Lithium carbonate attenuation of chemotherapy-induced neutropenia

Clozapine Optimization: A Delphi Consensus Guideline From the Treatment Response and Resistance in Psychosis Working Group

BACKGROUND AND HYPOTHESIS

There is limited evidence to guide the approaches to clozapine treatment. Accordingly, an international initiative was undertaken with the aim of developing consensus recommendations for the optimization of clozapine monotherapy.

STUDY DESIGN

We conducted an online Delphi survey among members of the Treatment Response and Resistance in Psychosis (TRRIP) working group comprising experts from twenty-nine countries. The threshold criterion for a consensus recommendation was ≥ 75% agreement ("agree" and "strongly agree" responses) on a question. Agreement of ≥ 50% but < 75% in a second or third Delphi round was deemed to provide guidance.

STUDY RESULTS

Forty-nine (first round), 32 (second round), and 48 (third round) of the 91 current TRRIP members participated. Expert recommendations at ≥ 75% comprised second-line treatment with clozapine in cases of persistent positive symptoms with co-occurring extrapyramidal symptoms, tardive dyskinesia, or suicidality/aggression. There was considerable disagreement on myocarditis screening parameters. The management of somatic and neuropsychiatric adverse drug reactions warrants further research for more evidence-based recommendations. Rechallenge with clozapine was recommended for eosinophilia, sinus tachycardia and fever and guidance (agreement ≥ 50%) was reached for pneumonia and thrombocytopenia.

CONCLUSIONS

Given the limited evidence available, this consensus-based series of recommendations and guidance statements supports clinical decision-making to optimize clozapine monotherapy and provides guidance for future research in treatment-resistant schizophrenia.

GSK3β-mediated Keap1-independent regulation of Nrf2 antioxidant response: A molecular rheostat of acute kidney injury to chronic kidney disease transition

Transition of acute kidney injury (AKI) to chronic kidney disease (CKD) represents an important cause of kidney failure. However, how AKI is transformed into CKD remains elusive. Following folic acid injury, mice developed AKI with ensuing CKD transition, featured by variable degrees of interstitial fibrosis and tubular cell atrophy and growth arrest. This lingering injury of renal tubules was associated with sustained oxidative stress that was concomitant with an impaired Nrf2 antioxidant defense, marked by mitigated Nrf2 nuclear accumulation and blunted induction of its target antioxidant enzymes, like heme oxygenase (HO)-1. Activation of the canonical Keap1/Nrf2 signaling, nevertheless, seems intact during CKD transition because Nrf2 in injured tubules remained activated and elevated in cytoplasm. Moreover, oxidative thiol modification and activation of Keap1, the cytoplasmic repressor of Nrf2, was barely associated with CKD transition. In contrast, glycogen synthase kinase (GSK)3β, a key modulator of the Keap1-independent Nrf2 regulation, was persistently overexpressed and hyperactive in injured tubules. Likewise, in patients who developed CKD following AKI due to diverse etiologies, like volume depletion and exposure to radiocontrast agents or aristolochic acid, sustained GSK3β overexpression was evident in renal tubules and coincided with oxidative damages, impaired Nrf2 nuclear accumulation and mitigated induction of antioxidant gene expression. Mechanistically, the Nrf2 response against oxidative insult was sabotaged in renal tubular cells expressing a constitutively active mutant of GSK3β, but reinforced by ectopic expression of dominant negative GSK3β in a Keap1-independent manner. In vivo in folic acid-injured mice, targeting GSK3β in renal tubules via conditional knockout or by weekly microdose lithium treatment reinstated Nrf2 antioxidant response in the kidney and hindered AKI to CKD transition. Ergo, our findings suggest that GSK3β-mediated Keap1-independent regulation of Nrf2 may serve as an actionable therapeutic target for modifying the long-term sequelae of AKI.

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AKI to CKD transition involves sustained GSK3β overactivation and impaired Nrf2 response in injured renal tubules.

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Microdose lithium rectifies GSK3β overactivity in the kidney, reinstates Nrf2 response and hinders AKI to CKD transition.

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GSK3β-mediated Keap1-independent regulation of Nrf2 is a novel therapeutic target for modifying long-term sequelae of AKI.

Lithium Carbonate in the Treatment of Drug-Induced Leukopenia in Patients with Solid Tumors

The authors report on the first part of an ongoing: controlled trial (52 cases) on the evaluation of the effectiveness of Li2CO3 treatment of drug-induced leukopenia in patients with solid tumors. The results indicate that treatment with 750 mg/day per os of Li2CO3 for 7 days is capable of raising the leukocyte count to a highly significant extent, without serious side effects. The leukocytosis is due to an increase in neutrophil granulocytes.

