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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 20 of 20. This is the beginning of the thread.
Posted by mogger on December 27, 2014, at 21:29:41
Hi there,
I have been blown away as to how helpful lithium has been for my depression. I have been at 1500mgs a day for a depression (5 300mg tablets of the ER version) and feel great however my libido has plummeted. My doctor has been away and he mentioned before he left that we could try lowering the lithium carbonate (controlled release) if the decreased libido does not subside but I can't get in touch with him as he is a away to ask him how to proceed. As these are extended release tablets you can't split them correct? I want to get down to the 1350mgs so I was thinking I could either alternate taking 4 tablets one night and 5 tablets the next to get an average of 1350 or just split the tablet? Sorry if this is complicated but any help would be appreciated. Many thanks.
Posted by SLS on December 28, 2014, at 6:36:54
In reply to lithium dosing question (controlled release), posted by mogger on December 27, 2014, at 21:29:41
> Hi there,
>
> I have been blown away as to how helpful lithium has been for my depression. I have been at 1500mgs a day for a depression (5 300mg tablets of the ER version) and feel great however my libido has plummeted. My doctor has been away and he mentioned before he left that we could try lowering the lithium carbonate (controlled release) if the decreased libido does not subside but I can't get in touch with him as he is a away to ask him how to proceed. As these are extended release tablets you can't split them correct? I want to get down to the 1350mgs so I was thinking I could either alternate taking 4 tablets one night and 5 tablets the next to get an average of 1350 or just split the tablet? Sorry if this is complicated but any help would be appreciated. Many thanks.I would not alternate days. Despite your using a controlled release form of lithium, I would expect blood levels to fall of quickly once fully absorbed. I don't like pulsing drugs. (Ketamine might be an exception). Why not just move down to 1200 mg/day? You can always go back up if necessary. I will be curious to see if the sexual side effects mitigate at all.
- Scott
Posted by mogger on December 28, 2014, at 20:44:43
In reply to Re: lithium dosing question (controlled release) » mogger, posted by SLS on December 28, 2014, at 6:36:54
Thank you Scott I will do as you say. I went down to 1200mgs last night so we shall see. At 1500mg my blood level is 1.0 which is ideal for my Dr. and 1200mg will be .8 as I have been tested at 1200mg before. Hope that will suffice. I am not manic actually quite the opposite ocd/anxiety/depression but I am clearly in the bipolar spectrum as Lithium is one of the most helpful meds since the addition of Lamotrigine for me. Thank you for your advice. Did you ever try Metformin?
Joseph
Posted by SLS on December 29, 2014, at 7:50:48
In reply to Re: lithium dosing question (controlled release) » SLS, posted by mogger on December 28, 2014, at 20:44:43
> Thank you Scott I will do as you say. I went down to 1200mgs last night so we shall see. At 1500mg my blood level is 1.0 which is ideal for my Dr. and 1200mg will be .8 as I have been tested at 1200mg before. Hope that will suffice. I am not manic actually quite the opposite ocd/anxiety/depression but I am clearly in the bipolar spectrum as Lithium is one of the most helpful meds since the addition of Lamotrigine for me.
Good luck with the lithium. For me, lithium 300 - 450 mg/day produces a noticeable antidepressant effect. My blood level can't be any more than 0.40 mEq/L. Anything higher than that, and I experience flat affect, apathy, and perhaps a general worsening of depression.
Is mania or rapid-cyclicity an issue with you?
Another reason why I continue to take lithium is that it might help to prevent the development of Alzheimers.
> Did you ever try Metformin?
No, but I will push to try it. Among its other potential metabolic benefits, metformin should reduce my triglycerides, which are elevated due to my taking Abilify. It might even help to prevent Alzheimers by reducing chronically high insulin levels (hyperinsulinemia), which is a factor in the development of diabetes type 2.
Thanks for reminding me...
