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Lithium as augmentation therapy in depression

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Lithium as augmentation therapy in depression

Summary of NICE guidance regarding use of lithium as augmentation therapy is detailed below (1):

for people with depression taking lithium, assess weight, renal and thyroid function and calcium levels before treatment and then monitor at least every 6 months during treatment, or more often if there is evidence of significant renal impairment
for women of reproductive age, in particular if they are planning a pregnancy, discuss the risks and benefits of lithium, preconception planning and the need for additional monitoring
monitor serum lithium levels 12 hours post dose, 1 week after starting treatment and 1 week after each dose change, and then weekly until levels are stable. Adjust the dose according to serum levels until the target level is reached:
- when the dose is stable, monitor every 3 months for the first year
- after the first year, measure plasma lithium levels every 6 months, or every 3 months for people in any of the following groups:
  - older people
  - people taking medicines that interact with lithium
  - people who are at risk of impaired renal or thyroid function, raised calcium levels or other complications
  - people who have poor symptom control
  - people with poor adherence
  - people whose last plasma lithium level was 0.8 mmol per litre or higher.
determine the dose of lithium according to response and tolerability:
- plasma lithium levels should not exceed 1.0 mmol/L (therapeutic levels for augmentation of antidepressant medication are usually at or above 0.4 mmol/L; consider levels 0.4 to 0.6 mmol/L for older people aged 65 or above)
- do not start repeat prescriptions until lithium levels and renal function are stable
- take into account a person's overall physical health when reviewing test results (including possible dehydration or infection)
- take into account any changes to concomitant medication (for example, angiotensin-converting enzyme inhibitors, angiotensin 2 receptor blockers, diuretics and non-steroidal anti-inflammatory drugs [NSAIDs], or over-the-counter preparations) which may affect lithium levels, and seek specialist advice if necessary
- monitor at each review for signs of lithium toxicity, including diarrhoea, vomiting, coarse tremor, ataxia, confusion and convulsions
- seek specialist advice if there is uncertainty about the interpretation of any test results.
manage lithium prescribing under shared care arrangements. If there are concerns about toxicity or side effects (for example, in older people or people with renal impairment), manage their lithium prescribing in conjunction with specialist secondary care services
consider electrocardiogram (ECG) monitoring in people taking lithium who have a high risk of, or existing, cardiovascular disease
provide people taking lithium with information on how to do so safely, including the NHS lithium treatment pack
only stop lithium in specialist mental health services, or with their advice. When stopping lithium, whenever possible reduce doses gradually over 1 to 3 months

For complete details then consult NICE (June 2022). Depression in adults: treatment and management

Reference:

NICE (June 2022). Depression in adults: treatment and management

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