Effects of lithium carbonate on carboplatin-induced thrombocytopenia in dogs

OBJECTIVE

To describe the effects of lithium carbonate on thrombopoiesis in clinically normal dogs and in dogs treated with carboplatin.

ANIMALS

18 young adult sexually intact female Beagles.

PROCEDURES

Dogs were assigned to each of 3 treatment groups (6 dogs/group). Group 1 received 150 mg of lithium carbonate (14 to 16 mg/kg), PO, every 12 hours on days 1 through 21. Group 2 received carboplatin (300 mg/m(2), IV) on day 0 and cephalexin (30 mg/kg, PO, q 12 h) on days 14 through 21. Group 3 received lithium, carboplatin, and cephalexin at the aforementioned doses and schedules. Plasma lithium and blood platelet concentrations were measured on days 0, 2, 4, 7, 9, 11, 14, 16, 18, and 21. Number of megakaryocytes in bone marrow specimens and the percentage of large unstained cells and CD34+ mononuclear cells in bone marrow aspirates were determined on days 0, 7, 14, and 21 by manual enumeration, automated hematologic analysis, and flow cytometric immunophenotyping, respectively.

RESULTS

Plasma lithium concentrations ranged from 0.12 to 2.41 mmol/L. All dogs given lithium achieved a concentration within the target interval of 0.5 to 1.5 mmol/L by days 4 to 7. Thrombopoiesis was increased in dogs receiving lithium alone. All dogs given carboplatin developed mild thrombocytopenia. There were no differences between group 2 and group 3 throughout the study.

CONCLUSIONS AND CLINICAL RELEVANCE

Lithium stimulated thrombopoiesis in clinically normal dogs. Lithium administration at the doses and schedules used, with concurrent administration of cephalexin, did not prevent thrombocytopenia induced by carboplatin.

Effects of lithium carbonate on hematopoietic cells in patients with persistent neutropenia following chemotherapy or radiotherapy

Neoplasm therapy is restricted by the haematological side effects of tumour-destructive therapy, requiring expensive supportive care to some extent to overcome and treat leucopenia and its consequences. An effective and very cost-effective alternative for treating neutropenia is to administer lithium carbonate. Lithium leads to a release of hematopoietic growth factors (CSF) and therefore to proliferation of neutrophil granulocytes. Normally, recombinant CSF is only administered when there are indications of severe neutropenia because of the high costs involved, all the more evident in the long-term treatment of persistent leucocytopenia. On the other hand, CSF and leucocytes play an essential role in tumour immunology and with regard to response rates to cytostatic drugs. Lithium salts have shown that they can increase the number of neutrophil granulocytes quite significantly and, to a lesser extent, the number of eosinophil granulocytes and lymphocytes as well. The average number of erythrocytes does not change significantly. Patient tolerability to lithium carbonate therapy is very good. It can be used to treat patients with chronic leucopenia following chemotherapy or radiotherapy extremely cost-effectively. Unfortunately this treatment has not won acceptance in clinical oncology in the face of highly cost-intensive treatment with recombinant CSF.

Molecular targets of lithium action

Lithium is highly effective in the treatment of bipolar disorder and also has multiple effects on embryonic development, glycogen synthesis, hematopoiesis, and other processes. However, the mechanism of lithium action is still unclear. A number of enzymes have been proposed as potential targets of lithium action, including inositol monophosphatase, a family of structurally related phosphomonoesterases, and the protein kinase glycogen synthase kinase-3. These potential targets are widely expressed, require metal ions for catalysis, and are generally inhibited by lithium in an uncompetitive manner, most likely by displacing a divalent cation. Thus, the challenge is to determine which target, if any, is responsible for a given response to lithium in cells. Comparison of lithium effects with genetic disruption of putative target molecules has helped to validate these targets, and the use of alternative inhibitors of a given target can also lend strong support for or against a proposed mechanism of lithium action. In this review, lithium sensitive enzymes are discussed, and a number of criteria are proposed to evaluate which of these enzymes are involved in the response to lithium in a given setting.

Cancer morbidity in psychiatric patients: influence of lithium carbonate treatment

The relationship between mental diseases and cancer development has been examined in a number of studies but the findings are still inconclusive and suffer from methodological problems. Studies conducted to examine the effect of lithium on malignant cells yielded inconsistent results. The study group included 609 patients treated by lithium carbonate and 2396 controls. A lower but non significant risk (RR = 0.79; CI = 0.17-3.60) to develop non-epithelial tumors was found among lithium carbonate treated psychiatric patients as compared to controls. A significantly (P = 0.05) inverse trend of cancer with lithium dose was observed. The risk of cancer development among each group of psychiatric patients was significantly lower than in the general population (RR = 0.68 for the lithium treated group versus 0.78 for controls). Mental patients have a lower cancer prevalence than the general population and lithium may have a protective effect.

