Maniac -depressive illness.

Cardiovascular- arrhythmias, hypotension, oeripheral circulatory collapse, bradycardia, sinus node dysfunction with severe bradycardia ECG changes- reversible flatttening .soelecticity or inversion of T -waves Neuromuscular- tremor, muscle irritability, ataxia, choreo-athetotic movements, hyperactive deep tendon refexes

Neurological- pseudotumor cerebri ( increased intracranial pressure has been reported. If undetected this condition may result in enlargement of the blind spot,constriction ofvisual fields and eventual blindness due to optic atrophy. Discontinue lithium if clinically possible if this syndrome occurs.

Thyroid- euthyroid goiter or hypothyroidism ( including myxedema) accompanied by by lower T3 and T4 .Iodine 131uptake may be elevated. Paradoxically rare case of hyperthyroidism have occured.

CNS- black out spells, epileptiform seizures,slurred speech, dizziness, vertigo, incontinuance of urine or feces, somnolence, psychomotor retardation, restlessness, confusion, stupor, coma, acute dystonia, downbeat nystagmus, blurred vision, starled response,hypertonicity , slowed intellectual functioning, hallucinations, poor memory, tongue movements, tics, tinnitus, cog wheel rigidity.

GI- anorexia, nausea, vomiting, diarrhea, dry mouth, gastritis, salivary gland swelling abdominal pain, excessive salivation, flatulence, indigestion.

GU- albuminuria, oliguria, polyuria, glycosuria, decreased creatinine clearance, symptoms of nephrogenic diabetes.

Dermatologic- drying and thinning of hair, anesthesia of skin, chronic folliculitis, xerosis cutis, alopecia, exacerbation of psoriasis, acne, angioedema.

Miscellaneous- fatigue, lethargy, sleepiness, dehyration, weight loss, transcient scotomata, impotence/sexual dysfunction, dysguusia/taste distortion,tightness in the chest, hypercalemia, hyperthyroidism, salty taste, thirst, swollen lips, swollen painful joints, fever, polyarthalgia, debtal caries.

Renal cardiac or CNS diseases.Additions disease. Decompensated heart. Pregnancy lactation. Hypothyroidism. Sodium balance disturbances.

Special precautions:

Initiate treatment in hospital.Maintain salt and fluid intake.Monitor thyroid function. Concomittant infection- withelevated temperature may necessiatitae a temporary reduction or cessation of medication.

Potentailly hazardous tasks- observe caution while driiiving or performing other tasks requiring alertness.

Tolerance to lithium- is greater during the acute maniac phase and decrease s when maniac symptoms subside.

Hypothyroidism- ocur with long term lithium administration( 5 % to 15%) Lithium -induced hypothyroidism may be treated with thyroid hormone replacement therapy.

Sodium depletion- lithium decreases renal sodium reabsorption which could lead to sodium depletion. Therfore the patient should maintain a normaldiet (including salt ) and an adequate fliud intake (2500 to 3000ml) at least during the initial stabilization period.

Parameters to monitor- perform the following tests prior to and periodically during lithium therapy. Serum creatinine, complete blood count (lithium may induce a benign leukocytosis), urinalysis, sodium and potassium , fasting glucose, electrocardiogram and thyroid function tests. Check lithium serum levels twice weekly until dosage is stabilized.

Tartrazine sensitivity- some of these products contsain tartrazine which may cause allergic-type reactions )including bronchial asthma) in susceptible indivuduals.

Warnings-

High risk patients- the risk of lithium toxicity is very high in patients with significant renal and or cardiovascular diseases,severe debiltation ,dehydration or sodium depletion , or in patients receiving diuretics. Undertake treatment with extreme caution

Encephalopathic syndrome- (charactrizedby weakness, lethargy, fever, tremuloousness, confusion, extrapyramidal symptoms, leukocytosis, elevated serum enzymes (BUN and FBS) has occured in a few patients given lithium plus a neuroleptic.

Renal functionimpairment- morphologic changes with glomerular and interstitial fibrosis and nephron atrophy have occured on chronic lithium therapy (up to 10% to 20%) and in maniac- depressive patients exposed to lithium.

Elderly- the decreased rate of excretion inthe elderly contributes to a high incidence of toxic efects. Use lower doses and more frequent monitoring.

Pregnancy- if patient becomes pregnany whiletaking lithium, appraise her of the potential risk to the fetus.

Lactation- do not nurse during lithium therapy, except in unusual instances where the potential benefits to the mother outweigh posible hazards to the infant

Children- safety and efficacy for use in children < 12 years old have not been established

Date of Approval    2004

Indications:

Maniac -depressive illness.

Dosage:

Individualise dose according to Serum levels and response . 600mg 3 times daily or 900mg twice daily for the slow release form.

Leukocytosis - ( 282 )

Altrarations of leukocyte counts and functions occur in a wide variety of hematolgic , infectiuos, infalmatory, metabolic, andneoplastic diseases. Because leucocytes are affected by so many diseases, the routine laboratory evaluation of many patients begins with the determination of leukocyte count and the examination and these blood studies Drugs causing adverse reactions - ( 585 )

1. Lithium

2. Corticosteroids

LITHIUM CARBONATE - ANTIMANIAC AGENT 

1.Take immediately after meals or with food or milk to avoid stomach upset.

