Drug reference
Monotherapy for the treatment of moderate to severe manic episodes associated with bipolar disorder ▶BY MOUTH ▶Adult: Initially 10 mg twice daily, reduced to 5 mg twice daily, adjusted according to response Combination therapy for the treatment of moderate to severe manic episodes associated with bipolar disorder ▶BY MOUTH ▶Adult: Initially 5 mg twice daily, increased if necessary to 10 mg twice daily, adjusted according to response
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Dementia with Lewy Bodies Avoid abrupt withdrawal. cardiac disease. concurrent ECT (may lower seizure threshold). diuretic treatment (risk of toxicity). elderly (reduce dose). epilepsy (may lower seizure threshold). myasthenia gravis. psoriasis (risk of exacerbation). QT interval prolongation. review dose as necessary in diarrhoea. review dose as necessary in intercurrent infection (especially if sweating profusely). review dose as necessary in vomiting. surgery CAUTIONS, FURTHER INFORMATION ▶Long-term use Long-term use of lithium has been associated with thyroid disorders and mild cognitive and memory impairment. Long-term treatment should therefore be undertaken only with careful assessment of risk and benefit, and with monitoring of thyroid function every 6 months (more often if there is evidence of deterioration). The need for continued therapy should be assessed regularly and patients should be maintained on lithium after 3–5 years only if benefit persists.
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Addison’s disease. cardiac disease associated with rhythm disorder. cardiac insufficiency. dehydration. family history of Brugada syndrome. low sodium diets. personal history of Brugada syndrome. untreated hypothyroidism
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→Appendix 1: asenapine
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▶Common or very common Anxiety. appetite increased. fatigue. muscle rigidity. nausea. oral disorders. taste altered ▶Uncommon Bundle branch block. dysarthria. dysphagia. hyperglycaemia. sexual dysfunction. syncope ▶Rare or very rare Accommodation disorder. rhabdomyolysis ▶Rare or very rare Nephropathy ▶Frequency not known Abdominal discomfort. alopecia. angioedema. appetite decreased. arrhythmias. atrioventricular block. cardiomyopathy. cerebellar syndrome. circulatory collapse. coma. delirium. diarrhoea. dizziness. dry mouth. electrolyte imbalance. encephalopathy. folliculitis. gastritis. goitre. hyperglycaemia. hyperparathyroidism. hypersalivation. hypotension. hypothyroidism. idiopathic intracranial hypertension. leucocytosis. memory loss. movement disorders. muscle weakness. myasthenia gravis. nausea. neoplasms. nystagmus. peripheral neuropathy. peripheral oedema. polyuria. QT interval prolongation. reflexes abnormal. renal disorders. renal impairment. rhabdomyolysis. seizure. sexual dysfunction. skin reactions. skin ulcer. speech impairment. taste altered. thyrotoxicosis. tremor. vertigo. vision disorders. vomiting. weight increased SIDE-EFFECTS, FURTHER INFORMATION Overdose Signs of intoxication require withdrawal of treatment and include increasing gastro-intestinal disturbances (vomiting, diarrhoea), visual disturbances, polyuria, muscle weakness, fine tremor increasing to coarse tremor, CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness, stupor); abnormal reflexes, myoclonus, incontinence, hypernatraemia. With severe overdosage seizures, cardiac arrhythmias (including sino-atrial block, bradycardia and first-degree heart block), blood pressure changes, circulatory failure, renal failure, coma and sudden death reported. For details on the management of poisoning, see Lithium, under Emergency treatment of poisoning p. 1430.
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Use only if potential benefit outweighs risk— toxicity in animal studies. Avoid if possible, particularly in the first trimester (risk of teratogenicity, including cardiac abnormalities). Dose adjustments Dose requirements increased during the second and third trimesters (but on delivery return abruptly to normal). Monitoring Close monitoring of serum-lithium concentration advised in pregnancy (risk of toxicity in neonate).
