1
Guidelines for the
Management of Patients on
Lithium
Review Date: September 2011
Introduction
These guidelines have been developed by a multidisciplinary team to ensure a
safe, effective and consistent approach to the management of patients receiving
lithium.
Scope of Guideline
These guidelines include advice to prescribers and other healthcare
professionals on managing patients on lithium, e.g. monitoring requirements,
managing lithium levels and also counselling points for patients.
This guidance does not cover treatment for under 18s, as this is a sub specialist
area requiring tertiary referral and monitoring.
Lithium Treatment Practice Points
To improve safety and management of patients on lithium the following practice
points identify essential elements for patient care:
Practice Point 1:
The hospital doctor should notify the GP in the agreed
standard letter format (see Appendix 1).
Necessary information:-
Treatment
• Current indication
• Dose regimen
• Brand prescribed
Monitoring
• Proposed therapeutic range
• Last recorded level
• Frequency of lithium monitoring (typically 3 monthly)
• When next level due
• Other monitoring requirements
Counselling Checklist
• Compliance essential
• Dosage/missed dose and appropriate action
• Need for regular monitoring requirements
• Risk of hypothyroidism
• Salt/fluid intake
• Lithium side effects/toxicity risks and appropriate actions
• Drug interactions
• Pregnancy or planning to start a family**
**(Seek advice before stopping contraception or if
pregnancy is suspected)
2
Minimum monitoring requirements for established lithium treatment
It is essential to monitor the following regularly:
• How lithium is being prescribed (e.g. the brand used, desired therapeutic range,
concomitant medication).
• How it is taken by the patient (e.g. compliance with dosing regimen, use of over the
counter preparations, in particular ibuprofen).
Practice Point 2:
Different preparations of lithium may vary widely in
bioavailability i.e. the amount absorbed into the blood.
• New patients in NHS Borders will be initiated on a
specific lithium brand, generally Priadel.
• Check that patient continues on same brand of lithium.
• All prescriptions for lithium should be written in
proprietary form, i.e. brand name.
• If changing between brands or between tablets and
liquid, more frequent monitoring may be required initially
as the change may result in alterations in lithium levels.
• Take particular care when changing from tablets to
liquid or vice versa. e.g.
Lithium carbonate tablet 200mg (Li
+
5.4 mmol)
is approx. equal to
Lithium citrate liquid 509mg/5ml (Li
+
5.4 mmol)
3
Practice Point 3:
After stabilization of new patients, blood lithium levels should be
monitored typically 3 monthly:
• Sample should be taken at least 8 hours post dose
• The time interval should be the same at each measurement
• State sample time clearly on the form
If ACE Inhibitor, diuretic or NSAID is started or there is
evidence of deterioration in renal function then eGFR
should be checked more frequently
Every 6 months – (see letter to GP – Appendix 1)
U&Es and eGFR
T4 /TSH
Every 12 months
• Weight, BP, pulse, urine dipstick
• Request eGFR
Practice Point 4:
Certain patients may require more frequent or additional
monitoring.
• If clinical indications arise
• "high risk" patients: - over 65s.
- those on interacting medicines.
- those with, or at risk of,
renal/thyroid/cardiac disease.
- serum calcium should be checked if
any clinical signs suggestive of
hypercalcaemia.
If further concerns re eGFR, contact renal Physicians.
Consider stopping lithium for up to 7 days in acute severe illness
with a metabolic or respiratory disturbance from whatever cause.
Practice Point 5:
If urine dipstick shows more than trace of blood or protein, the
dipstick should be repeated on an early morning sample. In the
absence of a urinary infection, if there is a positive dipstick (for
blood or protein), consider further investigation and possible
referral.
4
Side Effects
It is important to enquire about side effects and to consider how these might be best
managed.
Some side effects can be expected but it is vital to be alert for symptoms suggestive of
lithium toxicity (see below).
