Lithium haloperidol

Garfinkel PE, Stancer HC, Persad E. A comparison of haloperidol, lithium carbonate, and their combination in the treatment of mania. J Affect Disord 1980 2 279-288. 

Identical twin brothers, aged 37 years, had both suffered from bipolar disorder since their early twenties and had been treated with chlorpromazine, haloperidol, lithium, and carbamazepine before developing priapism. One of them developed priapism after taking trazodone 400 mg/day, and in the 2 years after the initial episode he suffered recurrent painless erections. Initially they occurred daily and lasted 4-5 hours. During a relapse of mania at age 37, he was given oral zuclopenthixol 40 mg/day. On the tenth day he presented with priapism of 4 days duration, which persisted despite zuclopenthixol withdrawal, needle aspiration, and phenylephrine instillation, but subsided 2 weeks later with conservative management. The... 

Psychotic patients are most often treated with clozapine, haloperidol, lithium, olanzapine, or one of the phenothi-azines, or a combination of these drugs. Because response to these drugs is unpredictable and patients are difficult to control, monitoring serum concentration may aid in adjusting therapy. Numerous methods to measure the serum concentration of the various neuroleptic agents have been reported. ... 

There are anecdotal and rare reports of severe adverse effects induced by the combined haloperidol-lithium regimen (extrapyramidal... 

In noncancer-related pharmacology, GSK3 is inhibited by lithium at therapeutic concentrations, implying that the long-established effectiveness of lithium in the treatment of psychiatric mood disorders (and more recently as a neuroprotective agent) may be linked to GSK3 inhibition. Antipsychotics such as haloperidol... 

Most psychotic and non-compliant patients are difficult to treat with lithium alone and need to be treated with neuroleptics. Haloperidol has been widely... 

Largactil is a proprietary preparation of chlorpromazine, an aliphatic antipsychotic with marked sedation and moderate antimuscarinic and extrapyramidal side-effects. Serenace is a proprietary preparation of haloperidol, a butyrophenone antipsychotic with marked extrapyramidal side-effects, moderate sedation but not very likely to cause hypotension. Tegretol is a proprietary preparation of carbamazepine, an anti-epileptic drug indicated in partial and secondary generalised tonic-clonic seizures, primary generalised tonic-clonic seizures, trigeminal neuralgia and in the prophylaxis of bipolar disorder unresponsive to lithium. 

Antipsychotic drugs, such as flupentixol and haloperidol are the mainstay of treatment for acute attacks of mania. Lithium is not indicated as it may take a few days before the drug exerts an effect. Lithium may be given concomitantly with an antipsychotic drug. 

Drugs that may be affected by methyidopa include haloperidol, levodopa, lithium, sympathomimetics, MAOIs, anesthetics, and phenothiazines. 

Drugs that may be affected by SSRIs Drugs that may be affected by SSRIs include alcohol, benzodiazepines, beta blockers, buspirone, carbamazepine, cisapride, clozapine, cyclosporine, diltiazem, digoxin, haloperidol, hydantoins, lithium, methadone, mexiletine, nonsedating antihistamines, NSAIDs, olanzapine, phenothiazines, phenytoin, pimozide, procyclidine, ritonavir, ropivacaine, sumatriptan, sulfonylureas, sympathomimetics, tacrine, theophylline, tolbutamide, tricyclic antidepressants, and warfarin. 

Encephalopathic syndrome - An encephalopathic syndrome (characterized by weakness, lethargy, fever, tremulousness, confusion, extrapyramidal symptoms, leukocytosis, elevated serum enzymes, blood urea nitrogen, fasting blood sugar) has occurred in a few patients treated with lithium plus an antipsychotic (haloperidol). 

Drugs that may affect lithium include acetazolamide, carbamazepine, fluoxetine, haloperidol, loop diuretics, methyidopa, NSAIDs, osmotic diuretics, theophyllines. 

Haloperidol (Haldol) Lithium Carbonate (Eskalith, Lithobid, others)... 

Aggravation of the extrapyramidal effects of antipsychotic agents have been described and it has been reported that the use of lithium in combination with haloperidol may result in irreversible neurological toxicity. Lithium can increase the hypothyroid effects of antithyroid agents or iodides. 

For more than 40 years, Li+ has been used to treat mania. While it is relatively inert in individuals without a mood disorder, lithium carbonate is effective in 60 to 80% of all acute manic episodes within 5 to 21 days of beginning treatment. Because of its delayed onset of action in the manic patient, Li+ is often used in conjunction with low doses of high-potency anxiolytics (e.g., lo-razepam) and antipsychotics (e.g. haloperidol) to stabilize the behavior of the patient. Over time, increased therapeutic responses to Li+ allow for a gradual reduction in the amount of anxiolytic or neuroleptic required, so that eventually Li+ is the sole agent used to maintain control of the mood disturbance. 

