Lithium (medication)

In 1970, lithium was approved by the United States Food and Drug Administration for the treatment of bipolar disorder, which remains its primary use in the United States. It is sometimes used when other treatments are not effective in a number of other conditions, including major depression, schizophrenia, disorders of impulse control, and some psychiatric disorders in children. The mechanisms of biological action of lithium are only partially understood. For instance, studies of lithium-treated patients with bipolar disorder show that, among many other effects, lithium partially reverses telomere shortening in these patients and also increases mitochondrial function, although how lithium produces these pharmacological effects is not understood. High blood levels of lithium can lead to lithium toxicity. Bipolar disorder Lithium is primarily used as a maintenance drug in the treatment of bipolar disorder to stabilize mood and prevent manic episodes. It is also effective in the acute treatment of manic episodes. It is effective for mania within the first 7 days of treatment. For acute treatment, although recommended by treatment guidelines for the treatment of depression in bipolar disorder, the evidence that lithium is superior to placebo for acute bipolar depression is low-quality. Atypical antipsychotics are considered more effective for treating acute bipolar depressive episodes. Lithium is effective for the long term prevention of bipolar depressive episodes. Within the therapeutic range there is a dose-response relationship. A limited amount of evidence suggests lithium carbonate may contribute to the treatment of substance use disorders for some people with bipolar disorder. People with bipolar disorder are at a 3 times higher risk for dementia. Schizophrenic disorders Lithium is recommended for the treatment of schizophrenic disorders only after other antipsychotics have failed; it has limited effectiveness when used alone. the symptoms of major depressive disorder (MDD) (also known as refractory depression or treatment resistant depression [TRD]) then a second augmentation agent is sometimes added to the therapy. Lithium is one of the few augmentation agents for antidepressants to demonstrate efficacy in treating MDD in multiple randomized controlled trials and it has been prescribed (off-label) for this purpose since the 1980s. While SSRIs have been mentioned above as a drug class in which lithium is used to augment, there are other classes in which lithium is added to increase effectiveness. Such classes are antipsychotics (used for bipolar disorder) as well as antiepileptic drugs (used for both psychiatric and epileptic cases). Lamotrigine and topiramate are two specific antiepileptic drugs in which lithium is used to augment. Monotherapy There are old studies indicating efficacy of lithium for acute depression with lithium having the same efficacy as tricyclic antidepressants. A 2019 systemic review of studies from the 1970s to 2000s found that lithium monotherapy was just as effective as antidepressant monotherapy. It is thought to exert this effect by treating the underlying mood disorder and through a reduction in impulsivity and aggressiveness. Lithium is proven to reduce the risk of suicide in mood disorders by 87% in randomized double-blind placebo-controlled trials. Some meta-analyses have not found a statistically significant association between lithium and a reduction in completed suicide, however these meta-analyses are disputed. Some evidence suggests lithium is effective in significantly reducing the risk of self-harm and unintentional injury for bipolar disorder in comparison to no treatment and to antipsychotics or valproate. In addition, lithium decreases all-cause mortality in people with bipolar disorder. The increased presence of trace amounts of lithium in drinking water is correlated with lower overall suicide rates, especially among men. Lithium in drinking water is also associated with lower rates of homicide, rape, drug arrests, and other crimes. Cluster headaches, migraine, and hypnic headache Studies testing prophylactic use of lithium in cluster headaches (when compared to verapamil), migraine attacks, and hypnic headache indicate good efficacy. Lithium concentrations in whole blood, plasma, serum, or urine may be measured using instrumental techniques as a guide to therapy, to confirm the diagnosis in potential poisoning victims, or to assist in the forensic investigation in a case of fatal overdosage. In clinical settings, lithium doses are adjusted to achieve a target serum concentration, usually measured 12 hours after the last dose (12-hour trough level). Lithium levels According to Stahl's Prescriber's Guide, target concentrations for acute mania should be 1.0–1.5 mEq/L. 0.6–1.0 mEq/L for depression, and 0.7–1.0 mEq/L for long-term maintenance of bipolar disorder. In the elderly, lower doses and lower lithium levels (<0.6 mEq/L) are often adequate and advisable. For the maintenance treatment of the elderly, the ISBD and ISGL guidelines recommend a more conservative approach of levels of 0.4–0.6 mmol/L, with the option to go up to 0.7 or 0.8 mmol/L at ages 65–79, and up to a maximum of 0.7 mmol/L over age 80. Discontinuation If lithium is stopped suddenly, there is a 50% risk of sudden mania within one month of stopping. In the first year after discontinuation of lithium, even if discontinued gradually, there is up to a 20-fold increase in the rate of attempted or completed suicide. ==Adverse effects==