Common side effects of lithium include
• GI disturbances (e.g. nausea, diarrhoea, dry mouth)
• Weight gain
• Oedema
• Fine tremor
• Polyuria
• Polydipsia
• Hypothyroidism
Side effects may be short term and are usually dose dependent.
They can often be prevented or relieved by a moderate reduction in dose.
Practice Point 6:
Signs of lithium toxicity include:
Blurred vision, muscle weakness, nausea, vomiting,
drowsiness, coarse tremor, dysarthria (slurred speech),
ataxia (unsteady gait, problems with balance, falling
over), confusion, convulsions, ECG changes.
Practice Point 7:
If patient exhibits signs of lithium toxicity (see
practice point above)
STOP LITHIUM IMMEDIATELY
• Check lithium levels, eGFR, U&Es
• Refer to hospital if clinical condition warrants
• Seek advice from psychiatrist for re-initiation of lithium
5
Drug Interactions
Some medicines may result in increased lithium levels and increase risk of toxicity. These
include:
• Diuretics (mainly thiazides)
• NSAIDs (e.g. ibuprofen)
• ACE inhibitors
• SSRIs (e.g. fluoxetine) and other psychotropic medicines
• Theophylline
Refer to Appendix 1 in the current BNF for further details and a full list of interacting
medication.
Psychiatric Review and Referral
For patients managed only in primary care, general practitioners may wish to consider
referring patients for formal psychiatric review after 2-5 years of treatment, to consider
appropriateness of continuing lithium therapy.
Other reasons for referral (at any stage) may include:
• Patient relapse
• Problematic side effects
• Deterioration of renal/thyroid function
• Requests to stop lithium
• Pregnancy or planning for pregnancy - see Appendix 6
Managing Lithium Levels
Practices will record information on the GPASS system wherever practical but a paper
system may be of additional use in some situations – see Appendix 4.
(Always check that the timing of the blood sample has been appropriate, i.e. at least 8
hours post-dose)
If the level is low (typically < 0.6 mmol/l )
• If the patient is well and the levels are consistently low but within the documented
specified range for that patient (this would be unusual but might be the specialist
recommendation), do not alter dose
• If the patient is unwell and pattern of levels have been bordering on the lower end of the
range:
- Assess compliance
- Increase the dose if appropriate
- Recheck the level in 5 days
• If the low level is inconsistent with the trend, i.e. a one off:
- Assess compliance
6
- Consider other factors, e.g. drug interactions, excess intake of fluid, brand change
- Recheck the level
If the level is within therapeutic range (typically 0.6-1.0 mmol/l)
• If the patient is well and tolerating lithium, do nothing!
• If the patient is well but complaining of side effects, e.g. polyuria, polydipsia, reduce the
dose and check:
- If change in diet e.g. dietary salt restriction or crash diets can cause blood lithium to
rise
- Initiation of interacting medicines by doctor or use of over the counter pharmaceutical
products/herbal or dietary supplement products.
• If the patient is clinically unwell, liaise further with CPN / psychiatrist
If the level is high (typically > 1.0 mmol/l), but with no signs of toxicity
• If there is an explanation for the high level e.g. dehydration, timing of level, interacting
medicines, brand change, correct where possible and recheck level
• If the level is part of a pattern of levels which have bordered on being too high:
- Decrease the dose
- Encourage fluids
- Recheck the level in 5 days
• If there is no clear explanation for high level:
- Recheck level
- Investigate renal function
Counselling Points for Patients on Lithium
Note
A patient information leaflet (Appendix 3) has been produced to accompany this guideline,
and may be freely photocopied.
People taking lithium need to know the following:
1. Name of drug
Reinforce importance of continuing on same brand of lithium and if possible, attend
same pharmacist.
2. What the drug is used for
Used mainly as a mood stabiliser to help normalise or even out mood swings. It also
prevents mood swings in the future.
It can also be used for other reasons, e.g. to increase the effect of
antidepressants/other medication when they are not working enough on their own.
