Medscape 2010 article

Based on the research findings, modest improvement can be anticipated in youths with acute-phase bipolar disorder. Adjunctive medications for symptom management of bipolar and comorbid diagnoses may be warranted. While lithium is an US FDA-approved medication for 12–18-year-olds with bipolar disorder, it requires diligent monitoring. Lithium's small therapeutic window (0.8 to 1.2 mEq/l) can precipitate significant adverse effects, particularly at toxic levels. To achieve an accurate lithium level, blood should be drawn 12 h after a dose. A physical examination should be completed before the start of lithium treatment, and the patient should not have any renal problems. Baseline blood work should include a lithium level, blood urea nitrogen, creatinine concentration, thyroid function tests, electrolytes and a complete blood count, and should be repeated every 6 months once steady state is achieved (usually reached after 1 week in children). Pregnancy tests should be obtained for adolescents of childbearing age and education on appropriate measures to prevent pregnancy should be discussed. The starting dose is usually 300 mg per day titrated up every 3–5 days until the level is within a therapeutic range. Patients should be educated regarding adequate fluid intake and the use of a reliable contraception method due to lithium's potential to cause birth defects. Lithium has demonstrated significant weight gain, and weight should be monitored. Adverse effects of lithium include nausea, vomiting, diarrhea, hypothyroidism, renal function abnormalities, polyuria, polydipsia, leukocytosis, tremors and acne. The dose should be either discontinued or lowered if lithium toxicity occurs. Lithium toxicity symptoms include loss of balance, increased diarrhea, vomiting, anorexia, weakness, ataxia, blurred vision, tinnitus, polyuria, coarse tremor, muscle twitching, irritability and agitation. Several drugs have been found to increase lithium levels including carbamazapine, nonsteriodal anti-inflammatory drugs, tetracyclines and thiazide diuretics.[37]Theophylline and caffeine promote lithium excretion, resulting in lower serum levels of lithium at the same oral dose. Clinicians should discuss these potential interactions with patients and families.

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