Following Li levels

[billypilgrim37]

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A question for the more experienced:

I'm on my first medicine month, and have learned a ton about chronic/acute lithium toxicity. Just d/c'ed a guy today who has been on Li, well controlled, for the past 20 years. All indications suggest that his outpatient psychiatrist hasn't checked his Li level, thyroid, or renal function in the past three years. His Cr stabilized to 3.3 eventually, his TSH was essentially 0 with free t3 and t4 and all those fun antibodies wnl. His li level on admission was 2.1, but by history, it seems he has probably been agitated simiarly since about January, when he was prescribed Risperdal to "chase" what has presented now as Li toxicity.

So my question; the op psychiatrist has records of ordering labs. The patient, who has significant social difficulties, was never able to f/u and get the labs. So which is more ethical,

a) keep prescribing the lithium, which has kept him "well-controlled" for almost 20 years, despite the inability to do proper monitoring, or

b) hold the lithium "hostage" until the pt gets the labs.

My personal bias is towards b), because I feel a lack of proper monitoring is essentially malpractice, and this guy wound up having like six consults to address all the issues that his chronic Li toxicity generated.

But I could be sympathetic to a), and our patients often have tremendous social barriers (as this one did) to following up with all aspects of care properly.

So, in real practice, what would you/do you do?

Oh yeah, and one of my other patients gave me a gnarly case of gastro, and I've been essentially delirious all evening. Ah, medicine!

 

[sunlioness]

Interesting question. I don't know what the "right" answer is, but I had a patient on lithium who "didn't get around" to her labs for 6 months. I kept her on it because she didn't have any signs of toxicity and she was on a fairly low dose. However, when she did finally make it to the lab her level was low end therapeutic. When we discussed her results, we also discussed the possibility of bumping up her dose a bit, which was something she wanted to do. At this higher dose, I told her straight out, that without proper lab tests within a proper period of time, I was lowering it right back down to the old dose. So that's my limited experience with it.

I'll be interested in seeing what more experiences folks have to say.

 

[Doc Samson]

If he's on lithium, he needs lab monitoring. Would consider transferring care to facility that can draw labs on site (i.e., immediately after office visit, pt is accompanied by nurse/tech/front desk staff for lab). In my experience, this means either a hospital setting or in some cases a community mental health center.

 

[Anasazi23]

I have a lot to say about this, since I'm involved in my forensic fellowship in a remarkably similar case of chronic Li poisoning in which the patient did not receive f/u levels.

To answer your question succinctly without divulging too much legally on my end - suffice it to say that from a legal standpoint, I'd definately stop the lithium, or at least extensively document the patient's inability/unwanting to get this necessary testing done.

To err on the other side, risking toxicity and potential permanent kidney, muscular, and brain damage, is much more difficult to climb out of - since it's now your word against theirs.