3. Dosage/missed dose
• Reinforce importance of taking:
- As directed
- At same time(s) each day
- With glass of water
• Important not to crush tablets as this will affect the sustained release preparations.
• If dose is missed, take as soon as possible as long as it is no longer than 3 hours
after the usual time. Advise that they should not take double the dose the following
day.
7
4. Blood tests
Advise patient that:
• It is essential to have regular blood tests to check lithium levels and that initially they
will be checked weekly or fortnightly. Once levels of lithium in the blood are steady,
they will be checked regularly (typically 3 monthly) at least 8 hours after the last
dose.
• They will have blood tests at least every 6 months to check on kidney and thyroid
function.
5. Other medicines
Advise patient that:
• Some medicines whether prescribed or bought from a pharmacy may result in
increased lithium levels and increase the risk of toxicity/side effects, e.g: water
tablets (mainly thiazides), anti-inflammatories (e.g. ibuprofen), sodium bicarbonate
(baking powder) and theophylline.
• They should always check with their doctor or pharmacist before starting any new
medication.
6. Salt/fluid intake
Advise patient that:
• The amount of salt in the diet can change the level of lithium in the blood and to
avoid changing from a high to low sodium diet and vice versa. It is important to
maintain a good fluid intake, particularly in situations where there is a risk of
dehydration, e.g. after exercise, long distance air travel, sickness, fever, diarrhoea
and hot weather.
• They should avoid crash diets.
• They should consult a doctor if they are elderly and develop a chest infection or
pneumonia or are immobile for long periods.
7. Alcohol intake
Advise patients that:
• Alcohol and lithium may cause drowsiness and alcohol can also change the level of
lithium in the blood.
• They should avoid alcohol in the first week, then drink in moderation, i.e. no more
than 1-2 units per day.
8. Women of child bearing age/pregnancy
Advise patients that they should:
• Seek medical advice before stopping contraception if they are planning to become
pregnant.
• Seek medical advice as soon as possible if they are taking lithium and are pregnant.
8
9. Compliance
Advise patient that:
• Lithium is not addictive
• It should not be stopped suddenly as original symptoms may return
• It may take several weeks or months to work
• Lithium will normally have to be taken long term, ie for at least 2-3 years
• They should carry a Lithium Treatment Card at all times – available from
Pharmacies
Patient Advice on Side Effects
NB. The following table is also available as a patient information leaflet (Appendix 3)
Common
Side Effect What happens/What you
may notice
What to do about it
Tremor Fine shaking of your hands This is not dangerous but it
can be irritating.
If it annoys you, your doctor
may be able to give you
something for it.
If it gets worse and spreads
to the legs or jaw, stop
taking your lithium and see
your doctor*
Stomach upset This includes feeling and
being sick and diarrhoea
If it is mild, see your
pharmacist. If it lasts for
more than a day, see your
doctor*
Polyuria Passing a lot of urine Don’t drink too much
alcohol. Tell your doctor
about it* – some blood and
urine tests may be needed
Metallic taste Your mouth tastes as if it
has had metal or something
bitter in it
This should wear off after a
few weeks - if not, mention
this to your doctor next time
you meet.* A change in
dose may help
Polydipsia Feeling very thirsty
Your mouth is dry and there
may be a metallic taste
Try drinking water or low
calorie drinks in
moderation. Try sucking
sugar free boiled sweets.
* The doctor who issues your prescription
9
Less common
Weight gain Eating and drinking more.
Putting on weight
Try drinking water or low
calorie drinks in
moderation. Exercise and
a healthy diet are
important - ask your
Practice Nurse for advice
Hypothyroidism Low thyroid activity.
You feel tired
Tell your doctor as it may
be necessary for him/her
to prescribe some thyroid
replacement tablets.*
Rare
Skin changes For example:- rash, acne,
psoriasis
Stop taking your lithium
and contact your doctor
immediately during
routine hours*.
Blurred vision Your lithium level may be
too high.
