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Published in Andrew Schofield, Paul Schofield, The Complete SAQ Study Guide, 2019
Andrew Schofield, Paul Schofield
Severe episodes may be complicated by psychotic symptoms, such as delusions of grandeur and hallucinations. Diagnosis is clinical, using psychiatric history taking and collateral histories from relatives. Acute presentations should have a suicide risk assessment as part of initial consultation. Most patients present in young adulthood, although it may present at any age. A manic episode may cause sufficient distress to the patient and families that hospitalisation is used. There is a strong genetic component, with many patients having a close relative with the disease. Rarely, the cause may be drug-induced or organic. Treatment centres on the halting of an acute episode with medications such as olanzapine, with follow-up maintenance treatment with lithium, valproate, carbamazepine or a combination of these. Lithium toxicity is a potentially fatal side effect of treatment. Follow-up will be long-term, with high risk of relapse.
Information on level of drugs into breastmilk
Published in Wendy Jones, Breastfeeding and Medication, 2018
Lithium is used to treat bipolar disorder. It is also regarded as a mood stabiliser (SIGN guidelines postnatal depression and puerperal psychosis 2012). It has a narrow therapeutic index and needs close monitoring to avoid toxicity. Signs of lithium toxicity include increasing diarrhoea, vomiting, muscle weakness and lethargy. In the UK mothers receiving lithium are generally advised to formula feed their infants. Chaudron and Jefferson (2000) searched databases for data on the use of lithium, valproate, carbamazepine, gabapentin or lamotrigine during lactation. They located eleven cases of lithium use, eight of which reported infant serum levels. Two cases reported symptoms relating to lithium toxicity in the infants. They recommended considering women’s individual circumstances when prescribing during lactation. It may be possible for breastfeeding mothers to take lithium and breastfeed their infants if the baby’s blood levels are monitored for lithium, thyroid stimulating hormone and creatinine, although alternative medication would be preferred (Schou and Amdisen 1973; Schou 1990; Sykes et al. 1976; Viguera et al. 2007). Lithium is generally felt to be a drug that should not be prescribed during lactation due to the risk of toxicity. If the baby’s state of hydration varies, e.g. during illness, levels may change rapidly.
100 MCQs from Dr. Michael Reilly and Colleagues
Published in David Browne, Selena Morgan Pillay, Guy Molyneaux, Brenda Wright, Bangaru Raju, Ijaz Hussein, Mohamed Ali Ahmed, Michael Reilly, MCQs for the New MRCPsych Paper A, 2017
Dr Mohamed Ali Ahmed, Dr Udumaga Ejike, Dr Ijaz Hussein, Dr Atif All Magbool, Dr Gary McDonald
A 35-year-old man on lithium for one year for the treatment of bipolar disorder is brought to Accident and Emergency by his family due to concerns related to a deterioration in his mental state. Following examination you suspect lithium toxicity. Which of the following would be of most concern?
Evaluating sacubitril/valsartan as a treatment option for heart failure with reduced ejection fraction and preserved ejection fraction
Published in Expert Opinion on Pharmacotherapy, 2022
Emanuel Raschi, Igor Diemberger, Mario Sabatino, Elisabetta Poluzzi, Fabrizio De Ponti, Luciano Potena
By virtue of the minimal involvement of CYP isoenzymes in the metabolism of sacubitril/valsartan, clinically significant interactions with inhibitors/inducers of CYP isoenzymes are unlikely. However, considering the large number of drugs used in HF, pharmacokinetic and pharmacodynamic interactions should not be overlooked, and were therefore investigated in dedicated studies. Both sacubitrilat and valsartan are weak inhibitors of CYP2C9 (uncertain clinical relevance). Inhibition in vitro of organic anion transporter protein (OATP) 1B1 [half maximal inhibitory concentration (IC50), 1.9 lM], OATP1B3 (IC50, 3.8 lM), and OAT3 (IC50, 0.8 lM) by sacubitril was observed at clinically relevant concentrations. Although sacubitrilat and valsartan are in vitro substrate of OAT3, a clinically relevant drug interaction at therapeutic doses is unlikely. As anticipated, sacubitril is a P-gp substrate, albeit with negligible expected impact. Pharmacokinetic interaction potential of sacubitril/valsartan was evaluated with a number of largely used drugs, including hydrochlorothiazide, carvedilol, omeprazole, warfarin, amlodipine, digoxin, atorvastatin, simvastatin, furosemide, metformin, oral contraceptives, as well as pharmacodynamic interaction potential with nitroglycerin and sildenafil. Increased maximum plasma concentration (~2.0-fold) and AUC (1.3-fold) were found only for atorvastatin, without effect on the pharmacokinetics of simvastatin. Conversely, concomitant use with lithium may result in a clinically important interaction with relevant lithium toxicity.
Effect of age on the severity of chronic lithium poisoning
Published in Clinical Toxicology, 2020
B. S. Chan, S. Cheng, K. Z. Isoardi, A. Chiew, W. Siu, B. Shulruf, E. Vecellio, N. A. Buckley
Our study showed that the toxicity severity score increased with worsening renal function as defined by lithium clearance. Our result is contrary to another study that was performed in an ICU setting, which suggested that renal function was not an important predictor of lithium toxicity [15]. This could be explained by the fact that the study included 125 patients in three different categories of exposures, acute, acute on chronic and chronic, with the chronic category having only 35 patients. Patients with chronic lithium toxicity have worse renal function resulting in longer exposure to toxic lithium concentrations and hence be expected to develop more severe toxicity. Such considerations are much less important in acute or acute on chronic overdosing, which have less morbidity.
Validation of a nomogram used to predict lithium concentration in overdose
Published in Clinical Toxicology, 2022
Khin Sam, Anselm Wong, Andis Graudins
Lithium is the oldest and only agent used specifically for the treatment of bipolar disorder [1]. Although effective in treatment and prevention of relapse from bipolar disorder, lithium is well known for its toxicity [2]. Three distinct patterns of lithium toxicity are recognised: “acute poisoning” in patients not previously receiving lithium, “acute on chronic poisoning” in the setting of current lithium treatment and “chronic accumulation” which arises insidiously in patients on therapeutic doses of lithium [3].