5.7 Mood Stabilizers V2
Mood stabilizers or anti-mania drugs are used to treat bipolar affective disorder. There are three different types of bipolar disorder but generally, it is a condition that is marked by shifts in mood, energy and ability to function. Periods of normal functioning are interrupted with periods with highs (manic) and lows (depression) (Halter, Pollard & Jacubec, 2019, pg. 277).
Lithium carbonate was the first medication used to stabilize clients with bipolar disorder in the manic phase. Lithium can be a monotherapy or used along with other medications such as anticonvulsants (valproic acid, carbamazepine, lamotrigine) and atypical antipsychotics (quetiapine). The use of lithium as a first line treatment has been surpassed by other medications such as divalproex sodium and valproic acid, although it is still frequently used today. Although lithium is very effective, it has a low therapeutic range and unfavourable side effects. It is still considered the gold standard for mania maintenance.
The treatment of mania for acute and maintenance therapy often includes more than one medication. Medications currently used:
- Lithium carbonate
- Anticonvulsants: valproic acid, carbamazepine, lamotrigine, gabapentin
- Atypical antipsychotics: quetiapine, olanzapine, risperidone, aripiprazole
Antianxiety drugs are also sometimes used to control agitation or if resistant to other meds and include diazepam, clonazepam, and lorazepam (Halter, Pollard & Jacubec, 2019, pg. 290).
In this unit, we will review lithium carbonate. Nurses need to be knowledgeable of the risks of toxicity and important monitoring and client teaching of this medication.
Lithium
Lithium is a very effective medication for the treatment of manic episodes in bipolar disorder and as maintenance treatment. It was the first medication used for mood stabilization. It is also used off-label for other conditions once typical therapies have proven ineffective.
Indications for Use
Lithium is often the drug of first choice or acute manic episodes. It is effective at treating a number of symptoms including: elation, flight of ideas, irritability, and anxiety. It helps control insomnia, agitation, distractibility, hypersexuality and paranoia (Halter, Pollard & Jacubec, 2019). It can be used as adjunct therapy for treating major depressive disorder, vascular headaches and alleviating neutropenia (Chokhawala; Lee & Saadabadi, 2024).
Mechanism of Action
Lithium alters sodium transport in nerve and muscle cells and causes a shift toward intraneuronal metabolism of catecholamines and serotonin, but the specific biochemical mechanism of lithium action in mania is unknown (Chokhawala; Lee & Saadabadi, 2024).
Pharmacokinetics
Lithium is readily absorbed following oral administration. For immediate release formulations, peak plasma concentration is 0.25-3 hours. It is not metabolized and is excreted by the kidney unchanged. About 80% of the excreted lithium undergoes reabsorption in the proximal tubule of the nephron. Renal excretion of lithium is affected by blood levels of sodium, so maintaining normal sodium levels is important (Rosenjack Burchum & Rosenthal, 2019). The half-life of lithium ranges from 18-36 hours.
Nursing Considerations
Pretreatment: a thorough medical examination is required to ensure lithium is the best choice for a client. This includes: physical examination, list of medical or psychiatric conditions and treatments, lab work (renal panel, electrolytes, thyroxine, TSH).
Administration: Oral administration only, immediate release, slow release or extended-release tablets.
- It is often prescribed BID or TID depending on clinic response and lithium levels. Due to its short half life as it is rapidly excreted renally, it is prescribed in divided daily doses.
- At the beginning of treatment, lithium dosages are low and gradually increased every few days until lithium therapeutic levels have been reached. This typically takes 7-14 days. The ideal lithium levels are between 0.6-1.2 mEq/L, but slightly higher may be more effective. Lithium levels must be lower than 1.5 mEq/L to avoid toxicity.
Treatment is effective if it results in symptom alleviation and remission. Some clients will not achieve this and alternate or additional meds may be required (Chokhawala; Lee & Saadabadi, 2024).
Normalization of symptoms during a manic episode can be 1-3 weeks. During this time, an antipsychotic or benzodiazepine is given until lithium levels become therapeutic. Those meds are then tapered off. In the maintenance phase of bipolar, lithium is prescribed 9-12 months, and for some clients they may be on it lifetime.
