Tremor lithium treatment

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... 

Zaninelli R, Bauer M, Jobert M, Muller-Oerlinghausen B. Changes in quantitatively assessed tremor during treatment of major depression with lithium augmented by paroxetine or amitriptyline. J Clin Psychopharmacol 2001 21(2) 190-8. 

Initial complaints, which usually diminish with time, include headache, lethargy, and muscle weakness. Nearly half of patients experience a fine hand tremor at some time during lithium treatment. For most people, this initial symptom remits however, for 10 percent of patients, it is a continuing side effect (American Society of Hospital Pharmacists 1993). Often the tremor becomes worse when the individual reaches for something. Sustained tremor, at therapeutic levels, can be managed with reassurance, and by limiting stimulants, such as caffeine, which may exacerbate the tremor. Sometimes this tremor is treated with beta blockers, usually propranolol (In-deral). 

Initial side effects are mild and include tremor, lethargy, nausea, diarrhea, and abdominal discomfort. Lithium treatment has been associated with headache symptoms described as episodes of moderately severe, throbbing occipital pain lasting 6 to 12 hours, but these headaches are easily distinguishable from the cluster headache and disappear when lithium is withdrawn. Lithium should be administered with caution to patients with significant renal or cardiovascular disease, dehydration, pregnancy, or concomitant diuretic use. 

A patient with systemic lupus erythematosus suffering from steroid-induced depression and moderate renal impairment was given lithium 600 mg daily and her depression improved. However, serum-lithium levels increased from 0.4 to 0.8 mmol/L within one week and the lithium treatment caused an exacerbation of a finger tremor. The lithium was discontinued and then restarted at 400 mg daily, resulting in serum levels of 0.4 mmol/L, which improved her depression and was associated with only a fine finger tremor. Three other patients with steroid-induced depression were also successfully treated with lithium. ... 

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). 

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... 

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. 

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. 

When 60 patients (22 men, 38 women) who had taken lithium for 1 year or more (mean 6.9 years mean serum concentration 0.74 mmol/1) were interviewed about adverse effects, 60% complained of polyuria-polydipsia syndrome (serum creatinine concentrations were normal) and 27% had hypothyroidism requiring treatment (108). Weight gain was more common in women (47 versus 18%) as were hypothyroidism (37 versus 9%) and skin problems (16 versus 9%), while tremor was more common in men (54 versus 26%). Weight gain of over 5 kg in the first year of treatment was the only independent variable predictive of hypothyroidism. 

Occasionally, long-term use of lithium is associated with cogwheel rigidity and a parkinsonian tremor (189). More often than not, concurrent or past treatment with an antipsychotic drug is involved. In a review of SSRI-induced extrapyramidal adverse effects, lithium was listed, but not discussed, as a possible risk factor (190). A review of drug-induced parkinsonism provided references to case reports of lithium s occasionally inducing or exacerbating parkinsonism (191). 

The adverse effects of lithium in elderly patients include cognitive status worsening, tremor, and hypothyroidism. The authors suggested that divalproex is also useful in elderly patients with mania and that concentrations of divalproex in the elderly are similar to those useful for the treatment of mania in younger patients. They noted that carbamazepine should be considered a second-line treatment for mania in the elderly. A partial response would warrant the addition of an atypical antipsychotic drug. For bipolar depression, they recommended lithium in combination with an antidepressant, such as an SSRI. They also noted that lamotrigine may be useful for bipolar depression. Electroconvulsive therapy (ECT) may also be useful, but there have been no comparisons of ECT and pharmacotherapy in elderly patients with bipolar depression. 

In an open-label pilot study of rapid administration of slow-release lithium (20 mg/kg/day in two divided doses) for acute mania, five of 15 patients completed 10 days of treatment, seven improved sooner and were discharged, two withdrew because of adverse effects (bradycardia in one and tremor, fatigue, and diarrhea in the other and one patient appears not to have been accounted for) two other patients also had asymptomatic bradycardia (129). 

Lithium augmentation of antidepressants is a well-established treatment for resistant depression and is usually well tolerated with all classes of antidepressants, although there have been a few reports of the serotonin syndrome with SSRIs (581). It is possible that shared adverse effects could be magnified by combining lithium with various antidepressants (for example tremor, weight... 

Lithium is administered orally, usually as lithium carbonate in tablet form at a total dose of up to 30 mmol (2 g) per day. Treatment is monitored using regular estimations of blood lithium, taken 12 hr after the previous dose (40, 41). These serum lithium concentrations should lie in the range 0.4-0.8 mM, and higher levels may be associated with toxic side effects, which can include tremor, dizziness, drowsiness, and diarrhea (42, 43). 

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