Understanding Lithium Dosage and Monitoring in Bipolar Disorder

QUESTION

A 24-year-old male client presented to the emergency department last evening accompanied by their mother with whom they live. Client was only wearing a pair of shorts and a tee-shirt despite the outdoor temperature of 30 degrees Fahrenheit. Client presented as loud and demanding, stating they were “king of the country.” Mother reports the client was diagnosed with Bipolar Disorder, Type I, while in college. Symptoms have been controlled with Lithium Carbonate, Risperidone, and out-patient therapy.

Mother believes the client has stopped taking their medications and is not sure the last time client saw their outpatient therapist. Reports the client has not slept for the past three nights, has lost approximately 10 lbs. in the past two weeks, and has not gone to work for a week. Client is employed as a computer software engineer but is stating “Those idiots at work don’t how brilliant I am. I refuse to work for people who do not appreciate me!” Client was admitted to the inpatient mental health unit at 0200 this morning.

Hospital Day 1:

Nurse’s Notes: 0400 Client admitted to inpatient unit. Initially refused to partake in nursing assessment process loudly stating “I am not staying in a room with any crazy guy! What do you have to eat around this place? I am starving!” Client adhered to assessment when advised they will have a private room and a sandwich was offered, which they were permitted to eat during the assessment.

Thought process is tangential and client is hyperactive. Client stood, stretched, and flexed muscles throughout the interview stating, “I need to keep my body in shape for all the ladies I date.” Client admits to only taking prescribed medications “when I remember…I really don’t need that stuff anymore.” Reports minimal need for sleep or food over the past few days. Denies suicidal or homicidal ideations. Client permitted the nurse to take vital signs and draw bloodwork. Client placed on 1:1 safety precaution until further assessment by treatment team is completed.

Sitting in dayroom with mental health technician at present. Requires frequent redirection not to yell and/or wander on unit while other patients are sleeping.

Vital Signs: 

• Pulse: 92; Blood Pressure 136/88; Respirations: 22; Temperature: 98.3 po

Labs:

• Lithium Level: 0.1 milliequivalents per liter (mEq/L)
• Urine Drug Screen: Negative
• Blood Alcohol Level (BAL): 0 %

Provider Orders:

• Admit to in-patient mental health unit
• 1:1 Observation
• Lithium Carbonate 300 mg po q am and 300 mg q HS
• Risperidone-M 2 mg po daily
• Risperidone 25 mg IM prn agitation (up to two doses per 24 hours)
• Lorazepam 2 mg PO/IM prn anxiety or agitation (maximum daily dose 6 mg)
• Milieu activities as tolerated
• Lithium level every 2 days

A. What is the rationale for the change of the Lithium dose?

B. What are signs and symptoms of Lithium toxicity?

ANSWER

 Understanding Lithium Dosage and Monitoring in Bipolar Disorder

Introduction

Lithium is a commonly used medication in the treatment of bipolar disorder, particularly in controlling manic episodes. This essay aims to discuss the rationale for the change in Lithium dose and explore signs and symptoms of Lithium toxicity based on the presented case scenario.

Rationale for the Change of Lithium Dose

In the given case, the client has been admitted to the inpatient mental health unit due to the exacerbation of manic symptoms. The client’s Lithium level is reported as 0.1 milliequivalents per liter (mEq/L). This level falls within the subtherapeutic range, suggesting that the client’s Lithium dose may not be adequately managing their symptoms. The rationale for changing the Lithium dose is to achieve a therapeutic level that effectively stabilizes the client’s mood and reduces the manic symptoms. Lithium’s therapeutic range typically falls between 0.6 to 1.2 mEq/L, depending on the individual’s response and the presence of adverse effects.

Signs and Symptoms of Lithium Toxicity

Lithium toxicity occurs when the Lithium level in the bloodstream becomes excessively elevated, leading to potential adverse effects. Signs and symptoms of Lithium toxicity include:

Gastrointestinal Symptoms: Nausea, vomiting, diarrhea, and abdominal pain.
Neurological Symptoms: Tremors, muscle twitching, confusion, agitation, and decreased coordination.
Renal Symptoms:Polyuria (excessive urination) and polydipsia (excessive thirst).
Cardiovascular Symptoms: Arrhythmias, hypotension, and increased heart rate.
Neuromuscular Symptoms: Hyperreflexia (increased reflexes) and muscle weakness.
Severe Symptoms: Seizures, delirium, coma, and death in extreme cases.

Since the client’s Lithium level is currently within the subtherapeutic range (0.1 mEq/L), the risk of Lithium toxicity appears to be low. However, it’s essential to monitor the client’s Lithium levels closely as the dose is adjusted to achieve a therapeutic range.

Conclusion

Lithium plays a crucial role in managing bipolar disorder, particularly manic episodes. In the presented case scenario, the change in Lithium dose is aimed at achieving a therapeutic level to effectively control manic symptoms. Awareness of signs and symptoms of Lithium toxicity is crucial to ensure the client’s safety and well-being. As the client’s Lithium dose is adjusted, close monitoring of Lithium levels and potential adverse effects is essential to optimize their treatment outcomes.