:-)
- Scott
Posted by mogger on December 29, 2014, at 8:48:10
In reply to Re: lithium dosing question (controlled release) » mogger, posted by SLS on December 29, 2014, at 7:50:48
Thanks Scott,
I really think it will put a stop to your abilify weight gain which would be uplifting for you in itself?!
Thanks for the tip. I hope the drop from 1500 to 1200mg of lithium doesn't have a huge impact on my mood. Do you think it is that big of a jump from 1.0 to .8? Feel a little rough this morning but hopefully it is just adjusting. I know maintenance doses are usually between 900-1200mg. Hope so. No manic episodes just unipolar depression but waves of frustration with ocd so could be a mixed episode. Thank you Scott,
Joseph
Posted by Mogger on December 30, 2014, at 17:49:16
In reply to Re: lithium dosing question (controlled release) » SLS, posted by mogger on December 29, 2014, at 8:48:10
Scott if you don't mind me asking. I see maintenance doses of lithium are around 900-1200mgs. I am 1.0 at 1500 mgs. My question is how variant can doses be with lithium? Meaning do you think I might be able to get away with 900 mg at one point as my blood level was at .6 when I got a blood test at 900? Hoping that there can be an effective range below 1.0. Thanks Scott,
Joseph
Posted by SLS on December 30, 2014, at 20:27:44
In reply to Re: lithium dosing question (controlled release) » mogger, posted by Mogger on December 30, 2014, at 17:49:16
> Scott if you don't mind me asking. I see maintenance doses of lithium are around 900-1200mgs. I am 1.0 at 1500 mgs. My question is how variant can doses be with lithium? Meaning do you think I might be able to get away with 900 mg at one point as my blood level was at .6 when I got a blood test at 900? Hoping that there can be an effective range below 1.0. Thanks Scott,
>
> JosephI think most doctors would allow for a level of 0.8 for maintenance. If mania is a problem, 0.6 is probably too low. 1200 mg/day for you seems reasonable.
If 1200 mg/day is too low, how would you know it? What would be your first sign of a return of symptoms?
- Scott
Posted by mogger on December 30, 2014, at 20:33:59
In reply to Re: lithium dosing question (controlled release) » Mogger, posted by SLS on December 30, 2014, at 20:27:44
The way I would clearly know is the return of a plummet in mood. What it is doing is keeping my mood stable instead of being unipolar depression. I have no mania never have just ocd and depression. I suppose I shall have to wait and see won't I. Hopeful to hear you say .8 might be ok. I am on day 4 of 1200mg from 1500mg. Slight dip in mood but maybe withdrawals that will even out? Haven't felt withdrawals from lithium before so don't know what to expect. Thanks Scott,
Joseph
Posted by SLS on December 30, 2014, at 23:05:37
In reply to Re: lithium dosing question (controlled release) » SLS, posted by mogger on December 30, 2014, at 20:33:59
> The way I would clearly know is the return of a plummet in mood. What it is doing is keeping my mood stable instead of being unipolar depression. I have no mania never have just ocd and depression. I suppose I shall have to wait and see won't I. Hopeful to hear you say .8 might be ok. I am on day 4 of 1200mg from 1500mg. Slight dip in mood but maybe withdrawals that will even out? Haven't felt withdrawals from lithium before so don't know what to expect. Thanks Scott,
>
> Joseph
Hi Joseph.I am unclear as to what drugs you are currently taking.
It is possible that your brain needs a day or two to adjust. You can always resume 1500 mg/day if you continue to deteriorate. Have a little patience, though. Perhaps you lie somewhere along the bipolar spectrum. Did you ever rapid-cycle? When was the last time that you felt well? At what age did you first get depressed? Was there any anxiety?
There was some work done 10 or more years ago at Harvard / Massachusetts General reporting the use of low-dosage lithium in the treatment of unipolar depression. The study group found that lithium at dosages of 300 - 600 mg/day were effective when used to augment antidepressants. Most people settled on 450 mg/day. I don't know of any such studies of lithium when used as monotherapy.