Campbell, M., Small, A.M., Green, W.H., Jennings, S.J., Perry, R., Bennett, W.G., and Anderson, L. (1984) Behavioral efficacy of haloperidol and lithium carbonate. A comparison in hospitalized aggressive children with conduct disorder. Arch Gen Psychiatry 41 650-656. 

Of the atypical antipsychotics, clozapine, olanzapine, and risperidone have been studied the most. Clozapine was used to treat 10 treatment refractory acutely manic patients and 15 schizomanic patients. Using reduction in the YMRS score as the outcome measure, 72% improved (non-rapid cycling, bipolar patients). Comparison of olanzapine (5-20 mg) with placebo showed significant reduction of the YMRS in 49% vs. 24% of subjects by 3 weeks, with significant change evident by the first week. In a trial comparing risperidone at 6 mg with haloperidol at 10 mg and low-dose lithium (800-1200 mg/day) efficacy was similar over the 28 days of the trial. 

Benzlpopine TbiQriduine FVodtloqMrazin Haloperidol Uothyronine (T9) Nortriptyline Desipromine Lithium carbonate... 

Freeman TW, Clothier JL, Pazzaglia P, et al A double-blind comparison of valproate and lithium in the treatment of acute mania. Am J Psychiatry 149 108-111,1992 Frenchman IB, Prince T Clinical experience with risperidone, haloperidol, and thioridazine for dementia-associated behavioral disturbances. Int Psychogeriatr 9 431-435, 1997... 

Hong J-S, Tilson HA, Yoshikawa K Effects of lithium and haloperidol administration on the rat brain levels of Substance P. J Pharmacol Exp Ther 224 590-597, 1983 Honig A, Bartlett JR, Bouras N, et al Amino acid levels in depression a preliminary investigation. J Psychiatr Res 22 159-164, 1989 Honjo H, Ogino Y, Natitoh K, et al In vivo effects by estrone sulphate on the central nervous system on senile dementia [Alzheimer s type). Journal of Steroid Biochemistry 34 521-525, 1989... 

Klein E, Bental E, Lerer B, et al Carbamazepine and halopeiidol vs. placebo and haloperidol in excited psychoses. Arch Gen Psychiatry 41 165-170, 1984a Klein E, Hefez A, Lavie P Effects of clomipramine infusion on sleep in depressed patients. Neuropsychobiology 1 85-88, 1984b Klein E, Lavie P, Meiraz R, et al Increased motor activity and recurrent manic episodes risk factors that predict rapid relapse in remitted bipolar disorder patients after lithium discontinuation—a double blind study. Biol Psychiatry 31 279-284, 1992... 

Oxcarbazepine is a keto derivative of carbamazepine but offers several advantages over carbamazepine. Oxcarbazepine does not require blood cell count, hepatic, or serum drug level monitoring. It causes less cytochrome P450 enzyme induction than does carbamazepine (but may decrease effectiveness of oral contraceptives containing ethinyl estradiol and levonorgestrel). As opposed to carbamazepine, oxcarbazepine does not induce its own metabolism. These properties, combined with its similarity to carbamazepine, led many clinicians to use this medication for the treatment of bipolar disorder. Randomized controlled trials suggested efficacy in the treatment of acute mania compared with lithium and haloperidol, but these trials were quite small and did not include a placebo control (Emrich 1990). 

Another use of the laboratory is for therapeutic drug monitoring (TDM) of psychotropics with defined optimal ranges, narrow therapeutic indices, or both. Although TDM is not essential for many psychotropics, it is for others, including lithium, several TCAs, valproate, and carbamazepine. It may also be helpful to optimize the use of certain antipsychotics (e.g., haloperidol, clozapine) ( 7). 

Lorazepam (2 mg i.m.) was found to be equivalent to haloperidol (5 mg i.m.) either alone or when added to ongoing antipsychotic treatment, and significantly reduced the likelihood of akathisia and dystonia (167). In the treatment of acute mania, lorazepam has also been reported useful as an adjunct to lithium, as well as antipsychotics (157, 163, 165, 168, 169). 

Limited evidence indicates that carbamazepine plus an antipsychotic may also benefit some schizophrenic patients. This is an interesting possibility in view of the similar antimanic properties of lithium and carbamazepine (375). This area requires further research, especially to clarify the indications for combining anticonvulsants with an antipsychotic. For example, mania complicated by psychotic features may benefit from lithium, valproate, or carbamazepine augmented by antipsychotics. Because carbamazepine induces the metabolism of at least some antipsychotics (e.g., haloperidol, thiothixene), dose adjustment based on TDM may be necessary to achieve the optimal effect. 

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