Hemodynamic, electrocardiographic, metabolic, and hematologic abnormalities resulting from lithium intoxication. A case report

The authors report a unique case that presented with hemodynamic abnormalities and severe bradycardia, necessitating the insertion of a temporary pacemaker, as well as metabolic disturbances, hematologic changes, and hepatic and renal dysfunction in an elderly individual owing to lithium intoxication. This case also demonstrates that these various serious side effects of lithium resolved with prompt recognition and discontinuation of lithium. Lithium should be used with extreme caution and frequent monitoring especially in the elderly.

Biochemical investigation of leukocyte functions during lithium therapy

1. The effect of lithium on phagocytic activity of polymorphonuclear leucocytes (PMNL) has been investigated by measurements of glucose-6-phosphate dehydrogenase (G6PD), NADPH oxidase and myeloperoxidase (MPO) both in lithium treated rats and lithium treated infected rats. 2. The results have been compared with two control groups, one of which was without lithium treatment and the other was only infected. 3. In the first experimental group increased activities of these enzymes have been observed, while in lithium-treated infected rats there was a decrease in the activities of the same three enzymes. 4. It is proposed that defense mechanisms against infection fail during the lithium treatment.

Management of lithium in patients with cancer

This article reviews the management of lithium in patients who require optimum management of cancer and simultaneous prevention of mania or depression in lithium-sensitive affective illness. Two cases are described. Discussion focuses on whether lithium should be continued during chemotherapy and radiation treatment, the complications that would lead to lithium toxicity in an otherwise stable patient, the likely settings for hypothyroidism, and the role of lithium to stabilize steroid-induced affective changes. The authors conclude that lithium may be withheld 1 or 2 days before cytotoxic chemotherapy and restarted when the patient is able to drink. It may be given as usual through routine radiation treatment, but it should be discontinued during cranial radiation. Calcium, renal, cardiac, and thyroid functions should be monitored.

Lithium stimulation of HPP-CFC and stromal growth factor production in murine Dexter culture

We have previously reported that the addition of lithium chloride (LiCl) to murine Dexter cultures results in increased numbers of progenitor and mature hematopoietic cells of the granulocyte, macrophage, and megakaryocyte lineages. We now report the effect of various levels of LiCl on the high proliferative potential colony-forming cell (HPP-CFC) in Dexter culture and on the induction of growth factors from Dexter stromal cells. LiCl (4 mEq/L) stimulated supernatant HPP-CFC for the first 4 weeks of culture (150-275%), and stimulated stromal HPP-CFC at week 3 (170-222%). Higher levels of lithium (8 and 12 mEq/L) selectively stimulated supernatant HPP-CFC, macrophage, and eosinophil production, whereas granulocytes and granulocyte-macrophage colony-forming cells (CFU-C) were inhibited. mRNA expression was evaluated from week 4 Dexter cultures that received a pulse or continuous exposure to lithium and had received either 0 or 1,100 cGy irradiation. Four mEq/L LiCl stimulated increased expression of G-CSF, GM-CSF, IL-6, and, in the nonirradiated stroma continuously exposed to lithium, CSF-1 mRNA. In general, the higher levels of lithium stimulated increased mRNA expression for these same growth factors. mRNA for the recently described Steel factor was decreased with increasing levels of lithium added to either normal or irradiated stroma. Bioassays of conditioned medium (cm) from irradiated cultures against the FDC-P1 and T1165 cell lines indicated cytokine activity, which was blocked by antibodies to GM-CSF and IL-6, respectively. Altogether these data show that lithium stimulates Dexter HPP-CFC, and this stimulation appears to be mediated by multiple growth factors that are induced from stromal cells.

Failure of lithium to reduce period of neutropenia during induction therapy of acute myeloid leukemia

Fifty-four patients treated with daunorubicin, cytosine arabinoside and thioquanine for acute myeloid leukemia were randomly assigned to receive oral lithium carbonate 1200 mg daily or no lithium. The duration of neutropenia (less than 0.5 x 10(9)/L) was similar between controls (median 22.5 days) and patients treated with lithium (median 24 days). The number of remissions, relapse-free survival and survival were similar for the lithium treated and control groups of patients. There was no apparent clinical efficacy in the use of lithium to reduce the period of neutropenia in patients undergoing remission induction therapy for acute myeloid leukemia.