Therapeutic and Toxic Levels: Lithium must be closely monitored with a narrow therapeutic serum range of 0.6 to 1.2 mmol/L (Medical Council of Canada, 2021). Below 0.6 and the med is ineffective, and above 1.2 and they risk toxicity. Monitor lithium levels daily to every 2-3 days, then every 3-6 months once stabilized. Lithium levels are drawn in the morning, 10-12 hours following the last dose.
Serum sodium levels should also be monitored for potential hyponatremia (McCuiston et al, 2018).
Contraindicated in renal or cardiovascular disease, severe dehydration or sodium depletion, and to clients receiving diuretics because the risk of lithium toxicity is very high in such clients.
Pregnancy: Lithium can cause fetal harm in pregnant women. Safety has not been established for children under 12 and is not recommended.
Caution with the older adult due to declining kidney function.
Adverse/Side Effects
Side effects: many clients experience nausea, vertigo and diarrhea, but resolve in a few days. Other side effects include weight gain, fine hand tremor, polyuria, metallic taste and mild thirst that may also persist throughout treatment (McCuistion et al, 2018).
Longterm effects include hypothyroidism which can be treated with levothyroxine. Lithium may also lead to a decline in GFR (Godden, 2024).
High Alert Med: Lithium toxicity is closely related to serum lithium levels and can occur at doses close to therapeutic levels at 1.5 mEq/L. It can also occur with normal lithium levels. Mild symptoms such as diarrhea, drowsiness, lack of coordination are experienced with mild toxicity, progressing to severe symptoms if not corrected. This includes seizures, abnormal electrocardiographic (ECG) findings and risk of sudden death.
Lithium toxicity is also classified as acute (intentional single overdose), acute-on-chronic (acute overdose with long term use), and chronic (complication of long-term therapy such as dehydration or deteriorating renal function). Treatment will vary slightly
Clients should be advised to seek immediate emergency assistance if they experience fainting, light-headedness, abnormal heartbeats, or shortness of breath. Clients need to be attuned to any change in how they feel physically, follow the treatment plan (taking meds as prescribed, routine lithium levels) and eating a normal diet.
Lithium Toxicity Symptoms and Interventions
Note: references vary with onset of possible symptoms and corresponding lab values. Use these values as a guide only. Clinical presentation is most important.
| Lithium Level
|
Symptoms | Interventions |
| Possible Expected Adverse Effects (at therapeutic levels)
0.4-1.5 mEq/L |
GI effects (nausea, diarrhea, anorexia), fine hand tremor, polyuria, mild thirst, weight gain | GI effects usually subside.
Tremor can be treated with propranolol if it interferes with motor skills. Polyuria (up to 3L/day) leading to nocturia and excess thirst. Can be treated with amiloride (K-sparing diuretic). Encourage fluids 8-12 glasses/day. |
| Mild lithium toxicity
1.5- 2.5 mEq/L
|
Nausea & vomiting, diarrhea, fatigue, weakness and confusion,
Other symptoms: course hand tremor, hyperirritability of muscles, tachycardia, ECG changes, light-headed |
Next dose of lithium held. Lithium levels and electrolytes, LFTs, FBG, Ca.
Vital signs, 12 lead ECG Hydration to increase urine output Correct any electrolyte abnormalities Hospitalization Possible gastric lavage if overdose with IR tablets |
| Moderate lithium toxicity
2.5 mEq/L to 3.5 mEq/L):
|
Ataxia, agitation, polyuria, serious ECG changes, tinnitus, blurred vision, stupor, severe hypertension | As above
Hasten drug excretion with hemodialysis.
|
| Severe lithium toxicity (>3.5 mEq/L): | Increased disorientation, coma, seizures, hyperthermia, hypotension, oliguria, death | As above
Hasten drug excretion with hemodialysis. |
(Godden, 2024; Hedya, Avula & Swoboda, 2023)
Treatment of lithium toxicity focuses on hydration and discontinuation of the drug. There is no specific antidote, but treatment of symptoms and supportive measures (Chokhawala; Lee & Saadabadi, 2024).
