lithium up titration

[Lauraaa]

Lithium w/ linear kinetics --
If you have a young healthy patient on 300 bid w/ a level at steady state of 0.3 and you want to increase the level to 0.6, would you feel comfortable doubling the dose right away to 600 bid right away?

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[OldPsychDoc]

yes.

 

[whopper]

Agree but also take into consideration the lab values, what they were before lithium, after 300 mg BID and how it affected the TSH and BMP, not just the serum level of lithium.

 

[MacDonaldTriad]

I agree with yes, but make sure the level was 8-12 hours post dose and that all doses where taken for 3 to 4 half lives. If the patient missed the evening dose before the level, this could be a problem. If the order you wrote wasn't implemented right away and they only got 2 1/2 days worth before the level, this is a problem.... 1200mg/day is not a lot for healthy kidneys in most cases.

 

[psychattending]

Yes, it is first order kinetics so doubling the dose would get you to 0.6. The biggest acute problems with uptitrating lithium are GI side effects. I usually don't go up more than 300 mg per dose time, e.g. I will go from 300 BID to 600 BID but not 300 BID to 600/900. I usually aim for a higher steady state level than 0.6.

 

[Shikima]

Totally watch for GI side effects... had this happen with me recently.
Personally, I just go with the rule of thumb for Li - start low and go slow.

 

[twright]

Yes you could, but in general I always go slow. It's really hard to give someone nasty GI side effects, then say "oh, that's just because we went too fast, let's go slower and it will be okay" and expect them to stick it out with you. Better to just go slow from the beginning.

 

[billypilgrim37]

Depends on what you're using it for. Acute mania? Worsening depression with worsening SI? Go for it. Heck, go faster! TID/QID dosing for less GI problems then consolidate doses later for easier compliance. Antidepressant augmentation? May do great at 0.45 too, hard to say. No reason to push. How sensitive is the person to side effects in general? Sounds like you're implying not very. That also gives you some guidance. And you can always present the option to the patient and let them choose w/ informed consent.

 

[Lauraaa]

Thanks everyone. Actually I'm not planning on raising for this particular patient since she's doing well at this dose for what our target is, but I started wondering just how fast most other people up-titrate in the community compared to us. Or rather, not how fast per se, but rather how much a jump in one increase would people be willing to do assuming that the person is healthy, the steady state was calculated correctly (received all doses), all lab values both at baseline and after starting was normal, the person wants to increase rapidly, the increase is clinically indicated, and the pt willing to tolerate some GI discomfort. For example, if you had a person w/ all those criteria listed above, at 300 bid, steady state level 0.3 and you wanted to get to 0.9 - would you feel comfortable going to 600 tid from 300 bid? What if the goal was 1.2, would you be gutsy enough to go even higher in one increase? Whats the biggest jump in one increase you would be wiling to make, and under what circumstances?

 

[vistaril]

Thanks everyone. Actually I'm not planning on raising for this particular patient since she's doing well at this dose for what our target is, but I started wondering just how fast most other people up-titrate in the community compared to us. Or rather, not how fast per se, but rather how much a jump in one increase would people be willing to do assuming that the person is healthy, the steady state was calculated correctly (received all doses), all lab values both at baseline and after starting was normal, the person wants to increase rapidly, the increase is clinically indicated, and the pt willing to tolerate some GI discomfort. For example, if you had a person w/ all those criteria listed above, at 300 bid, steady state level 0.3 and you wanted to get to 0.9 - would you feel comfortable going to 600 tid from 300 bid? What if the goal was 1.2, would you be gutsy enough to go even higher in one increase? Whats the biggest jump in one increase you would be wiling to make, and under what circumstances?

Put the patient on 600 BID. Get a level after 5 days(or whatever). If it's too low, go to 900 BID. Don't bother with tid dosing.....every clinician with 25+ years experience I've ever talked to just rolls their eyes at this. heck a lot don't even bother with BID. Look at the half life of Lithium. But telling a lot of these patients that they may have to break up the dose because it can cause GI distress is going to make them think they have.......GI distress. heck you could dose it 12 times daily at 100mg and if you tell them that dosing it q30 minutes instead of q1hr could help their upset stomach many are going to complain of upset stomach with q1 hr dosing.

I wouldn't have gotten a level with an otherwise healthy pt on a total daily dose of 600mg. That's just a waste of a lab trip, lab costs, etc all the way around if you are planning on getting the level to 1 or above. You're never going to get a level above 1 with a true trough in a health patient at 600mg total daily. That just inconveniences the patient.