Things look fuzzy and
you can’t focus properly.
Stop taking your lithium
and contact your doctor
immediately.*
Drowsiness Your lithium level may be
too high.
You feel sleepy and
sluggish in the daytime
Stop taking your lithium
and contact your doctor
immediately.*
Confusion Your lithium level may be
too high.
Your mind is all mixed up
Stop taking your lithium
and contact your doctor
immediately.*
Palpitations Your lithium level may be
too high
Your heartbeat feels fast.
Stop taking your lithium
and contact your doctor
immediately.*
* The doctor who issues your prescription or NHS 24 at evenings and weekends.
10
Authorship
Original Lithium Membership Group
Dr Bruce Low, Consultant Psychiatrist
David Usher, Top Grade Biochemist
Jackie Scott, Chief MLSO – Clinical Chemistry
Shirley Watson, Clinical Pharmacist
Jennifer Smith, Community Support Pharmacist
Ros Anderson, Senior Pharmacist, Medicines Management
Dr Declan Hegarty, GP & Chair, Primary Care Prescribing Group
Guideline document content updated by Adrian Mackenzie, Bruce Low and Ros Anderson
March 08. Approved by Mental Health Formulary and Prescribing Committee June 2008
Appendix 1
Letter to GP for Patients on lithium (normally Priadel)
The proprietary brand is ____________________________ (please specify)
Dear Dr
Your patient has been recommended to commence on lithium. This proprietary
brand should not be changed without considering the different bioavailability.
**Please use every opportunity to encourage your patient to take the
medication, (unless problems have emerged). Research shows many patients
take it only when they are due a blood test!
Patient Specific Details CHI No/Casenotes No: ………………
Name: ………………………….. Consultant Psychiatrist:: ………………………...
Date of Birth ……………………
Treatment
• Current indication …………………………………………………………………….
(eg, bipolar prophylaxis, augmentation)
• Dosage regimen ……………………………………………………………………
• Brand prescribed ……………………………………………………………………
• Proposed therapeutic range (if different from 0.6-1mmol/l) ……………………
• Last in-patient lithium level (where relevant) ……………………………………
• Frequency of lithium monitoring (typically 3 monthly) …………………………..
• Next level due ……………………………………………..
Other Minimum Monitoring Requirements (in primary care for all
out-patients)
• Urea, electrolytes and eGFR – 6 monthly
• T
4
/TSH – 6 monthly
• Weight/BP/pulse/urine dipstick – 12 monthly
NB: More frequent monitoring may be required if clinical indications arise and in
higher risk patients, eg over 65s, those on interacting drugs, those with or at
risk of renal/thyroid/cardiac disease.
Counselling Checklist
• Compliance essential
• Dosage/missed dose and appropriate action
• Need for regular monitoring requirements
• Risk of hypothyroidism
• Salt/fluid intake
• Lithium side effects/toxicity risks and appropriate actions
• Drug interactions
• All women of child- bearing age should be counselled about the need to
discuss pregnancy or planning a pregnancy with their GP.
Both the standard patient letter and patient leaflet are enclosed for your
information.
Full information on lithium monitoring and your role in primary care is provided.
Key points for new patients
• Check blood level weekly and adjust dose accordingly as per Guidelines
• On occasions the Consultant may specify a higher level as optimal, eg in
treatment refractory situations
• The guideline also confirms that any adjustment of the dose is the
responsibility of the GP who will bear in mind that there is a straight-line
relationship between dose and serum level, for example 400mg and level
of 0.4mmols would predict 600mg, will result in level of 0.6 mmols etc. The
half life is 20 hours in a person with normal renal function.
• For interpretation of result note time post-dose of the sample; it
should be at least 8 hours.
• If consecutive levels are stable and in agreed therapeutic range double the
interval up to a maximum of 3 months.
• Toxic levels can occur above 1.0mmol/l and patients should be assessed
for need for possible urgent hospital treatment; if level is above 2mmol/l
this will definitely be required.
