Discontinuation of lithium augmentation in an elderly cohort

Fahy, Sabina; Lawlor, Brian A.

doi:10.1002/gps.453

Cited by 33 publications

(27 citation statements)

References 26 publications

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“…8 Eleven or 52.4% of patients relapsed after discontinuation in a mean time of 7.8 months (SD 9.1 months). The nonrelapse group was followed for a total of 19.5 months.…”

Section: Resultsmentioning

confidence: 99%

“…Fahy and Lawlor's study 8 used a naturalistic study design, which was more revealing of true effectiveness than an RCT. Some of their statistical findings were rather obscure.…”

Section: Discussionmentioning

confidence: 99%

“…Fahy and Lawlor's study 8 was a naturalistic design and scored poorly on the EBMWG criteria because it was not randomized and had no control group. The information taken from it was useful as the design was otherwise rigorous and evaluated effectiveness rather than efficacy.…”

Section: Study Qualitymentioning

confidence: 99%

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Discontinuation of Lithium Augmentation in Geriatric Patients with Unipolar Depression: A Systematic Review

Ross

2008

Can J Psychiatry

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I n the geriatric population, many patients take lithium as an augmentation treatment and it might need to be discontinued after remission or recovery in some cases for various reasons. 1,2 Lithium use in the geriatric population is more complicated because of the different pharmacokinetics that are present in the elderly patient, decreased glomerular filtration rate, decreased volume of distribution, and increased risk of lithium toxicity. 3 One retrospective study of lithium augmentation in younger adults with treated unipolar depression found that at 2 years after discontinuation or maintenance on lithium, 8% of those on lithium had a relapse while 58% in the withdrawal group

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“…8 Eleven or 52.4% of patients relapsed after discontinuation in a mean time of 7.8 months (SD 9.1 months). The nonrelapse group was followed for a total of 19.5 months.…”

Section: Resultsmentioning

confidence: 99%

“…Fahy and Lawlor's study 8 used a naturalistic study design, which was more revealing of true effectiveness than an RCT. Some of their statistical findings were rather obscure.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Discontinuation of Lithium Augmentation in Geriatric Patients with Unipolar Depression: A Systematic Review

Ross

2008

Can J Psychiatry

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“…One last study of lithium augmentation discontinuation was published in 2001 (50). This was a naturalistic, prospective study (N=21) in a population with unipolar depression that was "clinically well" with combined AD plus lithium treatment.…”

Section: Maintenance Of Augmentation Medications Following Remissionmentioning

confidence: 99%

Going Beyond Antidepressant Monotherapy for Incomplete Response in Nonpsychotic Late-Life Depression: A Critical Review

Maust

Oslin

Thase

2013

The American Journal of Geriatric Psychiatry

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Many older adults with Major Depressive Disorder (MDD) do not respond to antidepressant monotherapy. While there are evidence-based treatment options to support treatment beyond monotherapy for adults, the evidence for such strategies specifically in late-life MDD is relatively scarce. This review examines the published data describing strategies for antidepressant augmentation or acceleration studied specifically in older adults, including lithium, stimulants, and second-generation antipsychotics. In addition, the authors suggest strategies for future research, such as study of specific agents, refining understanding of the impact of medical or cognitive comorbidity in late-life depression, and comparative effectiveness to examine methods already used in clinical practice.

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“…1 Despite the relatively low 0.5%-2% risk of serious long-term sequelae of lithium use, 7 acute toxicity frequently leads to lithium discontinuation and rates of mood disorder relapse of 33%-50%. 5,8 The potential for acute toxicity has led many clinicians to avoid prescribing lithium for older adults and choose agents, such as valproate, 9 even though cognitive dysfunction and dementia rates may be worse with valproate. 10 Whether lithium increases the long-term risk of chronic kidney disease 11 remains unclear.…”

mentioning

confidence: 99%

Acute renal and neurotoxicity in older lithium users: How can we manage and prevent these events in patients with late-life mood disorders?

Laliberté

Rej

2015

jpn

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A 72-year-old man with a longstanding history of bipolar affective disorder type 1 had been stable on lithium monotherapy of 900 mg/night at a serum level of 0.8 mmol/L for more than 20 years. His family physician started him on hydrochlorothiazide (12.5 mg/d) for hypertension. One week later, the patient's wife noticed unsteady gait, slurred speech and somnolence. The patient was brought to the emergency department, where he was found to have a lithium level of 1.7 mmol/L, a sodium level of 147 mmol/L, and an estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m 2 . While admitted to hospital for an acute kidney injury (AKI), the patient was switched to valproate. The AKI and neurologic sequelae resolved with hydration, and his renal function returned to his baseline 65 mL/min/1.73 m 2 within a year. In the years that followed, the patient was continued on valproate, but he experienced several depressive and hypo manic relapses.Lithium toxicity is common in older users, with an annual incidence of 1.5% per year.1 Severe toxicity primarily manifests with neurologic sequelae (coarse tremor, gait difficulties, delirium, seizures, somnolence) and sometimes cardiac dysrhythmias.2 In addition, AKI and acute renal toxicity occur in 1.3%-4% of older lithium users over 5-year follow-up.3 These acute neurologic and renal manifestations generally resolve completely within 9-12 months, 2,4 although sometimes renal impairment may be sustained. 3Toxicity symptoms are common at levels higher than 1.5 mEq/L, although chronic lithium intoxication at levels above 0.8mEq/L may also be dangerous in older adults.4 Natural aging also increases the risk for toxicity; the lithium dose required to achieve a given therapeutic serum level may decrease three-fold between the ages of 40 and 95 years, largely owing to decreased eGFR.5 Consequently, lithium and renal function need monitoring every 3 months with aging.4,5 Nephrogenic diabetes insipidus also increases toxicity risk, possibly through a feedback loop of elevated lithium levels causing acute diabetes insipidus and leading to further diuresis and lithium level elevations. 6 Other risk factors include medications commonly prescribed in late life, such as diuretics, loop diuretics, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and nonsteroid anti-inflammatory drugs, which can increase lithium levels up to 50%. 1 Despite the relatively low 0.5%-2% risk of serious long-term sequelae of lithium use, 7 acute toxicity frequently leads to lithium discontinuation and rates of mood disorder relapse of 33%-50%. 5,8 The potential for acute toxicity has led many clinicians to avoid prescribing lithium for older adults and choose agents, such as valproate, 9 even though cognitive dysfunction and dementia rates may be worse with valproate. 10 Whether lithium increases the long-term risk of chronic kidney disease 11 remains unclear. It is true that 0.5%-2% of patients may eventually require chronic dialysis and that continued lithium exposure can be associat...

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Discontinuation of lithium augmentation in an elderly cohort

Abstract: When lithium augmentation therapy is discontinued in elderly depressives over half of these patients relapse. A longer duration of prediscontinuation lithium treatment and more hospital admissions appear to be associated with increased risk of relapse.

Cited by 33 publications

References 26 publications

Discontinuation of Lithium Augmentation in Geriatric Patients with Unipolar Depression: A Systematic Review

Discontinuation of Lithium Augmentation in Geriatric Patients with Unipolar Depression: A Systematic Review

Going Beyond Antidepressant Monotherapy for Incomplete Response in Nonpsychotic Late-Life Depression: A Critical Review

Acute renal and neurotoxicity in older lithium users: How can we manage and prevent these events in patients with late-life mood disorders?

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