Lithium side effects 

 

Lithium is an interesting drug with some important side effects. It’s one of those drugs that has a very narrow therapeutic window (0.4-1.0mmol/L) and above 1.5mmol/L you’re at significant risk of developing toxicity.

It’s used primarily as a mood stabiliser in conditions such as Bipolar disorder and refractory depression, and it is important to remember that it’s cleared by the kidneys, so anything that interferes with kidney function can push your lithium levels up dangerously high.

Toxicity triggers:

  • Dehydration
  • Renal failure
  • Diuretics, especially anything ending in -azide
  • ACE inhibitors
  • NSAIDS
  • Metronidazole

Remember that the blood level of Lithium may be normal, but if they’ve got rubbish kidneys, they may still develop toxicity.

Contraindications:

  • Cardiac failure
  • Kidney failure
  • Untreated hypothyroidism
  • Addison’s disease (anything where the patient has low sodium)
  • Pregnancy and breast feeding – Lithium is bad for babies

Side effects:

  • Metallic taste in the mouth – classic sign, seems obvious given Lithium is a metal
  • Fine tremor
  • Weight gain and oedema
  • Abdominal pain
  • Nausea

Signs of toxicity:

  • Hyperreflexia
  • Coarse tremor*
  • Confusion
  • Seizures
  • Coma

*a fine tremor is to be expected at therapeutic levels, so don’t fret if your patient appears fine but a little shaky.

Alcohol History

 To do this properly, you need to encode. By this I mean read the passage, and after each sentence close your eyes and really picture it happening, in first person, as if you are the doctor in the room.

Picture the patient,

  • What does she look like?
  • What does she sound and smell like?
  • What has she got with her?
  • What questions are you asking her and what are her responses?

By doing this you anchor the facts onto an easily retrievable framework. This will help you in both exams and clinical practice, as you actually have something that you have seen before. Likewise, if you have seen a patient similar to this one, use it to build your framework around, and feel free to change some of the details to make it fit – remember mine is just a suggestion!

The Scene

Mrs Pimms is a 70 year old lady. She’s rather large around the middle, and sort of… waddles… into your consultation room. She’s come because her GP told her that her blood results show damage to her liver as a result of her drinking. As she sits down in front of you she smiles and you smell a waft of alcohol on her breath.

  • ascites
  • broad based gait
  • drank recently

She’s brought a dog in a cage with her, which strikes you as a little weird, but reminds you to ask:

CAGE

  • Have you felt like you should Cut down?
  • Do you get Annoyed when people ask about your drinking?
  • Do you ever feel Guilty when you drink?
  • Have you ever needed an Eye-opener in the morning? (hair of the dog)

She answers your questions, and doesn’t think she has a problem. She does feel she probably ought drink a bit less, and gets worked up when anyone talks about it. She occasionally feels guilty after drinking particularly large amounts and often has a quick drink in the morning to help her wake up.

Have you ever tried to give it up?

She says no.

You ask her how much she drinks. (exactly)

Specifically she drinks about two litres of white lightning a day. She buys it from the off license and begins drinking it as she walks home. When she gets home, she locks herself in her bedroom and watches television as she drinks. She usually keeps going until she falls asleep and often forgets to have dinner.

  • Large volume
  • Narrow repertoire
  • Can’t wait until home
  • Drinks alone
  • Loss of appetite

You then ask, “what would happen if you were to forget to buy the alcohol?”

She looks at you, shocked, “I never would! It’s the most important thing in my day! But I suppose I would feel terrible… I would be all shaky and sweaty, and terribly nervous”.

  • signs of withdrawal
  • physical and psychological dependence
  • psychological preoccupation

“When did you have your first drink?”

She had her first drink at the age of seven, as her father was a heavy drinker and often let the children have some to calm them down. As a teenager she went out regularly and got very drunk several times a week. She calmed down a little in her 20s when she began her job as a property manager, and would drink a couple of glasses of wine a night with her husband. After his death, her drinking escalated, becoming a major financial issue for her. As a result she could no longer afford to buy the nice wines that she was used to, so now she only buys white lightning. She usually has a drink in the morning and then is fine until about four o’clock in the afternoon, when she will then drink until she goes to bed.

  • started young
  • family Hx of alcohol abuse
  • bereavement as trigger 
  • financial implications

“Do you find yourself having to drink more to achieve the same effects?”