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Avoid—no information available. Present in milk and risk of toxicity in infant—avoid.
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Manufacturer advises caution in Nervous system moderate impairment; avoid in severe impairment (risk of increased exposure).
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Use with caution if eGFR less than 15 mL/minute/1.73 m2—no information available. Caution in mild to moderate impairment. Avoid in severe impairment. Monitoring In renal impairment monitor serum-lithium concentration closely and adjust dose accordingly.
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Manufacturer advises effective contraception during treatment for women of child bearing potential.
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▶Serum concentrations Lithium salts have a narrow therapeutic/toxic ratio and should therefore not be prescribed unless facilities for monitoring serum-lithium concentrations are available. Samples should be taken 12 hours after the dose to achieve a serum-lithium concentration of 0.4–1 mmol/litre (lower end of the range for maintenance therapy and elderly patients). A target serum-lithium concentration of 0.8–1 mmol/litre is recommended for acute episodes of mania, and for patients who have previously relapsed or have sub- syndromal symptoms. It is important to determine the optimum range for each individual patient. g Routine serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year, and every 6 months thereafter. Patients who are 65 years and older, taking drugs that interact with lithium, at risk of impaired renal or thyroid function, raised calcium levels or other complications, have poor symptom control or poor adherence, or whose last serum-lithium concentration was 0.8 mmol/litre or higher, should be monitored every 3 months. h Additional serum-lithium measurements should be made if a patient develops significant intercurrent disease or if there is a significant change in a patient’s sodium or fluid intake. ▶Manufacturer advises to assess renal, cardiac, and thyroid function before treatment initiation. g An ECG is recommended in patients with cardiovascular disease or risk factors for it. Body-weight or BMI, serum electrolytes, and a full blood count should also be measured before treatment initiation. ▶Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment, and more often if there is evidence of impaired renal or thyroid function, or raised calcium levels. h Manufacturer also advises to monitor cardiac function regularly.
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There can be variation in the licensing of different medicines containing the same drug. Sublingual tablet CAUTIONARY AND ADVISORY LABELS 2, 26 ▶Sycrest (Lundbeck Ltd) Asenapine (as Asenapine maleate) 5 mg Sycrest 5mg sublingual tablets sugar-free | 60 tablet P £102.60 DT = £102.60 Asenapine (as Asenapine maleate) 10 mg Sycrest 10mg sublingual tablets sugar-free | 60 tablet P £102.60 DT = £102.60 ANTIPSYCHOTICS › LITHIUM SALTS Lithium salts f
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Patient or carer should be given advice on how to administer asenapine sublingual tablet. Patients should be advised to report signs and symptoms of lithium toxicity, hypothyroidism, renal dysfunction (including polyuria and polydipsia), and benign intracranial hypertension (persistent headache and visual disturbance). Maintain adequate fluid intake and avoid dietary changes which reduce or increase sodium intake. Lithium treatment packs A lithium treatment pack should be given to patients on initiation of treatment with lithium. The pack consists of a patient information booklet, lithium alert card, and a record book for tracking serum-lithium concentration. Packs may be purchased from . 3M . 0845 610 1112 . nhsforms@mmm.uk.com Driving and skilled tasks May impair performance of skilled tasks (e.g. driving, operating machinery). eiiii F 374
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While there is no clear evidence of withdrawal or rebound psychosis, abrupt discontinuation of lithium increases the risk of relapse. If lithium is to be discontinued, the dose should be reduced gradually over a period of at least 4 weeks (preferably over a period of up to 3 months). Patients and their carers should be warned of the risk of relapse if lithium is discontinued abruptly. If lithium is stopped or is to be discontinued abruptly, consider changing therapy to an atypical antipsychotic or valproate.
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Initially 10 mg twice daily, reduced to 5 mg twice
First-line fragment. Read the complete Indications and Dose section above.
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Initially 5 mg twice daily, increased if necessary
First-line fragment. Read the complete Indications and Dose section above.
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