The adverse effects of lithium include: ;Very Common (> 10% incidence) adverse effects • Confusion • Constipation (usually transient, but can persist in some) • Decreased memory • Diarrhea (usually transient, but can persist in some) • Dry mouth • EKG changes – usually benign changes in T waves • Hand tremor (usually transient, but can persist in some) with an incidence of 27%. If severe, the psychiatrist may lower lithium dosage, change lithium salt type or modify lithium preparation from long to short-acting (despite lacking evidence for these procedures) or use pharmacological help • Headache • Hyperreflexia – overresponsive reflexes • Leukocytosis – elevated white blood cell count • Muscle weakness (usually transient, but can persist in some) • Myoclonus – muscle twitching • Nausea (usually transient) – 5% incidence, tends to start fast and then plateau. Usually ends at 1–2 kg. ;Unknown incidence • Sexual dysfunction – low blood sugar • Glycosuria – excretion of glucose into the urine In addition to tremors, lithium treatment appears to be a risk factor for development of parkinsonism-like symptoms, although the causal mechanism remains unknown. Depending on dosage and duration of use, lithium can be either pro-convulsant, or as its historical use suggests, anti-convulsant. Studies show that lithium does not decrease neurocognitive performance, and may actually improve neurocognitive performance in people with bipolar disorder. Most side effects of lithium are dose-dependent. The lowest effective dose is used to limit the risk of side effects. Hypothyroidism The rate of hypothyroidism is around six times higher in people who take lithium. Low thyroid hormone levels in turn increase the likelihood of developing depression. People taking lithium thus should routinely be assessed for hypothyroidism and treated with synthetic thyroxine if necessary. Lithium associated thyroid dysfunction is reversible and thyroid levels return to normal if lithium is discontinued. However, hypothyroidism can be corrected by treatment with thyroxine and does not require the lithium dose to be adjusted. Hyperparathyroidism Lithium-associated hyperparathyroidism leads to hypercalcemia in about 4% of lithium-treated patients. Calcium levels should be checked for patients undergoing long-term lithium treatment. Chronically increased serum calcium can lead to kidney stones, osteoporosis, dyspepsia, hypertension, and renal impairment. It is estimated that impaired urinary concentrating ability is present in at least half of individuals on chronic lithium therapy, a condition called lithium-induced nephrogenic diabetes insipidus, or lithium-induced AVP resistance. Continued use of lithium can lead to more serious kidney damage in an aggravated form of nephrogenic diabetes insipidus. Lithium specifically inhibits function of the aquaporin-2 water channel, leading to impaired reabsorption of water, polyuria, polydipsia, significant hypernatremia, which can lead to CNS symptoms such as confusion, lethargy, and coma. End-stage renal disease occurs in 0.53% of people treated with lithium versus 0.2% in the general population. Multiple daily doses are associated with more kidney damage. Dosing lithium once per day allows for long periods where the kidney is exposed to low levels of lithium, which minimizes kidney harm. In a 2018 meta-analysis, there was a statistically significant % increase in congenital malformations in general, but not for cardiac malformations specifically (% increase). Exposure during any part of the pregnancy is associated with a slight but statistically significant increase in the risks of preterm birth and of a larger-than-usual baby at birth. Lithium is effective for preventing relapse during and after pregnancy. The relatively low teratogenic risk of lithium allows such a choice. The decision should be made before the start of pregnancy, as there is no reason for stopping lithium once the pregnancy has started. Pregnancy is associated with a decrease in blood lithium levels (especially in the first and second trimesters), so more frequent monitoring with an increase in dose may be required to maintain control of symptoms. To prevent postpatrum psychosis, a higher blood lithium level may be desirable in the third trimester. == Interactions ==

Lithium plasma concentrations are known to be increased with concurrent use of diuretics—especially loop diuretics (such as furosemide) and thiazides—and non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Lithium is primarily cleared from the body through glomerular filtration, but some is then reabsorbed together with sodium through the proximal tubule. Its levels are therefore sensitive to water and electrolyte balance. Diuretics act by lowering water and sodium levels; this causes more reabsorption of lithium in the proximal tubules so that the removal of lithium from the body is less, leading to increased blood levels of lithium. ACE inhibitors have also been shown in a retrospective case-control study to increase lithium concentrations. This is likely due to constriction of the afferent arteriole of the glomerulus, resulting in decreased glomerular filtration rate and clearance. Another possible mechanism is that ACE inhibitors can lead to a decrease in sodium and water. This will increase lithium reabsorption and its concentrations in the body. Lithium is known to be a potential precipitant of serotonin syndrome in people concurrently on serotonergic medications such as antidepressants, buspirone and certain opioids such as pethidine (meperidine), tramadol, oxycodone, fentanyl and others. Lithium co-treatment is also a risk factor for neuroleptic malignant syndrome in people on antipsychotics and other antidopaminergic medications. High doses of haloperidol, fluphenazine, or flupenthixol may be hazardous when used with lithium; irreversible toxic encephalopathy has been reported. Indeed, these and other antipsychotics have been associated with an increased risk of lithium neurotoxicity, even with low therapeutic lithium doses. A high incidence of seizures has been reported with serotonergic psychedelics like psilocybin and LSD in people taking lithium. In an analysis of online reports, 47% of 62accounts reported seizures when a psychedelic was taken while on lithium. Of these instances, 39% sought emergency medical treatment. ==Overdose==