• Compliance should always be closely monitored in this patient population.
The Mental Health Community Team Annual Review covers the necessary
actions for lithium patients (see Appendix 5).
The Community Mental Health Team will follow up your patient in the future
unless advised otherwise.
Yours sincerely
Appendix 2
Letter to Patient on lithium (normally Priadel)
Dear
As I have discussed with you, I write to confirm the recommendation that you
commence on lithium (Priadel) as treatment for your bipolar illness/depression.
I enclose an information leaflet for you.
I would like to emphasise the importance of: -
• Taking your medication regularly at the same time of day, preferably in a
single dose at bed time.
• Attending your Health Centre for regular monitoring of the level of lithium
(normally Priadel) in a blood sample.
• Adjusting the dose if the GP recommends this after any of the blood test
results.
• Alerting anyone treating you, for example, when on holiday or if admitted
to hospital, that you are taking lithium.
• Always check with your Pharmacist before buying any medicines.
• Your medication will be adjusted to achieve a level between 0.6 and 1 on
your blood test unless otherwise recommended by your psychiatrist.
• It is important that you continue the lithium for the duration recommended
by your psychiatrist, usually 2 years in the first instance.
• Please bring any problems or side effects to the attention of your GP,
psychiatrist or CPN so that these can be discussed with you and an
appropriate plan agreed with you.
Yours sincerely
Appendix 3
Personal details, for you to complete
The trade name of my lithium is: -
……………………………………..
(Remember to tell you doctor or pharmacist this name)
In case of emergency, my doctor’s telephone
number is ………………………………….
Ask your doctor or pharmacist for a Lithium Treatment Card
which you should carry with you at all times.
This leaflet has been produced by NHS Borders Lithium Guideline
Working Group and may be freely photocopied.
Adapted from:
United Kingdom Psychiatric Pharmacy Group 2001
Lithium
(Lith – ee – um)
Why Have I been prescribed lithium?
Some people suffer from severe mood swings. Sometimes you may be full of
energy and feel very happy, or you may be very irritable and not feel like
sleeping. At other times, your mood can be low and you may feel depressed.
Lithium is used mainly as a mood stabiliser to help normalise or even out these
mood swings. It also prevents mood swings in the future. Lithium can also be
used for other reasons, for example, to increase the effect of other
antidepressant/other medication when they are not working well enough on their
own.
How should I take my lithium?
Always try to take your dose at the same time each day and with a full glass of
water. It is important not to crush the tablets. If a dose is missed, take as soon
as possible, as long as it is only up to three hours after the usual time – do not
take double the dose the following day. Always make sure that you tell your
doctor and pharmacist the trade name of your lithium – it is important to
continue on the same brand. Try to attend the same pharmacist if possible.
Why do I need to have some blood tests?
Regular blood tests are necessary to check lithium levels and to make sure you
are taking the right dose. They will be checked weekly or fortnightly at first.
Once levels of lithium in the blood are steady, they will be checked regularly
(typically 3 monthly), usually 12 hours after the last dose. You will also have
blood tests at least every 6 months to check on kidney and thyroid function
.
Is lithium safe to take with other medicines?
Some medicines, whether prescribed or bought from the pharmacist may result
in increased lithium levels and increase the risk of side effects. Examples of
such medicines include: water tablets, anti-inflammatories (such as ibuprofen),
sodium bicarbonate (baking powder) or theophylline. Always check with your
doctor or pharmacist before starting any new medication.
What about salt and fluid intake?
• The amount of salt in your diet can change the level of lithium in
your blood. Eat a balanced diet and avoid crash diets. It is
important to keep taking lots of fluid especially in situations where
there is risk of dehydration and increased loss of salt, eg after
exercise, long distance air travel, sickness, fever, diarrhoea and hot
weather.
What about alcohol?
Taking lithium and alcohol can make people feel very drowsy and can also
change the level of lithium in the blood. It’s best to avoid alcohol in the first week.
