Lithium Dosing and Serum Concentrations Across the Age Spectrum: From Early Adulthood to the Tenth Decade of Life

Abstract

The lithium dose required to achieve a given serum lithium concentration decreases threefold from middle to old age, with this trend continuing into the ninth and tenth decades of life. In order to avoid lithium toxicity in aging patients, continued serum concentration monitoring and judicious dose reduction may be required, particularly in those patients with reduced renal function.

A reduced risk of stroke with lithium exposure in bipolar disorder: a population‐based retrospective cohort study

“…Lin et al also pointed out that renal disease was a risk factor for stroke. However, lithium treatment is generally avoided in patients with severe renal disease, owing to a heightened risk of toxicity . None of the 635 patients with bipolar disorder in the lithium group in the current study had chronic kidney disease.…”

ECT and lithium in old age depression – cause or treatment of rapid cycling?

“…At the time of admission for ECT she was receiving venlafaxine 300mg daily, olanzapine 5mg nocte, and lithium 250mg daily, with lithium serum levels between 0.4 and 0.6mmol/l (higher doses had been associated with unacceptable side effects, and she had pre-existing renal impairment 15 ) as adjunctive treatment with the venlafaxine. She had developed psychogenic polydipsia and a tremor.…”

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

“…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.…”

“…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.…”