Lithium toxicity, which is also called "lithium overdose" or "lithium poisoning", is the condition of having too much lithium in the blood. This condition also happens in persons who are taking lithium in which the lithium levels are affected by drug interactions in the body. Lithium toxicity occurs at levels above 1.5 mmol/L. In chronic toxicity, people have primarily neurological symptoms which include nystagmus, tremor, hyperreflexia, ataxia, and change in mental status. During chronic toxicity, the gastrointestinal symptoms seen in acute toxicity are less prominent. The symptoms are often vague and nonspecific. If the lithium toxicity is mild or moderate, lithium dosage is reduced or stopped entirely. If the toxicity is severe, lithium may need to be removed from the body. ==Mechanism of action==

Unlike many other psychoactive drugs, Lithium typically produces no obvious psychotropic effects (such as euphoria) in normal individuals at therapeutic concentrations. Upon ingestion, lithium becomes widely distributed in the central nervous system and interacts with a number of neurotransmitters and receptors, decreasing norepinephrine release and increasing serotonin synthesis by neurons in the brain. In vitro studies performed on serotonergic neurons from rat raphe nuclei have shown that when these neurons are treated with lithium, serotonin release is enhanced during a depolarization compared to no lithium treatment and the same depolarization. Lithium has a plethora of proposed molecular targets: • Lithium both directly and indirectly inhibits GSK3β (glycogen synthase kinase 3β) which results in the activation of mTOR. This leads to an increase in neuroprotective mechanisms by facilitating the Akt signaling pathway. GSK-3β is a downstream target of monoamine systems. As such, it is directly implicated in cognition and mood regulation. • In addition, several authors proposed that pAp-phosphatase could be one of the therapeutic targets of lithium. This hypothesis was supported by the low Ki of lithium for human pAp-phosphatase compatible within the range of therapeutic concentrations of lithium in the plasma of people (0.8–1 mM). The Ki of human pAp-phosphatase is ten times lower than that of GSK3β (glycogen synthase kinase 3β). Inhibition of pAp-phosphatase by lithium leads to increased levels of pAp (3′–5′ phosphoadenosine phosphate), which was shown to inhibit PARP-1. • Another mechanism proposed in 2007 is that lithium may interact with nitric oxide (NO) signaling pathway in the central nervous system, which plays a crucial role in neural plasticity. The NO system could be involved in the antidepressant effect of lithium in the Porsolt forced swimming test in mice. • It was also reported that NMDA receptor blockage augments antidepressant-like effects of lithium in the mouse forced swimming test, indicating the possible involvement of NMDA receptor/NO signaling in the action of lithium in this animal model of learned helplessness. Lithium possesses neuroprotective properties by preventing apoptosis and increasing cell longevity. Although the search for a novel lithium-specific receptor is ongoing, the high concentration of lithium compounds required to elicit a significant pharmacological effect leads mainstream researchers to believe that the existence of such a receptor is unlikely. Oxidative metabolism Evidence suggests that mitochondrial dysfunction is present in people with bipolar disorder. Lithium counteracts these degrading processes by decreasing pro-apoptotic proteins and stimulating release of neuroprotective proteins. Cyclic AMP secondary messengers Lithium's therapeutic effects are thought to be partially attributable to its interactions with several signal transduction mechanisms. The cyclic AMP secondary messenger system is shown to be modulated by lithium. Lithium was found to increase the basal levels of cyclic AMP but impair receptor-coupled stimulation of cyclic AMP production. This effect has been suggested to be further enhanced with an inositol triphosphate reuptake inhibitor. Inositol disruptions have been linked to memory impairment and depression. It is known with good certainty that signals from the receptors coupled to the phosphoinositide signal transduction are affected by lithium. Myo-inositol is also regulated by the high affinity sodium mI transport system (SMIT). Lithium is hypothesized to inhibit mI entering the cells and mitigate the function of SMIT. Bipolar patients treated with lithium also have higher white matter integrity compared to those taking other drugs. Lithium also increases the expression of mesencephalic astrocyte-derived neurotrophic factor (MANF), another neurotrophic factor, via the AP-1 transcription factor. MANF is able to regulate proteostasis by interacting with GRP78, a protein involved in the unfolded protein response. ==History==

