Lithium prescription trends in psychiatric inpatient care 2014 to 2021: data from a Bavarian drug surveillance project

OBJECTIVES

Lithium (Li) remains one of the most valuable treatment options for mood disorders. However, current knowledge about prescription practices in Germany is limited. The objective of this study is to estimate the prevalence of current Li use over time and in selected diagnoses, highlighting clinically relevant aspects such as prescription rates in elderly patients, concomitant medications, important drug-drug interactions, and serious adverse events.

METHODS

We conducted a descriptive analysis of Li prescriptions, analyzing data from the ongoing Bavarian multicenter drug safety project Pharmaco-Epidemiology and Vigilance (Pharmako-EpiVig) from the years 2014-2021. Our study included 97,422 inpatients, 4543 of whom were prescribed Li.

RESULTS

The Li prescription rate in unipolar depression (UD) remained constant at 4.6% over the observational period. In bipolar disorder (BD), the prescription rate increased significantly from 28.8% in 2014 to 34.4% in 2019. Furthermore, 30.3% of patients with Li prescriptions did not have a diagnosis of BD or UD, and 15.3% of patients with schizoaffective disorder were prescribed Li. The majority (64%) of patients with Li prescriptions were prescribed five or more drugs. Most of the 178 high-priority drug-drug interactions were due to hydrochlorothiazide (N = 157) followed by olmesartan (N = 16).

CONCLUSION

Our study does not substantiate concerns about a decline in Li prescription. The decline in prescription rates observed in some diagnostic groups in 2020 and 2021 may be associated with the COVID-19 pandemic. The symptom-oriented use of Li beyond BD and UD is common. Polypharmacy and drug-drug interactions present a challenge in Li therapy. Old age and comorbid substance use disorder do not appear to be major deterrents for clinicians to initiate Li therapy.

Lithium induced hypercalcemia: an expert opinion and management algorithm

BACKGROUND

Lithium is the gold standard prophylactic treatment for bipolar disorder. Most clinical practice guidelines recommend regular calcium assessments as part of monitoring lithium treatment, but easy-to-implement specific management strategies in the event of abnormal calcium levels are lacking.

METHODS

Based on a narrative review of the effects of lithium on calcium and parathyroid hormone (PTH) homeostasis and its clinical implications, experts developed a step-by-step algorithm to guide the initial management of emergent hypercalcemia during lithium treatment.

RESULTS

In the event of albumin-corrected plasma calcium levels above the upper limit, PTH and calcium levels should be measured after two weeks. Measurement of PTH and calcium levels should preferably be repeated after one month in case of normal or high PTH level, and after one week in case of low PTH level, independently of calcium levels. Calcium levels above 2.8 mmol/l may require a more acute approach. If PTH and calcium levels are normalized, repeated measurements are suggested after six months. In case of persistent PTH and calcium abnormalities, referral to an endocrinologist is suggested since further examination may be needed.

CONCLUSIONS

Standardized consensus driven management may diminish the potential risk of clinicians avoiding the use of lithium because of uncertainties about managing side-effects and consequently hindering some patients from receiving an optimal treatment.

Heart Rate Variability and Omega-3 Index in Euthymic Patients with Bipolar Disorders

Background:

Affective disorders are associated with an increased risk of cardiovascular disease, which, at least partly, appears to be independent of psychopharmacological treatments used to manage these disorders. Reduced heart rate variability (SDNN) and a low Omega-3 Index have been shown to be associated with increased risk for death after myocardial infarction. Therefore, we set out to investigate heart rate variability and the Omega-3 Index in euthymic patients with bipolar disorders.

Methods:

We assessed heart rate variability (SDNN) and the Omega-3 Index in 90 euthymic, mostly medicated patients with bipolar disorders (Bipolar-I, Bipolar-II) on stable psychotropic medication, free of significant medical comorbidity and in 62 healthy controls. Heart rate variability was measured from electrocardiography under a standardized 30 minutes resting state condition. Age, sex, BMI, smoking, alcohol consumption and caffeine consumption as potential confounders were also assessed.

Results:

Heart rate variability (SDNN) was significantly lower in patients with bipolar disorders compared to healthy controls (35.4 msec versus 60.7 msec; P < 0.0001), whereas the Omega-3 Index did not differ significantly between the groups (5.2% versus 5.3%). In a linear regression model, only group membership (patients with bipolar disorders versus healthy controls) and age significantly predicted heart rate variability (SDNN).

Conclusion:

Heart rate variability (SDNN) may provide a useful tool to study the impact of interventions aimed at reducing the increased risk of cardiovascular disease in euthymic patients with bipolar disorders. The difference in SDNN between cases and controls cannot be explained by a difference in the Omega-3 Index.