Sandra C. Asks…

I have been diagnosed with Bipolar Disorder for 3 years. I spent one month and many drugs on a psych unit at the hospital where I was an RN on staff. After approximately one year, I got rid of oh so many drugs down to Lithium Carbonate and Ambien for sleep.

Three months ago, I had a toxic reaction to the Lithium after a month long hospitalization for a brain aneurysm. My lithium had continued to be administered per my routine dose and frequent levels where drawn. After being home for one and a half weeks, I returned to the hospital with the toxicity. What happened??

I stayed off lithium for approximately 1 month per my Dr.’s orders and then restarted at a decreased dose. After 3-4 days of resuming, I again started experiencing the signs and symptoms of the previous toxicity. I am now on NOTHING and I’m afraid I’m getting into trouble… I was diagnosed Bipolar Rapid Cycling.

Where do I go from here? Abilify? I will never take Depakote again…been there, tried that in combination and alone with the exception of lithium.

Dr. Fink Answers…

It seems that there are at least two major issues for you to be discussing with your prescriber:

1. Why you are getting toxic on lithium on low doses. Presumably you are still seeing a neurologist and/or neurosurgeon for the aneurysm episode. Has your pdoc had a conversation with one or both of your neuro people? What changed after the aneurysm that seems to have created such a low threshold for toxicity when it didn’t occur before? A change in kidney function could affect lithium clearance – I suspect you have had many labs drawn that would have indicated any changes in renal function, but it is something to pay attention to.
2. The next question is this: If, in fact, you are no longer able to tolerate any lithium, what medications should you try? This will again include ongoing conversations with your doctors and a systematic approach to try to avoid just layering a bunch of medications all at once. There are a number of options out there such as atypicals or other anticonvulsants such as lamotrigine or carbamazepine.

This type of complex situation demands excellent communication between doctors and patients and between all the medical professionals involved. Do what you can to encourage this communication to help get the best outcome.

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    Last reviewed: 22 May 2009