THERAPEUTICS

Brands

• Carbolith, Eskalith, Priadel, Litarex, Lithicarb, Lithotab, Camcolit, Quilonum

Generic?

• Yes

Class

• Mood stabilizer

Commonly Prescribed for

(FDA approved in bold)

• Manic episodes in bipolar disorder

• Maintenance treatment in bipolar disorder

• Cluster headache prophylaxis

• Hypnic headache

• Major depressive disorder

• Bipolar depression

• Borderline personality disorder

• Anorexia nervosa

• Hypersomnia

How the Drug Works

• Lithium exhibits mood-stabilizing effect by modulating pre and postsynaptic neurotransmission of dopamine, glutamate (NMDA), nitric oxide, and GABA. It also exhibits neuroprotective effect by modulating oxidative metabolism, glycogen synthase kinase 3β promotor, brain-derived neurotrophic factor, and autophagy. In mania, where the levels of neurotransmitters are high, lithium stabilizes the neurotransmission. In the absence of pathology, lithium increases the level of these neurotransmitters

• It influences the circadian clock by increasing BMAL1 expression, disrupting the natural cycle

• The exact mechanism for preventing cluster headache is unknown

How Long Until It Works

• Cluster headache prophylaxis: usually effective in 2–3 weeks

• Acute mania: normalization of symptomatology within 1–3 weeks

If It Works

• Produces reduction in the severity or frequency of attacks. Consider tapering or stopping if headaches remit (more than 2 weeks in episodic cluster patients) or if considering pregnancy

If It Doesn't Work

• Increase to highest tolerated dose

• Cluster/hypnic headache: address other issues, such as medication overuse, other coexisting medical disorders, such as anxiety, and consider changing to another agent or adding a second agent

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Cluster: at the start of the cycle can use a corticosteroid slam and taper. Verapamil is effective in cluster but may cause fluctuations in lithium levels. Valproate, topiramate, triptans, and methysergide are effective for many cluster patients

Tests

• Obtain baseline renal function, thyroid function, weight/BMI, and ECG before starting