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Question answered:12/10/06 Warning! this question is over two years old.

This question was answered by the NLH Mental Health Specialist Library.

Background:

Hypercalcaemia may arise as a result of toxic lithium levels, lithium and calcium levels should be monitored in patients on long-term lithium therapy.

It was not possible to exactly answer this question by reviewing the available evidence; however our search found the following information which may be useful to you.

The appropriate monitoring of patients with lithium-induced hypercalcaemia and decisions regarding parathyroidectomy are unclear. The decision to continue lithium therapy in the presence of hypercalcaemia should be individualized [1].

NICE  has the following advice on monitoring lithium [2]:

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.

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Definitions:

McHenry, C R and Lee, K. Lithium therapy and disorders of the parathyroid glands. Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, {Endocr-Pract}, Mar-Apr 1996, Vol. 2, No. 2, P. 103-9, Issn: 1530-891x.
The Management of bipolar disorder in adults, children and adolescents, in primary and secondary care. NICE, July 2006. http://www.nice.org.uk/page.aspx?o=CG38niceguidelineword

• Hypercalcaemia: The presence of an excess of calcium in the blood http://www2.merriam-webster.com/cgi-bin/mwmednlm?book=Medical&va=hypercalcaemia

Finally, the following clinical databases were search, and the following references were found:

Medline, Cinahl, Embase, Psychinfo:

1. Bachmeyer, C; Dhote, R; Sereni, D; Grateau, G; Labussiere, A S; Bonnichon, P, and Christoforov, B. Hypercalcemia and parathyroid adenoma in patients on lithium therapy. Three cases and review of the literature. European Journal of Internal Medicine {Eur-J-Intern-Med}, 1995, Vol /Iss/Pg. 6/4 (223-228), Issn: 0953-6205.

2. Livingstone, Callum Rampes Hagen. Lithium: A review of its metabolic adverse effects.

3. Macklin, J P and Green, F C. A guide to the initial management of hypercalcaemia.

4. McHenry, C R and Lee, K. Lithium therapy and disorders of the parathyroid glands. Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, {Endocr-Pract}, Mar-Apr 1996, Vol. 2, No. 2, P. 103-9, Issn: 1530-891x.

5. Rifai, M A; Moles, J K, and Harrington, D P. Lithium-induced hypercalcemia and parathyroid dysfunction. Psychosomatics, {Psychosomatics}, Jul-Aug 2001, Vol. 42, No. 4, P. 359-61, Issn: 0033-3182

6. Khandwala HM, Van Uum S. Reversible hypercalcemia and hyperparathyroidism associated with lithium therapy: case report and review of literature.  Endocrine Practice : Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, {Endocr-Pract}, Jan-Feb 2006, Vol. 12, No. 1, P. 54-8, 35 Refs, Issn: 1530-891x. 

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