Double-blind, placebo-controlled lithium treatment in chemotherapy induced aplasia for AML: reduced antibiotic requirement

A double-blind placebo-controlled study on lithium (Li) therapy after chemotherapy-induced bone marrow aplasia was undertaken in 53 patients with acute myeloblastic leukemia (AML). No difference was observed between the two groups for the duration of aplasia, the number of units of platelets or RBC transfused, the complete remission rate or the disease free survival. However, a statistically significant reduction in the number of days of antibiotic therapy required was found in the treated group (10.55 +/- 2.72 vs 12.73 +/- 3.60, P less than 0.05).

Approaches to ablating the myelotoxicity of chemotherapy

Myelotoxicity remains a significant dose-limiting side effect of chemotherapy contributing to the morbidity and mortality of patients undergoing treatment for cancer. A number of different experimental approaches are being studied, both in the clinic and in the laboratory, in an attempt to prevent this iatrogenic complication. The present review provides a synopsis of the various myeloprotective strategies now being employed in experimental trials. Emphasis is placed on the use of putative physiologic bioregulatory molecules (lactoferrin, prostaglandin E, interferon) to prevent or lessen chemotherapy-induced myelotoxicity, with consideration also given to other promising treatment modalities (i.e., adenosine, lithium, diethyldithiocarbanate).

The effect of lithium on platelet count

The effect of lithium on platelet count was studied by examining 12 patients treated with lithium carbonate without any additional medication, 13 patients treated with lithium carbonate with additional psychotropic medication, 25 patients with major affective disorder prior to any treatment, 25 patients with panic disorder prior to any treatment and 25 healthy controls. The platelet counts were increased in the group of subjects treated with lithium carbonate without any additional psychotropic medication. The increase was not clinically significant.

Enhanced lymphocyte response to PHA among leukemia patients taking oral lithium carbonate

Seven children receiving maintenance therapy for acute lymphoblastic leukemia (in remission) were given oral lithium carbonate for 12 weeks. Hematologic values, serum immunoglobulin levels, and responsiveness of peripheral blood mononuclear cells to mitogen stimulation were studied during the lithium treatment period, and compared to measurements made during a 12-week period when no lithium was administered (children served as their own controls). Changes attributable to treatment with lithium carbonate included increases in total white blood cell count, circulating neutrophil count, and response to phytohemagglutinin-P. No important toxicity to lithium carbonate was observed.

New concepts in management of neutropenia

Neutropenia is a life-threatening sequel of hematological disorders and a dominant factor limiting the dosage of cytotoxic chemotherapy. The role of the neutrophil is of such importance in defence against microbial invasion that measures that modify the behaviour of residual hemopoietic tissue to promote a modest increase in neutrophils, can confer considerable benefit by reducing the frequency and severity of infection. Such a change can be mediated in bone marrow depression by diversion of more progeny of immature precursors into the neutrophil series, or by enhancement of the stimulatory drive operating on neutrophil production. The former effect can be achieved by hypertransfusion of red cells to reduce the demand on the limited precursor population for cells of the erythroid series. The latter effect can be achieved by administration of lithium carbonate. Neutropenia caused by autoimmune injury to the neutrophil series can also be successfully modified by measures which suppress the underlying immune dyscrasia or the function of the reticulo-endothelial system. Corticosteroid administration and splenectomy can be helpful in certain specific types of neutropenia. Administration of cyclophosphamide and azathioprine has both mutagenic and marrow suppressive potential, but can induce remissions in severe chronic isolated neutropenia and in systemic lupus erythematosis.

Evolution of oligoleukemia

Chronic lithium administration to 22 patients with oligoleukemia did not alleviate cytopenia or stimulate bone marrow proliferative activity. The authors identified, however, pretreatment characteristics discriminating two evolutionary endpoints of oligoleukemia (marrow failure, 10 patients; overt acute leukemia, 12 patients): higher marrow leukemic infiltrate, normal myeloid precursor proportion, platelet count, and female sex all favored eventual transition to overt leukemia which, in comparison with marrow failure, was associated with a significantly longer survival duration from symptoms. For patients developing overt leukemia, survival from diagnosis was inversely correlated with the degree of marrow leukemic infiltrate. The lack of lithium responsiveness in oligoleukemia is consistent with the concept of differentiated leukemia with abnormalities either at the level of a lithium-responsive adherent cell elaborating colony stimulating activity (CSA) or at the level of CSA-responsive CFUs.

