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Lithium dosing strategies during pregnancy and the postpartum period

  • Richard Wesseloo (a1), André I. Wierdsma (a1), Inge L. van Kamp (a2), Trine Munk-Olsen (a3), Witte J. G. Hoogendijk (a4), Steven A. Kushner (a4) and Veerle Bergink (a4)...
Abstract
Background

Lithium is challenging to dose during pregnancy.

Aims

To provide guidance for dosing lithium during pregnancy.

Method

Retrospective observational cohort study. Data on lithium blood level measurements (n = 1101), the daily lithium dose, dosing alterations/frequency and creatinine blood levels were obtained from 113 pregnancies of women receiving lithium treatment during pregnancy and the postpartum period.

Results

Lithium blood levels decreased in the first trimester (−24%, 95% CI −15 to −35), reached a nadir in the second trimester (−36%, 95% CI −27 to −47), increased in the third trimester (−21%, 95% CI −13 to −30) and were still slightly increased postpartum (+9%, 95% CI +2 to +15). Delivery itself was not associated with an acute change in lithium and creatinine blood levels.

Conclusions

We recommend close monitoring of lithium blood levels until 34 weeks of pregnancy, then weekly until delivery and twice weekly for the first 2 weeks postpartum. We suggest creatinine blood levels are measured to monitor renal clearance.

Copyright
Corresponding author
Richard Wesseloo, MD, Department of Psychiatry, Erasmus Medical Centre, 's Gravendijkwal 230, 3000 CA, Rotterdam, The Netherlands. Email: r.wesseloo@erasmusmc.nl
Footnotes
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See editorial, pp. 3–4, this issue.

Declaration of interest

None.

Footnotes
References
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1 Geddes, JR, Miklowitz, DJ. Treatment of bipolar disorder. Lancet 2013; 381: 1672–82.
2 Gelenberg, AJ, Kane, JM, Keller, MB, Lavori, P, Rosenbaum, JF, Cole, K, et al. Comparison of standard and low serum levels of lithium for maintenance treatment of bipolar disorder. N Engl J Med 1989; 321: 1489–93.
3 Severus, WE, Kleindienst, N, Seemuller, F, Frangou, S, Moller, HJ, Greil, W. What is the optimal serum lithium level in the long-term treatment of bipolar disorder – a review? Bipolar Disord 2008; 10: 231–7.
4 Mitchell, PB. Australian and New Zealand clinical practice guidelines for the treatment of bipolar disorder. Aust NZ J Psychiatry 2004; 38: 280305.
5 Hirschfeld, RMA. Practice guideline for the treatment of patients with bipolar disorder. APA Practice Guidelines (2nd edn). APA, 2002.
6 National Institute of Health and Care Excellence. Bipolar Disorder: Assessment and Management. NICE Guidelines (CG185). NICE, 2014.
7 Deligiannidis, KM, Byatt, N, Freeman, MP. Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring. J Clin Psychopharmacol 2014; 34: 244–55.
8 Blake, LD, Lucas, DN, Aziz, K, Castello-Cortes, A, Robinson, PN. Lithium toxicity and the parturient: case report and literature review. Int J Obstet Anesth 2008; 17: 164–9.
9 Newport, DJ, Viguera, AC, Beach, AJ, Ritchie, JC, Cohen, LS, Stowe, ZN. Lithium placental passage and obstetrical outcome: implications for clinical management during late pregnancy. Am J Psychiatry 2005; 162: 2162–70.
10 Horton, S, Tuerk, A, Cook, D, Cook, J, Dhurjati, P. Maximum recommended dosage of lithium for pregnant women based on a PBPK model for lithium absorption. Adv Bioinformatics 2012; 2012: 352729.
11 Wesseloo, R, Kamperman, AM, Munk-Olsen, T, Pop, VJ, Kushner, SA, Bergink, V. Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. Am J Psychiatry 2016; 173: 117–27.
12 von Elm, E, Altman, DG, Egger, M, Pocock, SJ, Gotzsche, PC, Vandenbroucke, JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335: 806–8.
13 Goodwin, GM, Consensus Group of the British Association for Psychopharmacology. Evidence-based guidelines for treating bipolar disorder: revised second edition – recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2009; 23: 346–88.
14 Yatham, LN, Kennedy, SH, Parikh, SV, Schaffer, A, Beaulieu, S, Alda, M, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord 2013; 15: 144.
15 National Institute of Health and Care Excellence. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance. NICE Guidelines (CG192). NICE, 2014.
16 Dutch Association for Psychiatry. Richtlijn Bipolaire Stoornis [Bipolar Disorder Guideline]. NWP, 2014.
17 Jensen, HV, Davidsen, K, Toftegaard, L, Mellerup, ET, Plenge, P, Aggernaes, H, et al. Double-blind comparison of the side-effect profiles of daily versus alternate-day dosing schedules in lithium maintenance treatment of manic-depressive disorder. J Affect Disord 1996; 36: 8993.
18 Lafayette, RA, Druzin, M, Sibley, R, Derby, G, Malik, T, Huie, P, et al. Nature of glomerular dysfunction in pre-eclampsia. Kidney Int 1998; 54: 1240–9.
19 Nora, JJ, Nora, AH, Toews, WH. Lithium, Ebstein's anomaly, and other congenital heart defects (letter). Lancet 1974; 2: 594–5.
20 Weinstein, MR, Goldfield, M. Cardiovascular malformations with lithium use during pregnancy. Am J Psychiatry 1975; 132: 529–31.
21 McKnight, RF, Adida, M, Budge, K, Stockton, S, Goodwin, GM, Geddes, JR. Lithium toxicity profile: a systematic review and meta-analysis. Lancet 2012; 379: 721–8.
22 Boden, R, Lundgren, M, Brandt, L, Reutfors, J, Andersen, M, Kieler, H. Risks of adverse pregnancy and birth outcomes in women treated or not treated with mood stabilisers for bipolar disorder: population based cohort study, BMJ 2012; 345: e7085.
23 Bergink, V, Kushner, SA. Lithium during pregnancy. Am J Psychiatry 2014; 171: 712–5.
24 James, L, Barnes, TR, Lelliott, P, Taylor, D, Paton, C. Informing patients of the teratogenic potential of mood stabilizing drugs: a case note review of the practice of psychiatrists. J Psychopharmacol 2007; 21: 815–9.
25 Yonkers, KA, Wisner, KL, Stowe, Z, Leibenluft, E, Cohen, L, Miller, L, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004; 161: 608–20.
26 Galbally, M, Roberts, M, Buist, A, Perinatal Psychotropic Review Group. Mood stabilizers in pregnancy: a systematic review. Aust NZ J Psychiatry 2010; 44: 967–77.
27 Gentile, S. Lithium in pregnancy: the need to treat, the duty to ensure safety. Expert Opin Drug Saf 2012; 11: 425–37.
28 Bergink, V, Bouvy, PF, Vervoort, JSP, Koorengevel, KM, Steegers, EAP, Kushner, SA. Prevention of postpartum psychosis and mania in women at high risk. Am J Psychiatry 2012; 169: 609–15.
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Lithium dosing strategies during pregnancy and the postpartum period

  • Richard Wesseloo (a1), André I. Wierdsma (a1), Inge L. van Kamp (a2), Trine Munk-Olsen (a3), Witte J. G. Hoogendijk (a4), Steven A. Kushner (a4) and Veerle Bergink (a4)...
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