19th and early 20th centuries Lithium was first used in the 19th century as a treatment for gout after scientists discovered that, at least in the laboratory, lithium could dissolve uric acid crystals isolated from the kidneys. The levels of lithium needed to dissolve urate in the body, however, were toxic. Because of prevalent theories linking excess uric acid to a range of disorders, including depressive and manic disorders, Carl Lange in Denmark and William Alexander Hammond in New York City used lithium to treat mania from the 1870s onwards. As accumulating knowledge indicated a role for excess sodium intake in hypertension and heart disease, lithium salts were prescribed to patients for use as a replacement for dietary table salt (sodium chloride). This practice and the sale of lithium itself were both banned in the United States in February 1949, following the publication of reports detailing side effects and deaths. John Cade and the discovery of lithium's effect on mania In 1948, the Australian psychiatrist John Cade rediscovered the usefulness of lithium salts in treating mania while working at the Bundoora Repatriation Mental Hospital in Melbourne. He was injecting guinea pigs with urine extracts taken from manic patients in an attempt to isolate a metabolic compound which might be causing mental symptoms. Since uric acid in gout was known to be psychoactive, he needed soluble urate for a control. He used lithium urate, already known to be the most soluble urate compound, and observed that it caused the guinea pigs to become tranquil. In 1950, one of Cade's first patients died of lithium toxicity after Cade had successfully treated him and released him from the hospital. Afterward, Cade abandoned the research of lithium and focused instead on testing other salts of rubidium, cerium, and strontium for their potential utility in psychiatry. By 1952 Cade was superintendent of the prestigious Royal Park Hospital in Melbourne. He prohibited the use of lithium, his own discovery, in the hospital. Mogens Schou and proving lithium's efficacy In 1954, Mogens Schou of Denmark confirmed lithium's efficacy in a randomzied double-blind placebo-controlled study with his colleagues. Schou and Paul Baastrup organized other studies over the following years and decades and published a variety of research papers about lithium. However, lithium was met with great resistance by British psychiatry. To Aubrey Lewis and Michael Shepherd, from the Institute of Psychiatry at Maudsley Hospital, lithium was ‘dangerous nonsense’. Michael Shepherd and Harry Blackwell called lithium a 'therapeutic myth.' Largely through the research and other efforts of Mogens Schou and Paul Baastrup in Europe, and Samuel Gershon and Baron Shopsin in the U.S., resistance to lithium was slowly overcome. Lithium is unique among medications in that it was developed by academics without pharmaceutical company sponsorship. As it is a natural element, it cannot be patented. Lithium is the chief constituent of the calming drug in Ira Levin's dystopian novel This Perfect Day. Sirius XM Satellite Radio in North America has a 1990s alternative rock station called Lithium, and several songs refer to the use of lithium as a mood stabilizer. These include: "Equilibrium met Lithium" by South African artist Koos Kombuis, "Lithium" by Evanescence, "Lithium" by Nirvana, "Lithium and a Lover" by Sirenia, "Lithium Sunset", from the album Mercury Falling by Sting, and "Lithium" by Thin White Rope. 7 Up As with cocaine in Coca-Cola, lithium was widely marketed as one of several patent medicine products popular in the late 19th and early 20th centuries and was claimed to be included in many drinks including lithia water and 7 Up. It claimed to contain the mood stabilizer lithium citrate, and was one of many patent medicine products popular in the late-19th and early-20th centuries. All references to lithium were removed in 1937 after it became clear that 7Up contains no lithium. Many sources written by scientists (instead of historians) incorrectly report that 7 Up was forced to remove lithium in 1948, with an FDA action that supposedly banned lithium from beverages. Despite the supposed ban, in 1950, the Painesville Telegraph still carried an advertisement for a lithiated lemon beverage. ==Salts and product names==

Lithium carbonate () is the most commonly used form of lithium salts, a carbonic acid involving the lithium element and a carbonate ion. Other lithium salts are also used as medication, such as lithium citrate (), lithium sulfate, lithium chloride, and lithium orotate. Lithium bromide was used in the late 1800s. Nanoparticles and microemulsions have also been invented as drug delivery mechanisms. As of 2020, there is a lack of evidence that alternate formulations or salts of lithium would reduce the need for monitoring serum lithium levels or lower systemic toxicity. Lithium is available as lithium carbonate in tablets or capsules, and as lithium citrate in liquid form. In the United States, standard release tablets are available in 300 mg. Standard release capsules come in strengths of 150 mg, 300 mg, and 600 mg. Slow release tablets are available in 300 mg and 450 mg. Liquid lithium, in the form of lithium citrate, is available as an 8 mEq/5 mL solution. == See also ==