The effect of lithium carbonate on chemotherapy-induced neutropenia and thrombocytopenia

Lithium carbonate ameliorates neutropenia associated with cancer chemotherapy. The effect of lithium on platelet suppression has not, however, been well established. In the present study, five patients with ovarian carcinoma received daily lithium during alternate cycles of treatment with hexamethylmelamine, cyclophosphamide, adriamycin, and cis-platinum. Analysis of myelosuppression was performed on 24 paired consecutive cycles given at identical doses, one with and one without lithium. During lithium cycles, nadir leukocyte, neutrophil, and platelet counts were significantly higher (P less than 0.01, less than 0.01, less than 0.05 respectively) and the interval between treatments was shorter (P less than 0.01). One patient who has received 11 cycles of chemotherapy continues to receive 100% doses owing to the beneficial effect of lithium on chemotherapy-induced thrombocytopenia. Lithium was poorly tolerated by some patients because of either tremor or nausea and vomiting, in spite of nontoxic serum lithium levels. The amelioration of drug-induced platelet suppression as well as neutrophil suppression noted in this study suggests that lithium's effect on hematopoiesis is not limited to stimulation of neutrophil production. The ability of lithium to decrease chemotherapy-induced myelosuppression suggests that lithium administration may facilitate escalation of chemotherapy doses in selected patients.

Management of the immunocompromised host

This article deals with the management of the immunocompromised host. Mechanisms of immunocompromise include alterations in skin and mucosal barriers, normal oral and intestinal flora, splenic function, and number or function of T cells, B cells, granulocytes, and monocytes. Discussed in this article are ways for maintaining those defenses not altered by the primary disease, minimizing the environmental risks to the patient, anticipating potential infections in order to institute appropriate prophylactic measures, and diagnosing and aggressively treating infections as they occur.

A review of clinical trials of lithium in medicine

Since the approval of lithium use in treatment of acute mania, there have been numerous clinical trials of lithium in medical and psychiatric disorders. This paper gives a brief review of the literature on lithium trials in approximately fourteen medical conditions. These are: hyperthyroidism, metabolizing thyroid cancer, syndrome of inappropriate secretion of antidiuretic hormone, premenstrual tension syndrome, anorexia nervosa, Felty's syndrome, chemotherapy-induced neutropenia, aplastic anemia, seborrheic dermatitis, eczematoid dermatitis, cyclic vomiting, diabetes mellitus and asthma. Most of the case reports cited showed the efficacy of the side effects from lithium salt in the management of the symptoms and signs of these disorders, however, well-designed and controlled studies give negative results. The positive results are reported in the group of disorders having an underlying subdromal affective syndrome such as premenstrual tension syndrome and anorexia nervosa. Other encouraging reports include the effect of lithium to induce leucocytosis in Felty's syndrome and chemotherapy-induced neutropenia.

Lithium treatment in adults with acute myeloid leukemia receiving chemotherapy

To determine whether lithium can shorten chemotherapy-induced neutropenia, 35 adult patients with newly diagnosed acute myeloid leukemia undergoing initial chemotherapy were randomized either to receive oral lithium started at the time of biopsy-proven hypoplasia or to receive no lithium. This study failed to show statistically significant shortening of the duration of chemotherapy-induced neutropenia in the lithium treatment group.

The Na,K-ATPase hypothesis for manic-depression. II. The mechanism of action of lithium

A model as to how lithium may work in the treatment and prevention of manic-depression is presented. Lithium accumulates intracellularly, and accumulates preferentially in more active neurons. Intracellular accumulation of lithium displaces intracellular sodium, which, in turn, decreases intracellular calcium. A decrease of intracellular calcium normalizes neuron activity in both mania and depression. This model is supported by the majority of clinical and experimental data.

Lithium therapy for cyclic neutropenia in children

2 children with cyclic neutropenia were treated with lithium carbonate. In one patient, fever and stomatitis were ameliorated, but the duration of neutropenia was increased and parotitis occurred. In another patient, aphthous stomatitis disappeared but fever persisted. The duration of neutropenia was prolonged and submaxillaritis and sinusitis occurred. Thus, lithium administration may lead to complications when the duration of neutropenia is prolonged. We recommend discontinuation of the drug, even in the presence of amelioration of symptoms.