After this try a glass of your normal drink. If you feel OK you should be able to
drink in moderation, ie 1-2 units per day. Don’t stop taking lithium just because
you fancy a drink.
What about pregnancy?
Lithium may affect the unborn baby. If you are pregnant, tell your doctor now. If
you are planning a baby, speak to your doctor before stopping contraception.
When I feel better can I stop taking it?
No, lithium is not addictive but you should not stop taking it suddenly. This can be
dangerous and might bring back your original symptoms. You and your doctor
should decide together if and when you can come off it. Most people need to be
on lithium for quite a long time, usually, years
.
What will happen to me when I start taking my lithium?
Any depression should get better after only a couple of weeks. Your swings in
mood may, however, not go away for quite some months, but don’t give up. Good
days will be followed by bad days – this is quite normal. Eventually, you should
have fewer and fewer days when you feel sad or on edge. Give your lithium a
chance to work.
It’s a bit of a nuisance, but you might get some side-effects before your mood
gets any better. Most of these are quite mild and should go away after a week or
so. Sometimes, the amount of lithium in your body gets too high which can be
dangerous. You need to be able to spot the side-effects which can mean a high
level of lithium. Look at the table opposite. It tells you what to do if you get any
side-effects. Not everyone will get the side-effects shown
.
Side-Effect What
happens/What you
may notice
How
common
is it
What to do about it
Tremor Fine shaking of your
hands.
COMMON This is not dangerous but it
can be irritating. If it annoys
you, your doctor may be able
to give you something for it. If
it gets worse and spreads to
the legs or jaw, stop taking
your lithium and see your
doctor.*
Stomach Upset This includes feeling and
being sick and getting
diarrhoea.
COMMON If it is mild, see your
pharmacist. If it lasts for more
than a day, see your doctor.*
Polyuria Passing a lot of urine. COMMON Don’t drink too much alcohol.
Tell your doctor about it as
some blood and urine tests
may be needed.*
Metallic Taste Your mouth tastes as if it
has had metal or
something bitter in it
COMMON This should wear off after a
few weeks – if not, mention
this to your doctor next time
you meet*. A change in dose
may help.
Polydipsia Feeling very thirsty. Your
mouth is dry and there
may be a metallic taste.
COMMON Try drinking water or low
calorie drinks in moderation.
Try sucking sugar free boiled
sweets.
Weight gain Eating and drinking more.
Putting on weight
LESS
COMMON
Try drinking water or low
calorie drinks in moderation.
Exercise and a healthy diet
are important. Ask your
Practice Nurse for advice.
Hypothyroidism Low thyroid activity. You
feel tired.
LESS
COMMON
Tell your doctor as it may be
necessary for him/her to
prescribe some thyroid
replacement tablets.*
Skin Changes For example, rash, acne,
psoriasis
RARE Stop taking your lithium and
contact your doctor
immediately.*
Blurred Vision Your lithium level may be
too high. Things look
fuzzy and you can’t focus.
RARE Stop taking your lithium and
contact your doctor
immediately.*
Drowsiness Your lithium level may be
too high. Feeling sleepy
and sluggish in the
daytime.
RARE Stop taking your lithium and
contact your doctor
immediately.*
Confusion Your lithium level may be
too high.
Your mind is all mixed up.
RARE Stop taking your lithium and
contact your doctor
immediately.*
Palpitations Your lithium level may be
too high.
Your heartbeat feels fast.
RARE Stop taking your lithium and
contact your doctor
immediately.*
*The doctor who issues your prescription.
Appendix 4
GP Practice Lithium (Priadel) Monitoring Chart
Name: ……………………………………………… DofB: …………………
Address: ………………………………………………………………………
Tel No: ……………………………………. GP: …………………………
Diagnosis: ……………………………………………………………………..
