Lithium
lithium carbonate
What it isMood stabilizer inhibiting GSK-3beta and inositol monophosphatase; bipolar maintenance and depression augmentation.
Why this oneThe only agent with consistent evidence for reducing suicide in bipolar disorder.
What limits itNarrow therapeutic index with level monitoring. Renally cleared, so NSAIDs, thiazides and ACE inhibitors raise levels. Monitor thyroid and renal function.
FDA-approved for
- bipolar mania (1970)
Off-label
- antidepressant augmentation
- suicide-risk reduction
- cluster headache
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Bipolar I, acute manic/mixed | Adults & peds >30 kg (≥7 yr) | 300 mg TID | 600 mg BID–TID; serum 0.8–1.2 mEq/L | |
| Bipolar I, maintenance | Adults & peds >30 kg (≥7 yr) | 300–600 mg BID–TID; serum 0.8–1.0 mEq/L | ||
| Bipolar I, acute manic/mixed | Peds 20–30 kg | 300 mg BID | 600–1500 mg/day divided | |
| Bipolar I, maintenance | Peds 20–30 kg | 600–1200 mg/day divided |
Titration Increase by 300 mg every 3 days (weekly in peds 20–30 kg)
Renal CLcr 30–89 mL/min: start below normal dose, titrate slowly; CLcr <30 mL/min: avoid
Hepatic Undefined
Narrow therapeutic index; toxicity (≥1.5 mEq/L) close to therapeutic range (0.8–1.2 mEq/L)
Instructions
- Take with food to reduce GI upset
- Draw serum lithium 12 hr post-dose after 3 days and regularly until stable
- Decrease or discontinue 2–3 days before expected delivery
Cautions
- Lithium toxicity
- Lithium-induced polyuria / nephrogenic diabetes insipidus
- Hyponatremia (dehydration raises toxicity risk)
- Chronic kidney disease with long-term use
- Encephalopathic syndrome with antipsychotics
- MAOIs due to risk of serotonin syndrome
- Hypothyroidism or hyperthyroidism
- Hypercalcemia / hyperparathyroidism
- Unmasking of Brugada syndrome
Adverse reactions
- Fine hand tremor
- Polyuria
- Thirst
- Nausea
- General discomfort during initial treatment
- Peds: nausea/vomiting, thyroid abnormalities, ataxia/gait disturbance, dizziness
Pregnancy May cause fetal harm (cardiac malformations incl. Ebstein's anomaly with 1st-trimester use); neonatal/floppy-baby toxicity with late-pregnancy use
Lactation Present in human milk; breastfeeding not recommended — monitor infant for toxicity if breastfed
⚠ BOXED WARNING
- Lithium toxicity is closely related to serum concentration and can occur at doses close to therapeutic levels
Cost, est. cash$10–$500/month
Generic entry1986
Classes and tags
Clinical profile
Legacy pregnancy categoryD
Defining liabilityNarrow therapeutic index; nephrogenic diabetes insipidus
Mechanism of action: Lithium ballicule
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