Comparison of induction chemotherapies for metastatic breast cancer. An Eastern Cooperative Oncology Group Trial

Patients with advanced breast carcinoma and no prior chemotherapy were prospectively evaluated to assess the induction capabilities of cyclophosphamide, methotrexate and 5-fluorouracil (CMF), Adriamycin and vincristine (AV), and CMF plus prednisone (CMFP). The crossover responsiveness from CMF or CMFP to AV and of AV to CMF were also assessed. A disproportionate randomization led to 166 analyzable cases on AV, 79 on CMF were also assessed. A disproportionate randomization led to 166 analyzable cases on AV, 79 on CMF and 86 on CMFP induction. One hundred and twelve patients were evaluated on crossover. Induction response rates were similar with 56% on AV, 57% on CMF and 63% on CMFP. Crossover response rates ranged from 32% to 41%. CMFP and AV were superior to CMF in terms of response duration (P = 0.05), and CMFP was superior to either in terms of time to treatment failure (P = 0.04), and survival (P = 0.03). Treatment failures occurred in only the on-study organ sites of disease in 73% of the patients and did not appear to be related to the response achieved. CMF was associated with more thrombocytopenia than either AV or CMFP (P = 0.03). AV was associated with fewer infections than CMFP (P = 0.02), less diarrhea than CMFP (P = 0.04), more emesis than CMF (P = 0.02), and more neurologic toxicity than either CMF or CMFP (P less than 0.0001). There was also more emesis with CMF than with CMFP (P = 0.006). CMFP was associated with greater delivery of CMF than was the CMF regimen despite a similar day 1 leukocyte distribution. These results strongly suggest that CMF(P) and AV are clinically noncross-resistant regimens, that AV and CMF are essentially equivalently active induction regimens, and that CMFP is superior to CMF and AV.

Lithium enhances growth of human leukaemia cells in vitro

Lithium is known to cause leucocytosis in normal humans, and lithium salts have been used therapeutically in attenuating leucopenia in patients undergoing chemotherapy. Recent reports also described leukaemia development during lithium treatment. We have investigated the effect of lithium chloride on the proliferation of human myeloid, erythroblastic, and T- and B-lymphoblast leukaemia cells in vitro. Colony formation by cells of the myeloid leukaemia lines HL-60 and KG-1 was enhanced by lithium chloride, and maximal stimulation was seen at 5 X 10(-4) M. Lithium also increased the proliferation of KG-1a cells, a subline of KG-1 cells that does not respond to colony-stimulating factor, indicating a direct growth-promoting effect on myeloid leukaemia cells. Lithium was found to enhance colony formation by the T-lymphoblast cell line MOLT 4 and the B-lymphoblast line IM-9 at concentrations between 10(-6) and 10(-3) M. The addition of lithium chloride to murine Friend or human K-562 erythroleukaemia cells also caused an augmentation in colony formation. These observations may have relevance to the therapeutic use of lithium in patients with haematological malignancies.

The mechanism of lithium carbonate-induced augmentation of colony-stimulating activity elaboration in man

Lithium carbonate (Li) has been reported to elevate granulocyte counts in patients with certain neutropenic disorders and to improve chemotherapy-induced granulocytopenia. To investigate the mechanisms involved in the increase in myelopoiesis, the effect of Li on monocytemacrophage (M phi)- and T-lymphocyte (TL)-derived colony-stimulating activity (CSA) were studied in vitro. Li induced a dose-related increase in both M phi- and TL-derived CSA over that in non-Li-stimulated cell populations. However, the increase was significant (p less than 0.007) only at a higher concentration of Li (2 mEq/l). The results of co-incubating TL with M phi with or without Li indicated that Li significantly enhanced synergistic CSA production by the two cell populations (p less than 0.02). We further demonstrated the presence of a larger proportion of M phi with TL rosettes in the presence of Li (62%) than in its absence (21%). Further experiments with concanavalin A (Con-A)-inducible suppressor TL suggested that Li effectively blocks the suppressor TL-mediated suppression of CSA. These data suggest that Li enhances M phi and TL interaction which results in an augmented CSA elaboration. Further, Li would be more effective in those neutropenic disorders associated with enhanced suppressor TL activity. For an optimal effect, however, Li would require appropriately functioning M phi and non-suppressor subsets of TL and an intact stem cell pool.

Lithium carbonate and granulocyte production: dose optimization

To determine the optimal dose of lithium for inducing granulocytosis, the authors administered lithium carbonate to normal volunteers at five dose levels. The authors performed assessments of circulating and marginated blood pools of granulocytes and of marrow reserve granulocytes to confirm that the early granulocytosis following lithium administration is due to increased granulocyte production rather than redistribution. At 300 mg/day and 600 mg/day, lithium had no significant effect on granulocyte production. Doses of 900, 1200, and 1500 mg/day, corresponding to lithium levels of 0.55 to 1.50 mEq/liter, were associated with increased granulocyte production. Within this therapeutic range, no correlation between lithium level and granulocyte production was demonstrated. This study suggests that any lithium dose which achieves a lithium level of greater than 0.55 mEq/liter, i.e., doses greater than or equal to 900 mg/day, is adequate to induce granulocytosis. While lithium did not increase platelet production, doses of 900 mg/day to 1500 mg/day were associated with decreased bleeding times.

