Tricyclic antidepressants lithium

The use of drug plasma levels to effect optimal clinical response and to minimize adverse or toxic effects is standard practice in general medicine (e.g., phenytoin, digoxin), as well as in psychiatry (e.g., lithium, tricyclic antidepressants, valproate see Chapter 3). The theoretical basis for plasma level monitoring rests on several factors, including ... 

Opioids, benzodiazepines, barbiturates, corticosteroids, dopamine agonists (e.g., amantadine, bromocriptine, levodopa, pergolide, pramipexole, ropinirole), H2-receptor antagonists, anticholinergics (e.g., diphenhydramine, trihexylphenidyl), P-adrenergic blockers, clonidine, methyldopa, carbamazepine, phenytoin, baclofen, cyclobenzaprine, lithium, antidepressants (e.g., tricyclic antidepressants, selective serotonin reuptake inhibitors), and interleukin-2... 

Diphenhydramine, trihexiphenidyl, tricyclic antidepressants, phenothiazines, and lithium... 

Tricyclic antidepressants Monoamine oxidase inhibitors Selective serotonin reuptake inhibitors Antipsychotics Phenothiazines Risperidone Lithium... 

Bonson KR, Buckholtz JW, Murphy DL. (1996). Chronic administration of serotonergic antidepressants attenuates the subjective effects of LSD in humans. Neuropsychopharmacology. 14(6) 425-36, Bonson KR, Murphy DL. (1996). Alterations in responses to LSD in humans associated with chronic administration of tricyclic antidepressants, monoamine oxidase inhibitors, or lithium. Behav Brain Res. 73(1-2) 229-33. 

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. 

Drugs that may be affected by lithium include phenothiazines, sympathomimetics, iodide salts, neuromuscular blocking agents, and tricyclic antidepressants. 

Forced diuresis is occasionally useful. It may cause volume overload or electrolyte disturbances. Forced diuresis is useful for phenobarbital, bromides, lithium, salicylate, or amphetamines overdoses. Do not use for tricyclic antidepressants, sedative-hypnotics, or highly protein-bound medications. The most common agents employed are furosemide and osmotic diuretics with mannitol. 

Dmg-induced serotonin syndrome is generally mild and resolves when the offending drugs are stopped. However, it can be severe and deaths have occurred. A large number of drugs have been implicated including tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), selective serotonin re-uptake inhibitors (SSRIs), pethidine, lithium, and dextromethorphan. The most severe type of reaction has occurred with the combination of selective serotonin re-uptake inhibitors and monoamine oxidase inhibitors. Both non-selective MAOIs such as phenelzine and selective MAOIs such as moclobemide and selegiline have been implicated. 

Fetner, H.H. and Geller, B. (1992) Lithium and tricyclic antidepressants. Psychiatry Clin North Am 15 223-224. 

This case report (Figures 6-4Ato 6-4C) (McDermut et al. 1995) of selective response to dihydropyridine CCBs but not a phenylalkylamine CCB is of considerable interest in relationship to the patient s history of nonre-sponsivity to multiple tricyclic antidepressants, the selective serotonin reuptake inhibitors, lithium, carbamazepine (the patient developed drug-induced hepatitis on carbamazepine and was unable to be evaluated), alprazolam, trazodone, and phenelzine. This suggests that patients with refractory mood disorders may have differential responses to various CCBs and that nonresponse to one CCB does not preclude response to another CCB, particularly if the other CCB is from a different category (Table 6-3). 

Joffe RT, Singer W, Levitt AJ, et al A placebo-controlled comparison of lithium and triiodothyronine augmentation of tricyclic antidepressants in unipolar refractory depression. Arch Gen Psychiatry 50 387-393, 1993... 

First-order kinetics The amount of drug eliminated per unit of time is directly proportional to its concentration. In this state, the mechanisms for biotransformation and elimination are not saturated (e.g., benzodiazepines, tricyclic antidepressants, lithium carbonate). 

Garbutt J, Mayo J, Gillette G, et al. Lithium potentiation of tricyclic antidepressants following lack of T3 potentiation. Am J Psychiatry 1986 143 1038-1039. 

Schopf J, Lemarchand T. Lithium addition in endogemous depressions resistant to tricyclic antidepressants or related drugs relation to the status of the pituitarythyroid axis. 

These drugs are most commonly classified according to their principal pharmacological effect rather than by specific chemical structure (Table 10.4). The exception to this is the tricyclic antidepressants which share a common chemical structure and also common pharmacological effects. The other important type of drug used in the treatment of mood disorders is the mood stabilisers (lithium compounds and some anticonvulsants) which are discussed in the next section of this chapter. Tricyclic antidepressants... 

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. 

An interesting application of lithium that is relatively well supported by controlled studies is as an adjunct to tricyclic antidepressants and selective serotonin reuptake inhibitors in patients with unipolar depression who do not respond fully to monotherapy with the antidepressant. For this application, concentrations of lithium at the lower end of the recommended range for manic-depressive illness appear to be adequate. 

In combination with tricyclic antidepressants, lithium is used in treating recurrent endogenous depression. In combination with neuroleptics, it is used in the management of schizoaffective disorders. In combination with neuroleptics, it is used to control schizophrenia. Lithium is also used in the case of patients with alcoholism associated with depression and has been used to correct the neutropenia that occurs during cancer chemotherapy. 

Widening of the QRS complex duration to greater than 100 milliseconds is typical of tricyclic antidepressant and quinidine overdoses (Figure 59-1). The QTC interval may be prolonged to more than 440 milliseconds in many poisonings, including quinidine, tricyclic antidepressants, several newer antidepressants and antipsychotics, lithium, and arsenic (see also http //www.torsades.org/). Variable atrioventricular (AV) block and a variety of atrial and ventricular arrhythmias are common... 

Evidente VG, Caviness JN. Focal cortical transient preceding myoclonus during lithium and tricyclic antidepressant therapy. Neurology 1999 52(l) 211-3. 

Interactions of lithium with antidepressants have been reviewed tricyclic antidepressants and MAO inhibitors—no serious problems SSRIs—a few reports of the serotonin syndrome (65). 

Bonson KR, Murphy DL. Alterations in responses to LSD in humans associated with chronic administration of tricyclic antidepressants, monoamine oxidase inhibitors or lithium. Behav Brain Res 1996 73(l-2) 229-33. 

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