Lithium-Associated Hyperthyroidism Treated With Lithium Withdrawal: A Case Report

Abstract

Ms. R" is a 32-year-old woman of normal intelligence with over 50 psychiatric hospitalizations in the past 8 years, most for cutting behavior deemed dangerous to self because of the quantity and severity of the wounds. She had a diagnosis of recurrent major depressive disorder superimposed on borderline personality disorder, with micro-psychotic episodes and poor impulse control. The patient had failed to benefit from multiple adequate trials with various combinations of antidepressants, atypical antipsychotics, conventional antipsychotics, mood stabilizers, benzodiazepines, alpha^ antagonists, intensive case management, and elements of dialectical behavioral therapy. We discussed with the patient the risks and the potential benefits of a trial of naltrexone to reduce her urges to cut. Liver function test results were mildly elevated from fatty liver secondary to metabolic syndrome. Other psychotropic medications were not changed. The patient was treated with naltrexone, 25 mg/day, titrated up to 50 mg after 1 month. Her medications were given by her home health nurses or her grandmother, and she was compliant with taking them.Ms. R noted decreased urges to cut after 1 week of treatment, with a reduced frequency of cutting behavior after her dosage was increased to 50 mg/day. The patient stated that she used to think about cutting "constantly" and would cut one to three times per day, but now will go "days" without thinking about it and only cut one to two times per week at most. After 5 months of continuous treatment, she had a 6-month period with only one superficial cutting episode. Liver function tests improved from baseline, with the exception of a 16-point increase in aspartate aminotransferase, which was stable over the course of several months.This case highlights the potential efficacy of naltrexone in self-injurious behavior resistant to multiple psychopharmacological and behavioral interventions. Utilization of this treatment may allow for tapering or discontinuation of atypical antipsychotics and mood stabilizers that have significant metabolic side effects, including weight gain and diabetes. Although previous reports have described similar effects, the magnitude of the response, the medical comorbidities, and the resistance to treatment in this patient demonstrate a need to consider naltrexone sooner in treatment algorithms. Our group has also used naltrexone to treat an autistic man with sexually violent behavior and an elderly man with dementia and sexually inappropriate behavior, with resolution of symptoms and no adverse events. Large-scale randomized placebo-controlled trials are necessary to provide further evidence for the use of naltrexone in refractory cases of impulse control disorders. References 1. Modesto-Lowe V, Van Kirk J: Clinical uses of naltrexone: a review of the evidence. Exp Clin Psychopharmacol 2002; 10:213-227 2. Sandman CA, Touchette PE, Marion SD, Chicz-DeMet A: The role of proopiomelanocortin (POMC) in sequentially dependent self-injurious behavior. Dev Psychobiol 2008; 50:...

Three Patients with Lithium-Associated Hyperparathyroidism: Literature Review Regarding Medical and Surgical Management

“…The three cases we present in this series show the spectrum of disease in LAH and the different approaches that can be used in line with the literature [21, 33]. The best evidence currently indicates that stopping Li with any hypercalcemia or if a high PTH is present.…”

“…There are other disagreements about the diagnosis, medical, and surgical management of LAH. This is likely because most of the recommendations are based on case reports, retrospective data, and expert opinion, rather than clinical trials [4, 7, 12, 13, 17, 18, 19, 20, 21, 22]. This requires that diagnosis and treatment decisions be individualized to a patient's particular situation [17, 20, 22].…”

“…LAH is noted to be common among Li users with cross-sectional studies showing hypercalcemia in 15% of Li-treated patients [19]. It has been suggested that asymptomatic or mildly hypercalcemic patients are better suited to medical therapy, where more severe hypercalcemia and hyperparathyroidism warrant surgical therapy [21]. In patients with more advanced CKD, correcting the underlying vitamin D deficiency and the volume status might improve the condition and decrease the need for parathyroidectomy.…”

“…The best evidence currently indicates that stopping Li with any hypercalcemia or if a high PTH is present. Stopping Li can decrease hypercalcemia and in some cases can lead to the control of parathyroid disease in some patients on long-term Li therapy [21]. The risk of manic symptom relapse after stopping Li should be noted and patients should be appropriately counseled [17].…”

Thyrotoxicosis followed by hypothyroidism in a patient on lithium

“… 15 There is a report where thyroiditis improved after withdrawal of lithium, which is consistent with the theory of lithium’s direct toxic effect on thyrocytes. 16 As the patient was euthyroid before the onset of thyrotoxicosis and was compliant to lithium when the thyrotoxicosis symptoms appeared, probability of latent hyperthyroid was unlikely.…”