She says yes. Up until about three months ago she was having a single bottle of White Lightning, however has now increased to two.

  • signs of tolerance


“What impact is this having on your life?”

Because of her drinking routine, she is unable to socialise, and doesn’t really leave the house other than to buy alcohol. She feels an urge to drink, even when she feels like stopping, and will continue to drink until she falls asleep or passes out.

  • loss of socialising
  • continues despite negative consequences

“Who is with you at home?”

She doesn’t have any family and although she is retired, she was volunteering at a charity shop until recently when she found she would rather stay home and drink.

  • no support network
  • impact on occupation

“Have you ever been admitted to hospital because of your drinking before?” 

She has been admitted to hospital in the past for an upper GI bleed, and has had pancreatitis.

  • previous serious harm as a result of alcohol abuse

This scenario shouldn’t be too difficult to imagine, and gives a basic framework as to how to find out about someone’s drinking habits and the implications it is having on their life and health.

Background

  • Reason for their presentation
  • CAGE
    • Ever felt you should cut down on your drinking?
    • Ever been annoyed if people comment on how much you drink?
    • Ever feel guilty about how much you drink?
    • Ever need an eye-opener? (a drink in the morning to perk up)
  • Do you feel like you have a problem with alcohol?
    • what makes you feel that way?
  • When did you have your first drink?
    • Did you enjoy it?
  • What was the pattern of your drinking?
    • how much?
    • increase?
    • how quickly?
  • What caused the change in pattern?
    • stress
    • bereavement
  • What’s your current drinking pattern?
    • every day?
    • when during the day?
    • how much?
      • repertoire
      • how much do you spend on alcohol?
      • what makes you drink more or less?
      • where do you tend to drink?


Dependence and Withdrawal

    • biological signs
      • what happens if you stop drinking?
        • shakes
        • sweats
        • sick
        • cravings
      • do you need to drink more than you used to?
    • psychological signs
      • how important is drinking to you?
      • do you feel a compulsion to drink?
      • what happens if you stop drinking?
        • angry
        • anxious
        • down

Effects on daily living

  • How is alcohol impacting on your life?
    • relationships
    • money
    • activities
    • work
    • family
  • Do you want to stop drinking?
    • have you tried before?
      • if so why didn’t it work?

Previous Medical History

  • JAMTHREADS
    • Jaundice
    • Angina
    • MI
    • TB
    • Hypertension
    • Rhem (murmurs)
    • Epilepsy
    • Asthma
    • Diabetes
    • Stroke
  • Alcohol-specific disease
    • Liver disease
    • Peptic ulcers
    • Pancreatitis
    • Cardiac disease

Previous drug history

  • Regular medications
  • Over the counter
  • Recreational drug use
  • Allergies
  • Smoker?

Family History

  • Family mental illness
  • Family alcohol dependence

Risk assessment

  • How is your mood?
    • sleep?
    • appetite?
    • things you enjoy in life?
  • Have you had thoughts of hurting yourself?
  • Have you felt inclined to hurt others?
  • Do you feel like others would hurt you?
  • Who’s at home with you?
    • Any children?
    • Support network

Advice

  • Offer leaflet about alcohol dependence
  • Offer referral to alcohol rehabilitation service

As you ask these questions, you should be building a picture up in your mind about whether this person is drinking to much, and to what extent it is impacting on their life and health. Key features include:

  • Withdrawal
  • Tolerance
  • Clinical signs of liver damage
    • Jaundice
    • Ascites
    • Hepatomegaly

As well as these, there may be other signs present suggesting excessive alcohol use and damage as a result:

  • Nicotine codependence
  • Social/psychological problems
  • Nausea
  • Vomiting
  • Haematemesis
  • Muscle cramps, pain
  • Altered sensory perception
  • Hypertension
  • Tachycardia
  • Nutritional problems
  • Broad based gate

Management

  • Tests to order:
    • alcohol level
      • breath
      • blood
    • Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar)
    • AUDIT questionnaire
    • bloods
      • gamma-GT
      • ALT
      • AST
      • FBC
    • urine
      • urinary ethyl glucuronide
  • Treatment
    • Acute
      • vitamin supplementation (thiamine)
      • hydration
      • symptom management (chlordiazepoxide, lorazepam, oxazepam)
    • Chronic
      • psychosocial intervention
      • physician advice

A sad story – suicide risk assessment

This morbid story is designed to help remember the essentials of a risk assessment for patient that has attempted to commit suicide.