I might try to lower my dosage of lithium from 450 mg/day to 300 mg/day in order to see if I feel more motivated at the lower dosage. I want to get a blood level first, though.
- Scott
Posted by mogger on December 31, 2014, at 15:04:38
In reply to Re: lithium dosing question (controlled release) » mogger, posted by SLS on December 30, 2014, at 23:05:37
Thanks Scott.
I haven't felt well since I was about 13 and I am now 39. Ever since I was little I have had anxiety which then turned into OCD in High School and University. At about 15 was when I began to become very depressed (unipolar). The classic OCD physical compulsions stopped when I added inositol to my cocktail after University. So in answer to your question perhaps I am in the bipolar spectrum with micro cycling that occurs with my anxiety as it ebbs and flows. I am on a lot of medication as you see but by trial and error each has it's benefits as I have come off each of them at various points. Thank you for the research about low doses of lithium working that is hopeful. I am a tough case for my psychiatrist as I have had limited benefit from medicine. What did/does help is lamotrigine. When that was added I was finally able to get out of bed and feel somewhat better. That was back in 97. The addition of lithium has been remarkable but the sexual side effects are pretty rough. It is by far the best I have felt in years. As you see it could be that the addition to my meds that already cause sexual side effects (zoloft, zyprexa and clonazepam) could have created this perfect storm. I have tried decreasing zoloft and zyprexa but felt really rough. Anyways many thanks for your advice and help, happy new year to you,
Joseph
zyprexa 5mg
zoloft 150mg
lithium 1200mg
remeron 60mg
buspar 90mg
clonazepam 1mg
lamotrigine 300mg
Posted by mogger on January 1, 2015, at 22:08:26
In reply to Re: lithium dosing question (controlled release) » SLS, posted by mogger on December 31, 2014, at 15:04:38
Scott,
I have one question if you don't mind answering and then I promise I will stop bothering you! When I started 6 years ago inositol my libido dropped adding to all this. I noticed that lithium increases the amount of inositol in the brain? I could be reading the excerpt wrong below but just wonder your thoughts on it. It is from wikipedia. Thanks Scott,
Joseph
"Lithium treatment has been found to inhibit the enzyme inositol monophosphatase, leading to higher levels of inositol triphosphate.[63] This effect was enhanced further with an inositol triphosphate reuptake inhibitor. Inositol disruptions have been linked to memory impairment and depression.
In 2014, it was proposed that lithium treatment works by affecting calcium signaling by antagonizing N-methyl-d-aspartate (NMDA) receptors and inhibing inositol monophosphatase (IMP) to synergistically block the inflow of calcium into neurons from both external and internal calcium stores.[64]"
Posted by ed_uk2010 on January 5, 2015, at 2:37:21
In reply to Re: lithium dosing question (controlled release) » Mogger, posted by SLS on December 30, 2014, at 20:27:44
Hi,
>I am 1.0 at 1500 mgs. My question is how variant can doses be with lithium? Meaning do you think I might be able to get away with 900 mg at one point as my blood level was at .6 when I got a blood test at 900?
>Hoping that there can be an effective range below 1.0.
I think there will be. Maintaining a level of 1.0 is uncommon beyond the first few months of treatment, in any condition. This level is mainly used for stabilisation when acutely unwell. Levels of 0.7 to 0.8 are common for maintenance in bipolar I disorder, with 0.8 being common for those with a history of severe mania. 0.6-0.7 is more usual for those with a history of mainly hypomania eg. bipolar II disorder. 0.4-0.6 is common for maintenance in predominantly depressed pts with no recent mania or hypomanic episodes. Around ~ 0.4 is not uncommon for maintenance in unipolar depression, as an augmenting agent. As an aside, it is no longer common practice to aim for more than 1.0 in any condition, including acute mania - where 0.8-1.0 is preferable. Lithium is rarely the drug of first choice for stabilisation of acute mania these days, antipsychotics and Depakote are more popular for this purpose.... with lithium being a common combination strategy.... and a useful maintenance drug. Lithium monotherapy is too slow to reliably control acute mania on its own, and levels above 1.0 have been generally replaced by the use of additional medication such as Depakote and APs.
