The narrow therapeutic window of lithium makes monitoring blood levels essential during treatment. Increasing lithium blood levels over 1.2 mM gives rise to tremors - usually noticed in the fingers - and dosage reduction can usually reduce this effect to mild tremors. Some patients complain of slowed mental agility and forgetfulness. Memory problems are one of the leading causes of non-compliance and the third most common side effect. Extreme lithium doses produce chronic nausea and diarrhea; thus lithium poisoning is rare, but is sometimes seen after poor monitoring of clinical application or an unsuccessful suicide attempt. In a study of 15 deliberate self-poisonings, no deaths were seen, although as discussed in section 1.3.1, the lithium-induced deaths of the 1950s clearly show that some individuals are at risk. Episodic nausea can usually be relieved by taking lithium with food. Some patients gain weight progressively on lithium and it is the second most common reason patients stop taking it. Weight gain is greater in patients who are overweight to begin with. Some patients show decreased thyroid levels and rarely goiter. About 5% develop hypothyroidism and 30% have elevated thyroid-stimulating hormone levels. Polyuria (passing an excessive quantity of urine) or polydipsia (excessive thirst) occurs in one out of five patients. Aggravation of psoriasis and alopecia can occur but hair usually re-grows with or without the lithium.
Based on reports from the 1970s, kidney damage has been a concern for patients taking long-term lithium treatment. However, this worry has not been borne out in further study of correctly treated patients and in practice there appears to be a low incidence of renal damage, although kidney examination is recommended every 6-12 months. Harm can occur if patients are stabilized on lithium and given drugs which may affect renal balance. For instance, non-steroidal anti-inflammatory drugs can cause a 60% increase in blood lithium concentration because of their effect of reducing lithium clearance through the kidneys. These drugs can cause a doubling of the blood lithium levels and the patient may therefore show lithium toxicity. This can also occur with anti-inflammatory drugs like Ibuprofen®, Naproxen® and Indomethacin®.
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