Standard = lithium (Priadel) Level 3 monthly – U&E/TFTs 6 monthly
Current lithium therapy, dose and recommended therapeutic range
……………………………………………………………………………………
NB - If Lithium discontinued please notify BGH laboratory (Tel: 01896 826242)
U & E’s
eGFR T4/TSH Date Lithium
Level
Normal
Y/N
Result Normal
Y/N
Result Normal
Y/N
Result
Action
taken
Result
given to
patient(date
&initial)
U & Es
eGFR T4/TSH Date Lithium
Level
Normal
Y/N
Result Normal
Y/N
Result Normal
Y/N
Result
Action
taken
Result
given to
patient(date
&initial)
Appendix 5 Date……………..
Optional CHECK LIST FOR GP ANNUAL REVIEW
(Please tick boxes on completion)
Preventative Care – physical (use SPICE screens)
Weight ………… Height ………… BP ………. Cervical cytology Alcohol
Smoker Non-smoker Ex-smoker Illicit drug use
IHD risk factors discussed Diet Exercise
Symptoms suggestive of arrhythmias (anti-psychotics)
Risk of diabetes (in long-term psychosis and anti-psychotic drugs)
Psychiatric Symptom Review
Medication Review
Compliance If injections, given by:- T/R nurse or CPN
Side Effects Monitoring
Atypical anti-psychotic drugs
Urea and electrolytes Blood Sugar
Weight BP/pulse/urine dipstick
Lithium
eGFR
T4/TSH
Clozapine
Regular blood monitoring via CPMS (Clozapine Monitoring Service)
Sertindole
ECG
Alcohol above recommended limits
LFT with any anti-psychotic
Co-ordination Arrangements
CPN/psychiatrist name and contact details ………………………………………………………………………………..
Or refuses offer of secondary mental health service involvement
Support worker …………………………………………………………………………………………………………………
Other people or agencies (e.g. New Horizons, Penumbra, supported work, day care) ………………………………
Special circumstances form for out of hours care if appropriate
Consider ‘Adults with Incapacity’ act, if appropriate
Annual Review Recorded (SPICE Screen)
Taken from NICE clinical guideline 38 : Bipolar disorder
These guidelines will form part of the updated perinatal ICP standards.
Managing bipolar disorder in pregnant women
General principles
Discuss the absolute and relative risks of treating and not treating the bipolar disorder during pregnancy
and the postnatal period. Consider more frequent contact by specialist mental health services, working
with maternity services.
Develop a written plan for managing a woman’s bipolar disorder during the pregnancy, delivery and
postnatal period with the patient and significant others, and share it with her obstetrician, midwife, GP and
health visitor.
Record all medical decisions in all versions of the patient’s notes, and include information about her
medication in the birth plan and postnatal care notes.
If a pregnant woman is stable on an antipsychotic and likely to relapse without medication, continue
treatment and monitor for weight gain and diabetes.
Do not routinely prescribe lithium for pregnant women.
Women planning a pregnancy
Raised prolactin levels associated with some antipsychotics reduce the chances of conception. If prolactin
levels are raised, consider an alternative drug.
For a woman taking lithium who is planning a pregnancy, consider:
– if she is well and not at high risk of relapse – gradually stopping lithium
– if she is not well or is at high risk of relapse:
switching gradually to a low-dose typical or atypical antipsychotic, or
stopping lithium and restarting it in the second trimester if she is not planning to breastfeed
and her symptoms have responded better to lithium than to other drugs in the past, or
– continuing with lithium, after full discussion, if manic episodes have complicated her previous
pregnancies, and her symptoms have responded well to lithium.
If a woman remains on lithium during pregnancy, monitor serum levels every 4 weeks, then weekly from
the 36th week, and less than 24 hours after childbirth. Adjust the dose to keep serum levels within the
therapeutic range, and ensure the woman has an adequate fluid intake.
If a woman planning a pregnancy becomes depressed after stopping prophylactic medication, offer
psychological therapy (CBT) in preference to an antidepressant because of the risk of switching.