Treatment of neuroleptic-induced leukopenia with lithium carbonate

Based on the finding that lithium carbonate administration can stimulate leukocyte production, six patients were treated with neuroleptic and other drug-induced granulocytopenia with lithium carbonate. The average total leukocyte count of 2500/mm3 increased to 4566/mm3. Similarly the average neutrophil count of 1028/mm3 increased to 2893/mm3 after lithium therapy. In all six patients, neutrophils decreased upon discontinuation of lithium. On the other hand, total WBC count of 4566/mm3 decreased to 2650/mm3, and the total neutrophil count of 2893/mm3 decreased to 966/mm3 after four weeks without lithium. The results suggest that lithium carbonate is effective in the treatment of drug-induced leukopenia.

A prospective evaluation of chemohormonal therapy remission maintenance in advanced breast cancer

From October 1973 to October 1977 the ECOG prospectively evaluated cyclophosphamide, methotrexate, and fluorouracil (CMF) versus CMF plus fluoxymesterone (CMFH) maintenance therapies in responders to 6 months of induction therapy which consisted of either CMF, CMF plus prednisone (CMFP), or adriamycin plus vincristine (AV). Following the maintenance randomization 12% of the patients converted from a PR to a CR status. The median time from randomization to treatment failure was 9.5 months for CMFH and 6.7 months for CMF (p = 0.03). This difference was observed only for partial responders (p = 0.01) and not for complete responders. Patients receiving CMFH tended to maintain higher hemoglobin, leukocyte, and platelet levels, and receive a higher dosage of each of the cytotoxic drugs. The results are taken as evidence that the addition of fluoxymesterone to a maintenance CMF regimen provides a therapeutic advantage. It is hypothesized that this effect is due at least in part to fluoxymesterone associated maintenance of improved marrow function resulting in greater myelosuppressive drug delivery.

Lithium carbonate in patients with small cell lung cancer receiving combination chemotherapy

Lithium administration has been shown to attenuate the leukopenia associated with systemic chemotherapy. The results of a randomized trial of lithium in 45 patients with small cell lung cancer who received combination chemotherapy and radiation therapy are reported. Patients randomized to receive lithium were started on 300 mg three times daily for 18 days of every 21 day chemotherapy cycle. Patients who received lithium experienced significantly less mid-cycle leukocyte and neutrophil count depression and spent fewer days with leukopenia and neutropenia than control patients regardless of age or extent of disease. Patients who received lithium spent fewer days hospitalized and fewer days with fever in the presence of severe neutropenia than control patients. The cumulative risk of fever with signs of infection was greater in control patients regardless of age, disease extent or the presence of marrow involvement. Patients who were given lithium received significantly more chemotherapy than control patients. Patient survival was greatest in those with limited disease, in complete responders and in those who received more than 75 percent of their induction chemotherapy although it did not differ between the two study groups. The majority of patients required either reduction or discontinuation of lithium. Those who received lithium continuously demonstrated a higher objective response rate and longer survival than either patients in whom the lithium had to be discontinued or those randomized to the control group. Infection was an important cause of death in the control group and cardiovascular event occurred frequently in the lithium group, but the major cause of death in this patient population remains progressive malignant disease.

Lithium therapy of children with chronic neutropenia

We treated five children with chronic neutropenia using lithium carbonate and studied the effect in vivo on granulopoiesis. Granulocyte precursors (CFU-C) from blood and marrow, and colony-stimulating activity (CSA) from peripheral blood leukocytes, were assayed in a methylcellulose tissue culture system. Three patterns of response to lithium were seen. In patients with aplastic anemia (one acquired and two Fanconi's aplastic anemia) despite increased colony-stimulating activity, CFU-C numbers remained very low and the neutropenia persisted. In a patient with Kostmann neutropenia colony-stimulating activity, and blood and marrow CFU-C numbers increased, but the agranulocytosis was unchanged. An impressive therapeutic effect was seen in one patient with idiopathic neutropenia with low colony-stimulating activity who responded to lithium with an increase in colony-stimulating activity and CFU-C resulting in persisting normal neutrophil counts. Lithium appears useful in treating a select group of neutropenic patients in whom colony-stimulating activity production is responsive to lithium, and the granulocytic progenitor compartment is capable of producing mature neutrophils.

