Trip Answers

Question answered:28/01/08 Warning! this question is over two years old.

 

NICE guidance on Bipolar Disorder (1) (2006) has recommendations on monitoring for lithium therapy. This states:

 

 

“1.6.2.10 For patients with bipolar disorder on lithium treatment, prescribers should do the following.

 

• Monitor serum lithium levels normally every 3 months.

 

• Monitor older adults carefully for symptoms of lithium toxicity, because they may develop high serum levels of lithium at doses in the normal range, and lithium toxicity is possible at moderate serum lithium levels.

 

• Monitor weight, especially in patients with rapid weight gain.

 

• Undertake more frequent tests if there is evidence of clinical deterioration, abnormal results, a change in sodium intake, or symptoms suggesting abnormal renal or thyroid function such as unexplained fatigue, or other risk factors, for example, if the patient is starting medication such as ACE inhibitors, non-steroidal anti-inflammatory drugs, or diuretics.

 

• Arrange thyroid and renal function tests every 6 months, and more often if there is evidence of impaired renal function.

 

• Initiate closer monitoring of lithium dose and blood serum levels if urea and creatinine levels become elevated, and assess the rate of deterioration of renal function. The decision whether to continue lithium depends on clinical efficacy, and degree of renal impairment; prescribers should consider seeking advice from a renal specialist and a clinician with expertise in the management of bipolar disorder on this.

 

• Monitor for symptoms of neurotoxicity, including paraesthesia, ataxia, tremor and cognitive impairment, which can occur at therapeutic levels.

 

 

 

Appendix D, which is available in the full document, tabulates a monitoring schedule. The full document also has some additional information on lithium monitoring in pregnancy.

 

QOF targets (2) (Feb 2006) in the new GP contract include

 

MH 4. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months

 

MH 5. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months

 

The Dyfed Powys Care Effectiveness Team, part of National Public Health Service Wales, published a document in 2004 which included a section on lithium monitoring (3). This is currently being revised and it is hoped to be available in February.

On the issue of the benefit of the application of guidelines and primary versus secondary care, ATTRACT found one 2000 paper entitled Lithium monitoring before and after the distribution of clinical practice guidelines. The abstract does not describe outcomes related to improved patient stability or care but merely describes levels of monitoring prior to and after the introduction of guidelines. The abstract states;

 

 “OBJECTIVE: To determine whether distribution of clinical practice guidelines improves lithium monitoring and whether standards of monitoring differed between patients in psychiatric contact and those seen only in primary care. METHOD: Standards of monitoring were assessed for patients on lithium in northeast Scotland throughout 1995 and/or throughout 1996. Guidelines were circulated in January 1996 to all local general practitioners and psychiatrists. Monitoring was compared between 1995 and 1996 and for patients with and without psychiatric contact. RESULTS: Both primary care and psychiatric records were scrutinized for 422 and 403 patients prescribed lithium throughout 1995 and 1996, respectively. While monitoring was poor on several parameters during both years, frequency of measurement of both thyroid and renal function improved in 1996. Standards of monitoring were better for patients in psychiatric care. CONCLUSION: Standards of lithium monitoring require further improvement. Locally agreed practice guidelines are helpful but patients on lithium should be in continuing contact with an experienced psychiatrist.”

One other paper looking at the appropriateness of lithium monitoring guidelines may be of interest (5)

 

 

 

 

 

1. http://www.nice.org.uk/nicemedia/pdf/CG38niceguideline.pdf

 

2. http://www.bma.org.uk/ap.nsf/Content/qof06~summclinical#MentalHealth

 

3. Dyfed Powys Primary Care Effectiveness Team. Drug Monitoring A Risk Management System. 2004

 

4. Eagles JM, McCann I, MacLeod TN, Paterson N. 1: Acta Psychiatr Scand. 2000 May;101(5):349-53. Lithium monitoring before and after the distribution of clinical practice guidelines.

 

5. Gupta N. Guidelines for lithium monitoring: are they ideal? Acta Psychiatr Scand. 2001 Jul;104(1):76-7.

 

 

 

 

 

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