Causes of lithium toxicity: If clients are taking their meds as prescribed, they can still develop lithium toxicity. Clients need to be informed of potential causes and consult with their prescriber if any changes to their health. Causes of toxicity are often related to hyponatremia and include:
- dehydration (excess sweating, fever, illness such as vomiting or diarrhea),
- dietary changes (change to a low sodium diet may cause kidneys to retain lithium in place of salt),
- drug interactions – drugs that can reduce lithium levels (drugs that promote sodium clearance) are NSAIDs, thiazides, metronidazole, ACE inhibitors/ARBs.
The relationship between sodium and lithium
Sodium and lithium are monovalent positive ions, so one affects the other. Lithium is handled by the kidneys the same way as sodium. Any condition affecting sodium levels or fluid volume will impact the reabsorption of lithium in the kidney. Lithium decreases sodium reabsorption in renal tubules, resulting in sodium depletion.
If low sodium levels – less lithium excreted by the kidney resulting in more reabsorbed back into the body, elevating lithium levels. Conditions that can decrease sodium levels are dehydration, vomiting, diarrhea, febrile illness, low sodium diet.
If high sodium levels – more lithium is excreted and lithium will be at subtherapeutic levels.
Client Teaching
- Clients should take medication as directed, even if feeling well.
- Monitor weight, weight gain may occur.
- Inform client of causes of toxicity and to consult prescriber if they develop a febrile illness, dehydration, or any change to sodium in their diet.
- It is important to eat a normal diet with typical fluid intake 1500-3000 mL/day and a consistent and moderate sodium intake. Avoid a low sodium diet as it may predispose you to toxicity. Avoid excess coffee, tea or cola due to diuretic effect.
- Educate client on cues of lithium toxicity, including early signs of nausea, tremors, lethargy, irregular heart rate, or confusion.
- Do not miss lab work to monitor lithium and sodium levels.
- Do not take any OTC medications without consulting with the prescriber first.
- Do not suddenly stop taking lithium, consult with your prescriber.
(Halter, Pollard & Jacubec, 2019; Vallerand & Sanoski, 2024)
Lithium Medication Card
Now let’s take a closer look at the medication grid for lithium. Medication cards like this are intended to assist students to learn key points about each medication. Because information about medication is constantly changing, nurses should always consult evidence-based resources to review current recommendations before administering specific medication. Basic information is outlined below.
Downloadable file (.docx): Lithium Medication Card
Clinical Reasoning and Decision-Making Activity 5.7
A 42-year-old male was recently diagnosed with bipolar disorder after his partner became concerned about his extreme highs and lows in moods. His high mood swings were often associated with grandiose ideas, gambling, risky sexual behavior, and shopping sprees that were causing the couple to go bankrupt. The physician prescribed lithium.
- The client states, “The doctor told me I am having manic episodes. What does that mean?” What is the nurse’s best response?
- The nurse knows that there is a risk of lithium toxicity. What are the symptoms of lithium toxicity, and how will it be prevented?
- The client’s partner asks, “How quickly will the lithium work?” What is the nurse’s best response?
Note: Answers to the Clinical Reasoning Activities and Critical Thinking questions can be found in the “Answer Key” sections at the end of the book.
Interactive Activities
References:
- Godden, H. (2024). Lithium monitoring and toxicity management. Pharmaceutical Journal https://pharmaceutical-journal.com/article/ld/lithium-monitoring-and-toxicity-management
- Halter, M., Pollard, C. & Jacubec, S. (2019). Varcarolis’s Canadian Psychiatric Mental Health Nursing. A clinical approach (2nd ed.). Elsevier: Canada.
- Krutika P. Chokhawala, K., Lee, S. & Saadabadi, A. (2024). Lithium. National Library of Medicine. StatPearls – NCBI Bookshelf
- McCuistion, L., Vuljoin-DiMaggio, K., Winton, M, & Yeager, J. (2018). Pharmacology: A patient-centered nursing process approach. pp. 227-305. Elsevier.
- Medical Council of Canada. (2021). Clinical laboratory tests -Adult normal values. https://mcc.ca/objectives/normal-values/ ↵
- Shireen A. Hedya, A., Avula; A. & Swoboda, H. (2023). Lithium Toxicity. National Library of Medicine. [StatPearls]. Lithium Toxicity – StatPearls – NCBI Bookshelf
- Vallerand, A. & Sanoski, C. (2024). Davis’s Canadian drug guide for nurses (19th ed.). F.A. Davis Company: Canada