Maintaining levels above 0.7 on a long term basis is probably best avoided after stability has been achieved unless it's clear than lower levels are ineffective - which is most likely when there is a history of severe manic episodes. Such levels may be poorly tolerated in the long-term, particularly with respect to kidney function. Thyroid dysfunction is common in the long term and requires monitoring - symptoms may be confused with a relapse.
After several years of use (or shorter if 'acute phase' blood levels are maintained), a gradual deterioration in kidney function is common. Since lithium is excreted almost entirely via the kidneys, a decrease in dose is often possible over time. Elderly people who've taken Li for years often have very low maintenance dose.
>I see maintenance doses of lithium are around 900-1200mgs. I am 1.0 at 1500 mgs
>I see maintenance doses of lithium are around 900-1200mgs. I am 1.0 at 1500 mg.If I were you I'd probably want to reduce 1200mg now, with a target level of 0.8. After several months, if you are well, I would consider taking around 1000mg (exact dose depending on brand), with a target level of ~0.7. If still well after several more months, I would want to look at reducing to around 900mg. Over the next year or so, 900mg might permit a level of 0.6-0.7, with is usually satisfactory for those with no history of mania - and could be ideal for you in several months time, maybe a year - I suggest 1200mg for now. Given your particularly good response to a high dose, I suspect that aiming for 0.4-0.5 would be too low for you; this sort of range is more appropriate for maintenance/augmentation in unipolar depression in those who find high doses unpleasant and mood flattening.
In practice, doses up to a maximum of ~900mg are the norm for long-term maintenance, some need as little as 300mg (but almost certainly not you!), and occasionally less in the elderly. . 1200-1500mg is generally used in the acute phase only (and never in the elderly), with ~1000mg-1200mg being relatively uncommon in the long term (beyond the subacute phase) even in young people.... such doses were only common for the maintenance of bipolar disorder many years ago when lithium was more likely to be used as monotherapy due to fewer options being available for combination. Doses given in manufacturer's product literature are often misleading and out-of-date.
>Halving tablets.
It depends on the brand. All modified-release lithium tablets which can be broken into two equal halves have a score line down the middle. These tablets are designed to be halved without damaging the modified release mechanism. Obviously, the should not be crushed. In the UK, the brands Priadel MR and Camcolit MR can be halved, for example. This is very useful because it allows adjustments in steps as small as 100mg ie. half a 200mg Priadel tablet. I see that Eskalith CR 450mg tablets are scored, but I don't know about other brands which are not available here.
>Dosage interval
Lithium is generally given twice a day in the acute phase and once or twice a day for maintenance.
Alternate day dosing or different doses on alternate days is normally used only in patients who have a long half-life due to impaired kidney function. The fact that you require 1500mg (a lot) to produce a level of 1.0 suggests very good kidney function, and probably a half-life at the lower end of the range. Those with poor kidney function would reach 1.0 on a much lower dose.
Hope this helps.
Posted by SLS on January 5, 2015, at 4:45:47
In reply to Re: lithium and inositol » mogger, posted by mogger on January 1, 2015, at 22:08:26
Hi Joseph.
> I have one question if you don't mind answering and then I promise I will stop bothering you! When I started 6 years ago inositol my libido dropped adding to all this. I noticed that lithium increases the amount of inositol in the brain? I could be reading the excerpt wrong below but just wonder your thoughts on it. It is from wikipedia. Thanks Scott,
I'm afraid I can't help you out with this one. I am not at all familiar with the functions of inositol in this context. It would seem that lithium inhibits the production of inositol and reduces signal transduction. That's about all I can glean from this information.
