When carbamazepine (Tegretol) and lithium are used together, some patients may experience side effects, including dizziness, lethargy, and tremor. Central nervous system side effects also may occur when lithium is used with antidepressants, [for example, fluoxetine (Prozac) sertraline (Zoloft), and paroxetine (Paxil), fluvoxamine (Luvox), amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin)].

Medications which cause the urine to become alkaline (the opposite of acidic) can increase the amount of lithium that is lost into the urine. This results in lower blood concentrations of lithium and reduces the effects of lithium. Such drugs include potassium acetate, potassium citrate (Urocit-K), sodium bicarbonate, and sodium citrate (Bicitra, Cytra-2, Liqui-Citra, Oracit, Shohl's).

Caffeine appears to reduce serum lithium concentrations, and side effects of lithium have increased in frequency when caffeine is consumed.

Both diltiazem (Cardizem-CD, Tiazac, Dilacor-XR) and verapamil (Calan-SR, Isoptin-SR, Verelan, Covera-HS) have been reported to have variable effects on lithium levels in blood. In some patients there may be decreased lithium blood levels and in others lithium toxicity.

Methyldopa (Aldomet) may increase the likelihood of lithium toxicity.

Various reactions have resulted when lithium is administered with phenothiazines, [for example, chlorpromazine (Thorazine), thioridazine (Mellaril), trifluoperazine (Stelazine) or with haloperidol (Haldol)]. Such reactions have included delirium, seizures, encephalopathy, high fever or certain neurologic reactions that affect movement of muscles, called extrapyramidal symptoms.

Lithium can cause goiter or hypothyroidism. The use of lithium with potassium iodide can increase the likelihood of this adverse reaction.

The use of the beta blocker, propranolol (Inderal), with lithium can lead to a slow heart rate and dizziness. Other beta blockers, [for example, metoprolol (Lopressor), atenolol (Tenormin)] also may interact with lithium and be associated with a slow heart rate.

PREGNANCY: Lithium crosses the placenta and has been associated with toxicity in the fetus. Children born to women taking lithium during pregnancy have an increased risk of goiter and cardiac anomalies. If possible, lithium should be withheld during the first trimester. Women of childbearing age who may require lithium should be counseled about becoming pregnant.

NURSING MOTHERS: Lithium is secreted into breast milk. Symptoms of lithium toxicity, including changes in the electrocardiogram, have been seen in some breast-fed infants, whose mothers were taking lithium. If possible, women taking lithium should not breast-feed their infants.

SIDE EFFECTS: The most common side effects that can occur in persons taking lithium are fine hand tremor, dry mouth, altered taste perception, weight gain, increased thirst, increased frequency of urination, mild nausea or vomiting, impotence, decreased libido, diarrhea, and kidney abnormalities. Many of the gastrointestinal side effects (nausea, taste alterations, diarrhea) often disappear with continued therapy. Additionally, they may be less common if lithium is taken in divided doses with meals. If diarrhea or excessive urination lead to dehydration, lithium toxicity is possible. Lithium can also cause changes in the electrocardiogram, low blood pressure, and decreased heart rate.

The following side effects suggest that lithium blood levels may be too high, and that the dose of lithium may need to be reduced (after confirmation by measurement of lithium levels in blood):

• loss of appetite,
  
  
• visual impairment,
  
  
• tiredness; muscle weakness,
  
  
• muscle fasciculations (twitches),
  
  
• tremor,
  
  
• unsteady gait,
  
  
• confusion, seizure,
  
  
• arrhythmias,
  
  
• slurred speech,
  
  
• coma.

About 1 in every 25 persons who receives lithium develops a goiter (an enlarged thyroid gland). Hypothyroidism (low thyroid hormone levels) has been reported. Signs of hypothyroidism may include:

• dry rough skin,
  
  
• hair loss,
  
  
• hoarseness,
  
  
• mania,
  
  
• mental depression,
  
  
• increased sensitivity to cold, and
  
  
• swelling of the feet, lower legs, and neck.

Reference: FDA Prescribing Information

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