Lithium, therapeutic activity

Lithium was introduced by Cade in 1949 for the treatment of acute mania (30). Unfortunately, the serious toxic effects of lithium were first recognized quite independently at about the same time, when lithium salts were used as a substitute for table salt in treatment of hypertension in the United States. Use of Westral, a lithium-containing salt substitute, caused a number of deaths (31,32). This unfortunate coincidence delayed the acceptance of lithium in psychiatry until Schou and others showed that lithium could safely be used in manic depressive disorder at rather lower doses than those used by Cade (33). The therapeutic index, however, is low. After its reluctant acceptance, the spectrum of therapeutic activity claimed for lithium then widened for a time, to include a broad range of psychiatric disorders, including schizophrenia. 

Other agents are also used for the treatment of manic-depressive disorders based on preliminary clinical results (177). The antiepileptic carbamazepine [298-46-4] has been reported in some clinical studies to be therapeutically beneficial in mild-to-moderate manic depression. Carbamazepine treatment is used especially in bipolar patients intolerant to lithium or nonresponders. A majority of Hthium-resistant, rapidly cycling manic-depressive patients were reported in one study to improve on carbamazepine (178). Carbamazepine blocks noradrenaline reuptake and inhibits noradrenaline exocytosis. The main adverse events are those found commonly with antiepileptics, ie, vigilance problems, nystagmus, ataxia, and anemia, in addition to nausea, diarrhea, or constipation. Carbamazepine can be used in combination with lithium. Several clinical studies report that the calcium channel blocker verapamil [52-53-9] registered for angina pectoris and supraventricular arrhythmias, may also be effective in the treatment of acute mania. Its use as a mood stabilizer may be unrelated to its calcium-blocking properties. Verapamil also decreases the activity of several neurotransmitters. Severe manic depression is often treated with antipsychotics or benzodiazepine anxiolytics. 

Recent studies have demonstrated that lithium (and to a lesser extent VPA) produces, at therapeutically relevant concentrations, complex alterations in basal and/or stimulated DNA-binding of 12-o-tetradecanoyl-phorbol 13-acetate (TPA) response element (TRE) to AP-1 transcription factors. These alterations are produced not only in human SH-SY5Y cells in vitro, but also in rodent brain following chronic, in vivo administration [5, 7, 15-21]. Corresponding to an increase in basal AP-1 DNA-binding activity, lithium and VPA have been shown to increase the expression of a luciferase reporter gene driven by an SV40 promoter that contains TREs in a time- and concentration-dependent fashion. Mutations in the TRE... 

Evidence accumulating from various laboratories has clearly demonstrated that lithium, at therapeutically relevant concentrations, exerts significant effects on the PKC signaling cascade. Current data suggest that chronic lithium attenuates PKC activity, and down-regulates the expression of PKC isozymes V in the frontal cortex and hippocampus [79, 80], Chronic lithium has also been demonstrated to dramatically reduce the hippocampal levels of a major PKC substrate, myristoylated-alanine-rich C kinase substrate (MARCKS), which has been implicated in regulating long-term neuroplastic events. 

Many of the adverse effects of lithium can be ascribed to the action of lithium on adenylate cyclase, the key enz)nne that links many hormones and neurotransmitters with their intracellular actions. Thus antidiuretic hormone and thyroid-stimulating-hormone-sensitive adenylate cyclases are inhibited by therapeutic concentrations of the drug, which frequently leads to enhanced diuresis, h)rpoth)n oidism and even goitre. Aldosterone synthesis is increased following chronic lithium treatment and is probably a secondary consequence of the enhanced diuresis caused by the inhibition of antidiuretic-hormone-sensitive adenylate cyclase in the kidney. There is also evidence that chronic lithium treatment causes an increase in serum parathyroid hormone levels and, with this, a rise in calcium and magnesium concentrations. A decrease in plasma phosphate and in bone mineralization can also be attributed to the effects of the drug on parathyroid activity. Whether these changes are of any clinical consequence is unclear. 

The anticonvulsant properties of the drug would appear to be due to its ability to inhibit fast sodium channels, which may be unrelated to its psychotropic effects. Like lithium, it has been shown to decrease the release of noradrenaline and reduce noradrenaline-induced adenylate cyclase activity unlike lithium, it seems to have little effect on tryptophan or 5-HT levels in patients at therapeutically relevant concentrations. It also reduces dopamine turnover in manic patients and increases acetylcholine... 

Flame Photometry, Atomic Absorption, and Neutron Activation. Comparatively few substances amenable to measurement by these techniques are used therapeutically chief among those that are being sodium, potassium, lithium, calcium, magnesium, zinc, copper, and iron, for all of which one or other of the techniques is the method of choice. 

The clinical value of monitoring drug therapy by measuring plasma levels is probably best exemplified by reference to lithium (F6). It is a useful drug, which has a narrow therapeutic index, and treatment without reference to plasma levels is probably not ethically justified. Toxic side effects are predictable and severe. It has an acceptably long plasma half-life, and its measurement both in blood and urine is comparatively simple. Moreover, there is no problem of interference from either active or inactive metabolites. 

Mallinger AG, Hanin 1, Himmeloch JM, et al Stimulation of cell membrane sodium transport activity by lithium possible relationship to therapeutic action. Psychiatry Res 22 49-59, 1987... 

Unlike antipsychotic or antidepressant drugs, which exert several actions on the central or autonomic nervous system, lithium ion at therapeutic concentrations is devoid of autonomic blocking effects and of activating or sedating effects, though it can produce nausea and tremor. 

Lithium (Li) is a common mood stabilizer and it used in the treatment of bipolar disorder. There are numerous evidences that the therapeutic effect of Li is mediated via an inositol triphosphate (IP3) and protein kynase C (PKC)-mediated mechanism (Amsten, 2008). Since the IP3 and PKC are involved the signal transduction pathway of oti -adrenoceptors, it is possible that there receptor are target of Li treatment. Indeed, it has been observed that chronic Li suppress the al-mediated IP3 formation and PKC activation. It has been also observed that chronic Li deregulates al3 a2 and p-adrcnoceptors in the brain (Devaki et al., 2006). 

Lithium is toxic in rats at the same serum concentrations as in humans (Schou, 1976). In a rat study by Smith and Smith (1973), lithium was administered in the low therapeutic range for a period of only 1 week. The authors summarized, The most consistent effect of lithium was to decrease the voluntary activity of the rats. ... 

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