Tremor with lithium

Tremor was reported as an adverse effect of lithium in 12 of 22 men and 10 of 38 women who had taken it for at least 1 year (108). In an open study, there was full remission of lithium tremor in four of five patients treated with vitamin B6 (213). 

A patient taking lithium carbonate developed a serum-lithium level of 2.35 mmol/L and toxicity (tremor, dysarthria, digestive problems) within 10 days of starting to take captopril 50 mg daily. He was restabilised on half his previous dose of lithium. A retrospective study also reports a case of increased lithium levels with captopril (see under (c) Lisinopril, below). 

The concurrent use of lithium and verapamil can be uneventful, but neurotoxicity (ataxia, movement disorders, tremors) with unchanged lithium levels has been reported in a few patients. Reduced and increased lithium levels have also occurred with verapamil. An acute parkinsonian syndrome and marked psychosis has been seen in at least one patient taking lithium and diltiazem. Reduced lithium clearance, and one possible case of increased lithium levels have been reported with nifedipine. 

In patients taking lithium, high coffee consumption and caffeine withdrawal have been associated with an increase in lithium tremors (Grandjean and Aubry 2009 Mester et al. 1995). A series of case reports and a related small trial indicated that coffee may inhibit intestinal absorption of thyroxine (T4) (Benvenga et al. 2008). 

Tremor A review of lithium-associated tremor examined 64 articles [83 " ]. Lithium tremor occurs in nearly a tiiird of patients. It can occur at any time during lithium treatment. It is related to lithium levels, and is usually not progressive. It is usually limited to die upper extremihes, it occurs at rest and worsens with activity. Consequently, dose reduction is helpful. Beta blockers have been studied in 12 randomized trials. Propranolol at 60-320mg daily is the most commonly used treatment for lithium-associated tremor but nadolol (20-80mg/day), metoprolol (200-400mg/day), and practolol (120 mg/day) have also been used. Gabapentin and primidone have also been recommended [83 ]. 

Treatment of Manic—Depressive Illness. Siace the 1960s, lithium carbonate [10377-37-4] and other lithium salts have represented the standard treatment of mild-to-moderate manic-depressive disorders (175). It is effective ia about 60—80% of all acute manic episodes within one to three weeks of adrninistration. Lithium ions can reduce the frequency of manic or depressive episodes ia bipolar patients providing a mood-stabilising effect. Patients ate maintained on low, stabilising doses of lithium salts indefinitely as a prophylaxis. However, the therapeutic iadex is low, thus requiring monitoring of semm concentration. Adverse effects iaclude tremor, diarrhea, problems with eyes (adaptation to darkness), hypothyroidism, and cardiac problems (bradycardia—tachycardia syndrome). 

Remember to take lithium with food or immediately after meals to avoid stomach upset. Drink at least 10 large glasses of fluid each day and add extra salt to food. Prolonged exposure to the sun may lead to dehydration. If any of the following occurs, do not take the next dose and immediately notify the primary health care provider diarrhea, vomiting, fever, tremors, drowsiness, lack of muscle coordination, or muscle weakness. 

Following initial assessment, including evaluation of potential suicidality, support systems, and need for inpatient versus outpatient treatment, MW was hospitalized briefly, then followed in the community on medication along with psychotherapy. She has abstained from illicit substances and has returned to her job. She has responded well to treatment with sustained-release lithium carbonate 900 mg once daily at bedtime with a snack. Steady-state 12-hour serum lithium concentrations have stabilized at 0.9 mEq/L (0.9 mmol/L). She now returns to clinic for routine followup. She has tolerated the lithium except for a mild tremor and a gain of 7 pounds (3.2 kg). She is willing to accept these side effects for now, but asks about how long she must take medication since she is now feeling well. 

Augmenting antidepressants with lithium has repeatedly been shown to be effective. But lithium is a difficult medication to take. It is very dangerous in overdose and can quickly reach toxic levels due to fluid loss from diarrhea, profuse sweating, or high fevers. Even at treatment levels, lithium can produce unpleasant side effects such as dizziness, frequent urination, and tremors. Despite all its problems, lithium... 

Polyuria, polydipsia, tremor, ataxia, nausea, diarrhea, weight gain, drowsiness, acne, hair loss Possible effects on thyroid and renal functioning with longterm administration Children prone to dehydration are at higher risk for acute lithium toxicity... 

Lithium salts are used in the treatment of bipolar affective disorder (i.e., manic depression) and occasionally in mania (but its slow onset of action is somewhat of a disadvantage in this case). Its mechanism of action is still open to debate, but lithium has effects on brain monoamines, on neuronal transmembrane sodium flux, and on cellular phosphatidylinositides related to second messenger systems. Lithium is administered in two salt forms, lithium carbonate (8.98) and lithium citrate (8.99). Side effects are common and include diarrhea, kidney failure, and drowsiness with tremor. 

SSRIs reduce dopamine cell firing in the substantia nigra through their effects on serotonin input to this nucleus. The net result is that they can cause generally mild extrapyramidal side effects (EPS) (500). The most common are restlessness and tremors. The same mechanism is probably responsible for their interaction with other agents that affect central motor systems. Thus, the SSRIs can potentiate the tremor seen with lithium, as well as EPS caused by antipsychotics, bupropion, and psychostimulants (376, 500). 

Levodopa or dopamine agonists produce diverse dyskinesias as a dose-related phenomenon in patients with Parkinson s disease dose reduction reverses them. Chorea may also develop in patients receiving phenytoin, carbamazepine, amphetamines, lithium, and oral contraceptives, and it resolves with discontinuance of the offending medication. Dystonia has resulted from administration of dopaminergic agents, lithium, serotonin reuptake inhibitors, carbamazepine, and metoclopramide and postural tremor from theophylline, caffeine, lithium, valproic acid, thyroid hormone, tricyclic antidepressants, and isoproterenol. 

Tremor is one of the most common adverse effects of lithium treatment, and it occurs with therapeutic doses. Propranolol and atenolol, which have been reported to be effective in essential tremor, also alleviate lithium-induced tremor. Other reported neurologic abnormalities include choreoathetosis, motor hyperactivity, ataxia, dysarthria, and aphasia. Psychiatric disturbances at toxic concentrations are generally marked by mental confusion and... 

Lithium Carbonate Common symptoms of lithium toxicity are nausea, vomiting, and diarrhea followed by tremor, increased muscle tone, and rigidity. Acute kidney problems and nephrogenic diabetes insipidus may be possible hazards. In serious cases, coma and convulsions can be observed along with toxicity. 

In keeping with this medication spellbinding effect, normal volunteers on small doses suffer impairments of their reflexes but do not realize or acknowledge the impairment (Linnoila et al., 1974). Lithium patients who report no side effects often have grossly obvious tremors. The failure of patients on maintenance therapy to notice their own neurologic defects clearly demonstrates that long-term treatment with lithium is medication spellbinding. 

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