Lithium interactions with non-steroidal anti-inflammatory drugs and diuretics – A review

Nunes, Rui Pedro

doi:10.1590/0101-60830000000153

Cited by 6 publications

(6 citation statements)

References 11 publications

(59 reference statements)

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“…Moreover, men showed lower aLi compared to women, possibly due to a larger lean mass and less fat mass compared to women [27]. Diuretics, ACE inhibitors, AT1 antagonists, and NSAIDs have previously been associated with lithium intoxication or increased lithium concentration [18,[28][29][30][31][32][33]. Likewise, it has been reported that the creatinine clearance gradually decreased in patients when combining these target drugs [19,20,34].…”

Section: Discussionmentioning

confidence: 99%

“…Interestingly, only NSAIDs showed a positive association with aLi independent from other factors. NSAIDs reduce lithium clearance by inhibition of renal prostaglandin synthesis [14], leading to 2 processes that can increase aLi simultaneously: (I) decreased renal blood flow and (II) increased tubular sodium and lithium reabsorption [14,18,40]. Thus, the 2-sided attack may explain the significant association of NSAIDs independent from other factors.…”

Section: Discussionmentioning

confidence: 99%

“…profoundly increase the serum concentration of lithium [7,[11][12][13][14][15][16]. However, reports on the impact of ACE inhibitors and NSAIDs on lithium excretion were variable [11,13,17], and different drugs of the same class showed different effects [7,18]. These discrepancies may be related to other factors modulating renal function.…”

Section: Drug-drug Interactions Between Lithium and Cardiovascular Asmentioning

confidence: 99%

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Drug-Drug Interactions Between Lithium and Cardiovascular as Well as Anti-Inflammatory Drugs

et al. 2020

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Introduction Lithium is the gold standard in treating bipolar affective disorders. As patients become increasingly older, drug-drug interactions leading to decreased excretion of lithium represent a key issue in lithium safety. As no study considered the effect of comedications on lithium serum concentration in combination, we aimed to quantify the impact of drugs affecting renal blood flow and function and thus potentially interacting drugs (diuretics, ACE inhibitors, AT1 antagonists, and non-steroidal anti-inflammatory drugs) on lithium serum levels in addition to age, sex, and sodium and potassium serum levels as well as renal function. Methods Retrospective data of lithium serum levels were analyzed in 501 psychiatric inpatients (2008–2015) by means of linear regression modelling. Results The number of potentially interacting drugs was significantly associated with increasing serum levels of lithium in addition to the established factors of age, renal function, and sodium concentration. Additionally, absolute lithium levels were dependent on sex, with higher values in females. However, only NSAIDs were identified to increase lithium levels independently. Discussion Routine clinical practice needs to focus on drugs affecting renal blood flow and function, especially on NSAIDs as over-the-counter medication that may lead to an increase in lithium serum concentration. To prevent intoxications, clinicians should carefully monitor the comedications, and they should inform patients about possible intoxications due to NSAIDs.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Drug-drug Interactions Between Lithium and Cardiovascular Asmentioning

confidence: 99%

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Drug-Drug Interactions Between Lithium and Cardiovascular as Well as Anti-Inflammatory Drugs

et al. 2020

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“…Whether a substance was considered psychiatric or somatic co-medication was dependent on the respective indication/diagnosis. Risk medication, that is medication which increases the risk for lithium intoxication, includes thiazide (Ward, Musa et al 1994, Finley, Warner et al 1995, Berkowitz 2001) and loop diuretics (Okusa and Crystal 1994, Finley, Warner et al 1995, Oakley, Whyte et al 2001, Nunes 2018, ACE inhibitors (Finley, Warner et al 1995, Finley, O'Brien et al 1996, Nunes 2018, ARBs (Su, Chang et al 2007, Hayashi, Nishida et al 2016, Nagamine 2020, and NSAIDs (Okusa and Crystal 1994, Ward, Musa et al 1994, Oakley, Whyte et al 2001). While there are limited studies investigating the impact of ARB on lithium clearance, their pharmacodynamic similarity to ACE inhibitors, combined with the well-established link between ACE inhibitors and an increased risk of lithium intoxication (Finley et al, 1995(Finley et al, , 1996Juurlink et al, 2004), led us to include ARB in the risk medication category.…”

Section: Clinical Variablesmentioning

confidence: 99%

Causes, clinical characteristics, and outcomes of high lithium levels and intoxications: Retrospective analysis of patient records

Kaczmarczyk,

Batke,

Wingenfeld

et al. 2023

J Psychopharmacol

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Background: The mood stabilizer lithium has a narrow therapeutic index with a relevant risk of intoxication. We used real-world hospital data to identify causes, treatment courses, and outcomes of high lithium levels and intoxications. Methods: Retrospective chart review of patients with a lithium concentration of ⩾1.1 mmol/L, who were treated at Charité University Medical Center Berlin. Results: We identified 136 patients (58% women; mean age: 54.7 years) with high lithium levels or intoxication. 66.9% were chronic (stable lithium dose but changes in other variables such as co-medication). 40.4% took at least one risk medication with a relative contraindication for concurrent lithium treatment. 11.1% of the cases with a high therapeutic level showed moderate to severe intoxications. Feverish infections were significantly associated with severe intoxications. Overall, 97.1% (132/136) of patients fully recovered, two had residual but mild symptoms and two died during hospitalization (unlikely related to the intoxication). In 37.5% of patients, no psychiatrist was involved in the management of high lithium levels or intoxication. In these patients, lithium treatment was adjusted or discontinued in 37.3% of the cases compared to 64.7% when a psychiatrist was involved (χ²(1) = 9.683, p = 0.002). Conclusions: Patients and medical doctors should be aware of the increased risk of lithium intoxication already within the high therapeutic range and should consider alternative medications without relative contraindications for concurrent lithium use. Involving psychiatrists during or after an intoxication event is associated with more frequent adjustment of the maintenance lithium dose and should be considered in most cases.

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“…Some evidence also indicates that NSAIDs can reduce the therapeutic index and precipitate the toxicity of drugs like lithium 3. NSAIDs can also act synergistically to precipitate bleeding with antidepressants4; patients on lithium or antidepressants who are taking or about to start taking NSAIDs must inform their doctors for proper monitoring and dosing.…”

mentioning

confidence: 99%

Non-steroidal anti-inflammatory drugs can interact with lithium and antidepressants

Dara

Talabi

Iderapalli

2021

BMJ

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Lithium interactions with non-steroidal anti-inflammatory drugs and diuretics – A review

Cited by 6 publications

References 11 publications

Drug-Drug Interactions Between Lithium and Cardiovascular as Well as Anti-Inflammatory Drugs

Drug-Drug Interactions Between Lithium and Cardiovascular as Well as Anti-Inflammatory Drugs

Causes, clinical characteristics, and outcomes of high lithium levels and intoxications: Retrospective analysis of patient records

Non-steroidal anti-inflammatory drugs can interact with lithium and antidepressants

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