- Scott--------------------------------------
> "Lithium treatment has been found to inhibit the enzyme inositol monophosphatase, leading to higher levels of inositol triphosphate.[63] This effect was enhanced further with an inositol triphosphate reuptake inhibitor. Inositol disruptions have been linked to memory impairment and depression.
> In 2014, it was proposed that lithium treatment works by affecting calcium signaling by antagonizing N-methyl-d-aspartate (NMDA) receptors and inhibing inositol monophosphatase (IMP) to synergistically block the inflow of calcium into neurons from both external and internal calcium stores.[64]"
Posted by mogger on January 5, 2015, at 11:05:23
In reply to Re: lithium dosing question (controlled release), posted by ed_uk2010 on January 5, 2015, at 2:37:21
Thanks so much Ed you are a wealth of knowledge and I appreciate such a thorough response. I tried going down to 1200 for a week and my depression returned so I am back up to 1500 for the time being until my doctor and I can figure something out. For me lithium has been a life changer so I am grateful for it. It will just take some fiddling with as far as dosing to get things right. Many thanks again and happy new year to you,
Joseph
Posted by mogger on January 5, 2015, at 11:06:41
In reply to Re: lithium and inositol » mogger, posted by SLS on January 5, 2015, at 4:45:47
Thank you Scott! Hope you have your script for metformin soon. Let me know how it goes. It calms down my AP induced appetite tremendously.
Joseph
Posted by ed_uk2010 on January 6, 2015, at 9:22:59
In reply to Re: lithium dosing question (controlled release) » ed_uk2010, posted by mogger on January 5, 2015, at 11:05:23
Hi there! Happy new year to you too :) Very pleased hear how much you've improved.
>I tried going down to 1200 for a week and my depression returned so I am back up to 1500 for the time being until my doctor and I can figure something out. For me lithium has been a life changer so I am grateful for it. It will just take some fiddling with as far as dosing to get things right.
How long have you been on lithium? Perhaps you'll be able to re-try 1200mg in a few months time. I think you've only been on it a few weeks? It could be that you'll need to be stable for longer before considering any further adjustments.
Posted by mogger on January 6, 2015, at 9:32:18
In reply to Re: lithium dosing question (controlled release) » mogger, posted by ed_uk2010 on January 6, 2015, at 9:22:59
Good point Ed,
I have been on 1500 mg for about a month and started lithium back in November at 900mg, then 1200mg and then 1500mg as I say for about a month. I am hoping that will be the case that I can drop down. Many thanks for your help. Hope you are doing well,
Joseph
Posted by ed_uk2010 on January 7, 2015, at 7:43:07
In reply to Re: lithium dosing question (controlled release) » ed_uk2010, posted by mogger on January 6, 2015, at 9:32:18
> Good point Ed,
>
> I have been on 1500 mg for about a month and started lithium back in November at 900mg, then 1200mg and then 1500mg as I say for about a month. I am hoping that will be the case that I can drop down. Many thanks for your help. Hope you are doing well,
>
> JosephHi Joseph,
I'm not too bad thanks. I think it looks like you'll need to stay on the same dose for several months before looking at possibly changing anything. Do you have any side effects?
Posted by mogger on January 9, 2015, at 10:32:40
In reply to Re: lithium dosing question (controlled release) » mogger, posted by ed_uk2010 on January 7, 2015, at 7:43:07
Good to hear you are not too bad Ed. I have no side effects whatsoever besides decreased libido/sexual dysfunction. I am trying to creap down on my sertraline slowly as I believe that will help but I am keeping my fingers crossed. Hope you are improving.
Joseph
Posted by ed_uk2010 on January 9, 2015, at 13:46:44
In reply to Re: lithium dosing question (controlled release) » ed_uk2010, posted by mogger on January 9, 2015, at 10:32:40
> Good to hear you are not too bad Ed. I have no side effects whatsoever besides decreased libido/sexual dysfunction.
That could be from several meds I think. Hope the decrease in sertraline is helpful. Let us know.
This is the end of the thread.
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