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Lithium in General Practice

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Baseline tests and monitoring

Recommended baseline tests and ongoing monitoring are described in Table 2. There may be slight local variations in these guidelines. As well as biochemical monitoring it is important to look for and educate patents about physical signs and symptoms associated with adverse effects and toxicity. These include tremor, tiredness, lethargy, nausea, vomiting and diarrhoea, dehydration, polydipsia, polyuria and nocturia. Although baseline tests will be carried out when lithium is initiated by a specialist, check that the results are complete and readily available for reference.

Table 2 Lithium baseline tests and monitoring.6,9 (adapted from Livingstone 2006, Waitemata DHB 2006)

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  Baseline Routine maintenance Comments
Serum lithium concentrations Important to establish reliable steady state concentration associated with therapeutic response 3-monthly Monitor more frequently in high risk patients, e.g. those on potentially interacting drugs, poor compliance, elderly, unstable renal function, physical illness
Thyroid Function Baseline thyroid function (T4, TSH) TSH 3 months after initiation and then 6-monthly T4 not routinely required. Monitor for symptoms of hypothyroidism
Electrolytes Baseline Check with lithium serum levels every 3 months Particularly important to monitor sodium as it competes for reabsorption in proximal renal tubule
Serum creatinine and renal function Exclude renal disease. Baseline creatinine and estimation of renal function Check at same time as lithium levels, at least every 3 months Estimate renal function using the Cockcroft and Gault Equation* based on ideal body weight
Serum calcium and magnesium Baseline Check every 2 years Lithium may rarely cause hypercalcaemia and hypermagnesium
Parathyroid Hormone (PTH)     Measure only if serum calcium is elevated. PTH must be interpreted relative to serum calcium measurement on the same specimen
Weight Baseline weight Monthly, reduce frequency after 6-12 months if weight is stable Encourage self-monitoring and weight control measures
Pregnancy Test Baseline in women of childbearing age    
ECG Baseline in patients with cardiac problems or aged over 45 years 12-monthly in patients with cardiac problems or aged over 45 years Conduct more frequently if clinically indicated
*The bpac creatine clearance calculator is based on the Cockroft-Gault equation

For correspondence regarding baseline ECG for lithium patients, see "Correspondence: Aspirin in children", BPJ 13 (May, 2008).

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