If an antidepressant is used, it should usually be an SSRI (but not paroxetine because of the risk to the
fetus). Monitor the woman closely.
Women with an unplanned pregnancy
If a woman with bipolar disorder has an unplanned pregnancy:
– confirm the pregnancy as quickly as possible
– advise her to stop taking valproate, carbamazepine and lamotrigine*
– if the pregnancy is confirmed in the first trimester, and the woman is stable, stop lithium gradually
over 4 weeks, and explain there is still risk of cardiac defects in the fetus
– if the woman remains on lithium, check serum levels every 4 weeks, then weekly from the 36
th
week,
and less than 24 hours after childbirth; adjust the dose to keep serum levels within the therapeutic
range and ensure the woman has an adequate fluid intake
– offer an antipsychotic as prophylactic medication
– if the woman stays on medication, offer screening and counselling about continuing with the
pregnancy, the need for additional monitoring and the risks to the fetus.
The newborn baby should have a full paediatric assessment, and the mother and child should have social
and medical help.
Treating acute symptoms in pregnant women
Acute mania
Drug names marked with an asterisk * did not have UK marketing authorisation for the indication in question at the time
of CG38 publication (July 2006) and publication of this document. Prescribers should check each drug’s summary of
product characteristics for current licensed indications.
If the woman is not currently on medication:
– consider an atypical or a typical antipsychotic
– keep the dose as low as possible and monitor carefully.
If the woman is taking prophylactic medication:
– check the dose of the prophylactic agent and adherence
– increase the dose if the woman is taking an antipsychotic, or consider changing to an antipsychotic if
she is not
– if there is no response and mania is severe, consider ECT, lithium and, rarely, valproate.
For mild symptoms:
– guided self-help and computerised CBT
– brief psychological interventions
– anti-depressant medication.
If symptoms are moderate to severe:
– consider CBT (moderate symptoms)
– consider combined medication and structured psychological interventions (severe symptoms)
– if prescribing, consider quetiapine* alone or SSRIs (but not paroxetine) with prophylactic medication;
monitor closely for switching and stop the SSRI if manic or hypomanic symptoms develop
– tell women taking an antidepressant about the potential short-lived, adverse effects of
antidepressants on the neonate.
Care in the perinatal period
Women taking lithium should deliver in hospital, and be monitored by the obstetric medical team as well as
midwives. Fluid balance should be monitored, because of the risk of dehydration and lithium toxicity.
After delivery, if a woman who is not on medication is at high risk of developing an acute episode, consider
establishing or reinstating medication as soon as the fluid balance is established.
If a woman maintained on lithium is at high risk of a manic relapse in the postnatal period, consider
augmenting with an antipsychotic.
If a woman develops severe manic or psychotic symptoms and behavioural disturbance in the intrapartum
period, consider rapid tranquillisation with an antipsychotic in preference to a benzodiazepine because of
the risk of floppy baby syndrome. Treatment should be in collaboration with an anaesthetist.
Breastfeeding and care of the infant
If a woman is taking psychotropic medication:
– advise on the risks and benefits of breastfeeding
– advise not to breastfeed if taking lithium, benzodiazepines or lamotrigine* and offer an alternative
prophylactic agent that can be used when breastfeeding (normally an antipsychotic, but not
clozapine*)
– prescribe an SSRI if an antidepressant is used (but not fluoxetine or citalopram).
Monitor babies whose mothers took psychotropic drugs during pregnancy in the first few weeks for
adverse drug effects, drug toxicity or withdrawal (for example, floppy baby syndrome, irritability, constant
crying, shivering, tremor, restlessness, increased tone, feeding and sleeping difficulties and rarely
seizures). These may be a serotonergic toxicity syndrome, rather than a withdrawal reaction.
* In this guideline, drug names are marked with an asterisk if they do not have UK marketing authorization for the
indication in question at the time of publication (July 2006) Prescribers should check each drug’s summary of
product characteristics for current licensed indications.