The effect of lithium carbonate on leukopenia after chemotherapy

To evaluate the efficacy of lithium carbonate in ameliorating leukopenia, 37 patients (3 to 26 years old, mea (less than or equal to 1,000/mm3) over 40% of the time were designated at random on the last day of 82 separate chemotherapy courses to receive lithium or no treatment. Four could not take the drug because of the size of the capsules. There were 39 controls and 39 patients given lithium. Blood levels were maintained at 0.2 to 1.2 mEq/1 (median 0.7). The median drop of WBC in the treated group was 3,400/mm3 with a nadir of 1,800/mm3 vs 5,000 and 1,400, respectively, for the untreated patients (P LESS THAN 0.01). Eight patients (21%) in the lithium-treated group became severly leukopenic (less than or equal to 1,000/mm3) while 14 (36%) in the control group became leukopenic to that extent. Twenty-four patient days were spent with the WBC less than or equal to 1,000/mm3 after lithium and 57 days in the control group. Three patients required admission for 24 hospital days for fever while leukopenic after lithium, whereas seven patients spent 62 days in the hospital in the control group. Lithium reduces the period of leukopenia after chemotherapy during which time the patients may acquire infections.

The effect of lithium on murine hematopoiesis in a liquid culture system

Lithium carbonate has been shown to increase granulocyte production. We studied the effect of lithium on murine hematopoiesis in a liquid culture system providing for the prolonged growth of stem cells and their progeny. After one week of incubation, lithium, at a supernatant concentration of 1 mmol per liter, increased murine pluripotent stem cells (CFU-S, or colony-forming units in spleen) to 232 per cent of control values (P less than 0.001), granulocyte-monocyte progenitor cells (CFU-C, or colony-forming units in culture) to 218 per cent of control values (P less than 0.0001), granulocytes to 125 per cent of control values (P less than 0.01), and megakaryocytes to 246 per cent of control values (P less than 0.001). These increases were associated with transient elevations in colony-stimulatory activity. Prolonged exposure to lithium (three to 12 weeks) was associated with a dose-dependent progressive depletion of stem cells and their progeny. Lithium enhancement of granulopoiesis may be explained by primary stimulation of the pluripotent stem cell. Prolonged proliferative stress induced by lithium when the stem-cell reserve is limited may be associated with diminished replicative potential of the stem cells and rapid depletion of cells.

[Hematopoietic stimulation for enhanced bone marrow regeneration after chemotherapy (author's transl)]

The aggressivity of cancer chemotherapy is limited by hematologic side effects or makes expensive supportive therapy necessary. This article summarizes known and clinically usable methods of stimulating hematopoiesis to enhance bone marrow recovery after therapy. Longest known is the stimulatory effect of anabolic steroids, which may accelerate the regeneration of granulopoiesis and erythropoiesis. Lithium increases CSA-levels and enhances the regeneration of granulopoiesis and questionably thrombopoiesis according to several publications. The stem cell shift by hypertransfusion promotes granulopoiesis. As malnutrition limits hematopoietic recovery, optimal nutrition after chemotherapy should favor maximal hematopoiesis. Further studies are necessary before the application of the above mentioned methods to stimulate bone marrow - singly or in combination - can be recommended.

The use of lithium carbonate to reduce infection and leukopenia during systemic chemotherapy

To investigate whether lithium ameliorates the infectious complications that accompany systemic chemotherapy, we studied 45 patients with small-cell bronchogenic carcinoma receiving combination chemotherapy and radiation therapy. Twenty received lithium carbonate, and 25 received no additional therapy. Control subjects experienced more days with neutropenia than the lithium-treated group (2.17 days per 100 patient-days vs. 0.29), more severe febrile episodes (seven patients vs. one patient), more days hospitalized with fever and neutropenia (1.92 per 100 patient-days vs. 0.18), and more infection-related deaths (five vs. none). Infection-free survival was significantly longer in the lithium-treated group than in controls (P less than 0.05). Delay in subsequent chemotherapy was longer (P less than 0.01) and the number of dose reductions greater (P less than 0.01) in the control group. For both leukocytes and neutrophils, the first cycle nadir, mean of all treatment nadirs, and the lowest nadir observed during treatment were significantly higher in the lithium group. Mean mid-cycle monocyte counts were greater in the lithium group (P less than 0.05) and correlated with concurrent serum lithium levels (rs = 0.74, P less than 0.05). We believe that lithium carbonate shows promise as a means of lowering the risk of infection among patients receiving cytotoxic therapy.