Mr Suicide has come into the emergency department having taken an overdose. You are the doctor on call and have to decide how to manage his case. You must perform a risk assessment to see if he’s safe to go home.

The Background

Mr Jones is a 70 year old man who lives on his own in a small house on a hill.

Mr Jones has been planning his suicide for a long time. He’s just not felt like himself since his divorce, and was already depressed after the death of his first wife.

Mr Jones used to work at a chainsaw factory, because his dad killed himself with a chainsaw, and since then Mr Jones was determined to make chainsaws as safe as possible to stop this from happening.

Mr Jones’ job at the chainsaw factory ended when the factory was shut down for unsafe working conditions, as many of the employees, Mr Jones included, had contracted irreparable lung damage from the particulate matter in the air. To fill this void in his life he’s been drinking more, to the point where he admits to himself he’s probably dependent on alcohol. Being quite an impulsive person he had also spent a lot of his money on gambling.

Mr Jones’ plan for this evening was the same as the last two times he tried. He was going to drink a lot to make himself feel better, and then take a lot of paracetamol. Last time he tried, he didn’t take enough and he was angry that it didn’t work, so this time he’s been stockpiling them from the local chemist’s for months.

Mr Jones has never really been satisfied with his life, he has always felt like somewhat of a failure, and believes this is largely due to the impact his father had on him as a child. His father would hit him with a belt every time he was ‘bad’, but often randomly, so he didn’t really know how to behave to make his father happy.

 As a result he’s always been very anxious around other people and very worried about doing the wrong thing. He was told that his father had a mental illness of some sort, and that’s why his behaviour was so strange, but it didn’t really ever get better, and he’s always thought that he might take his own life at some point.

The attempt


Mr Jones took as many paracetamol as he could, but doesn’t remember exactly at what time, and then hid in his bathroom and locked the door so that he wouldn’t be found. He hadn’t written a note because he didn’t feel there was anyone to tell.

It was only by chance that a neighbour had popped round to ask him to keep an eye on their house while they went on holiday, and heard someone crying inside. They called the police and then an ambulance, and Mr Jones was brought in.

When you see him, he feels very upset that it didn’t work, and wants to be discharged so that he can go home and do it properly. He refuses any sort of help from the hospital or the mental health team and there is no next of kin that you can call. He claims there is ‘nothing he wants to stay alive for‘.

Summary

This is a ‘worst case’ scenario, designed to highlight the relevant risk factors that may help you decide the risk of a person with a suicide attempt. The following are the key points:

  • Male
  • >65
  • Alone
  • Planning
  • Divorced, single, widower
  • Hx of mental illness
  • Access to lethal means
  • FHx of suicide
  • Unemployed
  • Chronic health issue
  • Substance abuse
  • Impulsive personality
  • Loss of money
  • FHx of mental illness
  • Ongoing intent to take own life
  • Didn’t want to be found
  • Upset that attempt failed
  • Intent to try again
  • Refusal of help
  • No support network
  • No children
  • No reason to stay alive

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Table from bestpractice.bmj.com

Management


Once you have assessed the major components of suicide:

  1. Suicidal ideation
  2. Intent and plan
  3. Access to lethal means
  4. History of attempts

You should do the following:

  • Remove means for suicide (treat overdose/address wounds)
  • Stabilise the patient medically
  • Try and obtain a collateral history and locate next of kin
  • High risk patients should be admitted for observation
  • Those with chronic ideation but no prior attempts may be monitored on an outpatient basis
    • The main factors are providing a support network
  • Address any pre-existing mental issues
    • depression
    • anxiety
    • psychosis
    • substance abuse
    • eating disorders
  • Psychosocial and psychotherapeutic interventions may be warranted:
    • CBT
    • Psychotherapy
    • Psychodynamic interpersonal therapy

and don’t forget those around the person! Suicide attempts hit families hard, and have huge consequences especially in children. Make sure they’re not neglected.

I hope that having this ‘disaster’ scenario in the back of your mind will help remind you the questions that you need to ask when assessing someone’s risk with regards to a suicide attempt.