) the report bears little
reference to its potential nephrotoxic effect. Lithium as a cause of both
chronic (relatively rare) and acute (more common) is well documented (3).
Lithium has been shown by robust retrospective database analyses to be the
only or major aetiological factor in a number of patients on dialysis (4).
Anecdotal evidence is also supportive.
We would agree the importance of checking serum creatinine on a
regular basis, however the interpretation of eGFR is fraught with
difficulties; for example many elderly patients will have an abnormal GFR
suggesting renal impairment, with little other evidence that this
represents a disease, but more likely a normal factor of ageing (5,6).
The prescription of lithium could be made safer by the careful
consideration in those with risk factors for renal disease such as chronic
inflammatory conditions, diabetes and a family history of renal disease.
In addition safety could be further enhanced by the identification of
those with pre-existing renal disease by screening for urinary
abnormalities by way of dipstick urine testing for invisible haematuria
and albumin creatinine ratio, and interpreting their result in the context
of eGFR (7).
Reference to these important risk factors, and the use of a
potentially more specific and sensitive test are lacking mention in this
publication.
Yours sincerely,
Dr James Shawcross. StR Nephrology. Freeman Hospital, Newcastle upon
Tyne, UK
Dr Mukesh Kriplani. Consultant Psychiatrist, Tees, Esk and Wear
Valley NHS Foundation Trust, St. Luke's Hospital, Middlesbrough, UK
1. Gerret D, Lamont T, Paton C, Barnes TRE, Shah A. Prescribing and
monitoring lithium therapy: summary of a safety report from the National
Patient Safety Agency. BMJ 2010; 341:c6258
2. The National Collaborating Centre for Chronic Conditions. Chronic
Kidney Disease. National Guidelines for early identification and
management in adults in primary and secondary care.
http://guidance.nice.org.uk/CG73/Guidance/pdf/English
3. Candlish CA, Beard RJ, Benn K. Lithium therapy: how safe is
current practice used to prevent lithium toxicity? Pharmacopepidem Drug
Safety. 2007; 16:589
4. Bendz H, Schon S, Attman PO, Aurell M. Renal failure occurs in
chronic Lithium Treatment but is uncommon. Kid Int 2010; 77: 219-224
5. Poggio ED, Rule AD. A critical evaluation of chronic kidney
disease - should isolated reduced estimated glomerular filtration rate be
considered a 'disease'? Nephrol Dial Transplant 2009; 24: 698-700
6. Glasscock RJ, Winnearls C. Screening for CKD with eGFR: Doubts and
Dangers. Clin J Am Soc Nephrol 3: 1563-1568, 2008
7. Kripalani M, Shawcross J, Reilly J, Main J. Lithium and chronic
kidney disease. BMJ 2009;339:b2452
Competing interests: No competing interests
Once we are satisfied that Lithium is a worthy candidate to be used
for various symptoms of mental illness, may I suggest we look at the work
of a great man of medicine, psychiatrist and biochemist, the late Dr.
Abram Hoffer, of Canada.
Singlehandedly, he found an effective treatment for schizophrenia,
MDI (bipolar) and more, over 50 years ago.
He too, used orphan type drugs, mostly niacin in conjunction with
ascorbate etc. and there was little interest displayed in mainstream
psychiatry.
Yet his success rate, which can be attributed to the treatment
addressing the cause(s) of the affliction(s), is far above what modern
psychiatry offers today.
Yes, the institutions have been emptied and the inmates are
recovering (?) in boarding houses, on the streets and in prisons. How many
are paying taxes?
Lithium is a cop-out drug that trades a set of symptoms for adverse
effects on health.
Competing interests: No competing interests
It is good and necessary to remind doctors of the fundamentals of lithium
precribing from time to time.
Nevertheless, my experiences are that lithium is undervalued and far too
seldom prescribed.
You mostly read about side effects and seldom about its benefits.
Surely, lithium is cheap, no big money in it, so you will not find any
advertisements.
The impressions I have got are that in UK (admittedly subjective
impressions as I do not have the means to do an exact survey) esp. the
anti-suicidal effect of lithium is not well known.
Lithium is a life saving drug.
Its anti-suicidal abilities are scientically proven.(1)
It can turn human fates around for the better.
Lithium is cheap.
Its economical advantages have been calculated according costs of missing
lives (suicides), and less hospital admissions.(1)
Lithium is special as it can cause all those side effects mentioned.
Its use has to be learned and thus taught. Using lithium means the
prescriber has to teach the patient and carer, too.
It is worth the extra effort that it needs to become a sophisticated
'user' (prescriber and patient taking lithium).
So additionally to the mentioned brochure
I want to recommend the following texts:
- Manic-Depressive Illness by Jamison and Goodwin
- Lithium in Neuropsychiatry by Bauer, Grof, Mueller-Oerlinghausen
The latter book has been published by IGSLI, International Group for
The Study of Lithium Treated Patients.
UK members are missing!
Reference
1) Several studies are described in the mentioned books and at www.igsli.org
Competing interests: No competing interests
Re:Lithium is life saving
I am a foundation year 2 doctor in the County Durham and Darlington
Foundation Trust and I am currently doing a placement in Old Age
Psychiatry.
A lady is with us currently with chronic bipolar disorder. She was on
Lithium following a prolonged stay in our hospital a few years ago. It had
been hard to maintain her well on many different drugs, but after being
stabilised on a therapeutic dose of Lithium she was much better.
She was discharged into the community and the GP practice took over
the monitoring of her Lithium and the prescribing of it.
She had to be admitted as an emergency to the local general hospital
a few months later, due to being Lithium Toxic. The hospital subsequently
took her off the Lithium and her mood deteriorated. She was transferred to
Psychiatric Care, where we started to look into how she had become toxic.
It transpired that in the last couple of prescriptions from her GP
they had prescribed her current dose of Lithium AND the previous dose she
had been on. So she had effectively been double dosed almost, hence why
she had become toxic.
She is now back as an inpatient, and is responding very badly to
treatments, having had a course of at least 18 ECT treatments, but still
severely depressed.
She had had such a good effect to Lithium, and her daughter recently
commented that at that point she had been 'the best she'd ever been in her
life'. But her and her family were so scared by how critically ill she
became that they are adamantly against it being tried again. And with her
ageing as well now, it is a risky thing anyway to re-instigate.
I think there is a real need for a system to be put in place for
accurate management of Lithium patients, especially including
communication between Primary and Secondary Care. This is a drug which as
mentioned above is very effective, and can dramatically improve patients
mental state.
There needs to be safe measures in place for monitoring Lithium
whilst in the community. As well as communication between the specialist
services who have recommended or commenced Lithium treatment, and the
primary care team who are going to continue to look after these patients.
This is an effective, but potentially dangerous drug, and patients
should not have their chance of being well being hampered by the inability
of care providers to prescribe their medications safely.
Patient consent obtained.
Competing interests: No competing interests