2. Stop medication and contact physician if signs of overdose or toxicity occurs;such as, diarrhoea,vomiting,unsteady walking,tremor drowsiness,or muscle weakness.

3.May cause drowsiness. use caution while driving or performing tasks requiring alertness.

4. Drink 8 to 12 glasses of water or other liquid while on this drug. maintain regular diet(including salt). Contact if fever occurs.

5.Allergies- Tell your doctor if you have ever had any unusual or allergic reaction to lithium. Also tell your doctor if you are allergic to any other substances, such as foods, presrvatives or dyes.

6. Diet- Make certain that your doctor knows if you are on a low sodium or low salt diet, Too little salt in your diet could lead to serious side effects.

7.Pregnancy - Lithium is not recommeded for use during pregnancy especially during the first 3 months.

8.Breast feeding- Lithium passes into breast milk and reported to cause unwanted effects. Before taking this medicine make sure that you dicuss with your doctor about the risks and benefits of breast feeding

9 Children - Lithium may cause weakened bones in children during treatment

10. Elderly- Side effects are more likely to occur in elderrly patients than in younger adults.

11. Other medicines - Let your doctor know what other medicines you are taking, so that he can advice you accordingly. Antipsychotics - blood levels of both medicines may change, increasing the chance of serious side effects. Diuretics- or Inflamation or pain medicine except narcotics - higher blood levels of lithium may occur, increasing the chance of serious side effects Medicines for asthma, bronchitis or cystic fibrosis that contain the following- Calcium iodide or Iodinated glycerol or Potassium Iodide- unwanted effects on the thyroid may occur.

12. Other medical problems - Tell your doctor if you have any other medical problems especially - Brain disease or Schizophrenia - you may especially sensitive to lithium and mental effects (such as increased confusion) may occur Diabetes mellitus - lithium may increase the blood levels of insulin , the dose of insulin you need to take may change Difficult urination or Infection severe or Kidney disease - higher blood levels of lithium may occur, increassing the chance of serious side effects Epilepsy or Goiter or other thyroid disease or Heart disease or Parkinsons disease or Psoriasis - lithium may make the condition worse Leukemia - lithium may cause the leukemia to occur again

13. Missed dose - If you miss a dose of this medicine, take it as soon as possible. however, if it is almost time for the next dose, skip the missed dose. Do not double doses.

14. Storage - Keep out of reach of children. Store away from heat or direct sunlight. Do not store the capsule in bathroom, near the kitchen sink, or in other damp places.

15. Outdated medicines - Do not keep outdated medicine or medicine no longer needed. Be sure that any discarded medicine is out of reach of children.

Pharmacology:

Lithium alters sodium transport in nerve and muscle cells and effects shift towards intraneuronal catecholamine metabolism. The specific mechanism in mania is unknown.

Pharmacokinetics:

Lithium is readily absorbed from the GI tract. Absorption is not significantly impaired by food. Peak serum levels appear in 1 to 4 hours and complete absorption in 8 hours.

Overdsosage-

Symptoms Toxic lithium levels are very close to therapeutic. The likeli-hood of toxicity increases with increasing serum lithium levels. Serum levels > 1.5mEq/L carry a greater risk than lower levels. Do not permit levels to exceed 2 mEq/L during the acute treatment phase. Discontinue the drug if early symptoms occur. Lithium levels < 2mEq/L - diarrhea, vomiting, nausea, drowsiness, muscular weakness, lack of corodination. May be early signs of toxicity. Lithium levels 2 to 3 mEq/L- giddiness, ataxia, blurred vision,tinnitus, verigo, increasing confusion, slured speech, blackouts, fasciculations, myoclonic twitching or movements of entire limbs,choreoathetpoid movements, urinary or facia incontinence, agitation, or mabiac like behaviour, hyperflexia, hypertonia,dysarthria. Lithium levels >3mEq/L may produce a clinical complex clinical pictureinvloving multiple organ systems including- seizures (generalized and focal) arrjythmias, hypotension, peripheral vascular collapse, stupor, muscle group twitching,spaticity, coma.

Treatment

1.Early symptoms can easily be treated by dosage reduction or cessation and resumption of treatment at a lower dose afterr 14 to 48 hours.

2. In severe cases first eliminate the ion from the patient.

3. Treatment is essentially the same as that used in barbiturate toxicity, gastric lavage, correction of fluid and electrolyte imbalance including the use of normal saline, regulation of kidney function.

4. Charcoal is of no value.

5. Urea, mannitol and aminophylline all produce significant increases in lithium excretrion.

6. Infection prophylaxis, chest x-rays , presevation of respiration and moinitoring of thyriod status are essential.

7. Hemodialysis effectively and rapidly lowers serum lithium levels in the severly toxic patients (generally levels > 3.5 to 4mEq/L ) however, in some circumstances it may be indicated for patients with lower lithium levels.

Missed dose-

1. If you miss a dose of this medicine, take it as soon as possible.

2. However, if it is almost time for next dose, skip the missed dose and go back to your regular dosing schedule.

3. Do not double doses.

Absoption not significantly affected by food.

Pregnancy:

Use in women of childbearing age only when clearly needed and when benefits outwegh the hazards.

Lactation:

Safety in nursing mother has not been established.

Children-

Do not use in children below 6 years,since safety and efficacy not established.