Lithium and NSAIDS

While Lithium is one of the most commonly prescribed mood stabilizers for bipolar disorder, it is also a drug that requires careful monitoring and comes with a big list of do’s and don’ts. After all, there are many different things that can effect the amount of lithium in the bloodstream at any given time, and ideally we want that amount to be stable.

In a perfect world, someone who takes lithium needs to be fairly vigilant. What I mean by that is that though there are things we can’t exactly control that might impact our lithium levels (sweating a lot, vomiting, diarrhea, fever), there are some specific things we can do to avoid spikes or troughs in lithium levels. Things like eating a diet with a consistent amount of salt from day to day, avoiding having too much caffeine, remembering to take/taking lithium at the same time each day, and (today’s focus) avoiding NSAIDS.

Avoiding NSAIDS might sound simple at first, especially if you have no idea what an “NSAID” is. This acronym is short for Nonsteroidal Anti-Inflammatory Agents which boils down to the group of over-the-counter and prescription drugs used to treat aches, pains, and inflammation. These medications include:

  • Aspirin
  • Ibuprofen, which can be purchased generically or found in brand name products like Advil or Motrin
  • Naproxen, which can be found in Aleve or Naprosyn

There are also a whole host of prescription NSAIDS and you can find a comprehensive list created by the FDA here.

The reason NSAIDS shouldn’t be mixed with lithium is that they can raise the amount of lithium in the bloodstream. Those of us who take lithium have our blood drawn fairly often is to ensure that the amount of lithium in our blood stays at a therapeutic level (a safe amount that is in the range of what should help our symptoms). The tricky bit is that just above that therapeutic range is the danger zone, where lithium toxicity occurs.

Most people who have lithium levels in the therapeutic range seem to be able to manage small fluctuations, however big spikes (say, due to using an NSAID) can throw one into that danger area where toxicity begins. That is part of the reason it is so important to try to maintain a consistent lithium level, and while people who follow the guidelines that come with their prescription shouldn’t have a problem, those that go rouge (or who don’t know enough to avoid things like NSAIDS) can be putting themselves at risk for serious injury.

Usually over the counter medications of this type all have “NSAID” written in big letters on the box, so steering clear of purchasing them is fairly straightforward. The problem I have ran into (time and time again) is how often I am told to take ibuprofen by many different medical professionals, in regard to treating problems that aren’t related to mental health.

In fact, if I had a dollar for every time I’ve been told I should take an NSAID by a medical professional who knows what medications I am taking (hello, lithium!) I could at least take myself out for a nice dinner!

This has been the case when I have had oral surgery and seen doctors for anything from headaches to back pain to menstrual pain to you name it. 

This is where the vigilance I was talking about before comes in. Know your medications! Know what drugs interact with them! Because if you are relying on a doctor, nurse, dentist, even a pharmacist to catch a bad interactions before it happens, think again.

As someone who has firsthand experience with lithium overdose (due to lithium levels getting too high in my bloodstream) I have to admit (albeit a bit ashamedly) that I haven’t experienced lithium toxicity once, but twice now.

Here’s the thing… instead of relying on the warning labels on the lithium and everything I believed about avoiding NSAIDS up to that point, there was a time where I caved. It was just after I had my wisdom teeth taken out, and I shuffled up to the pharmacist with some ibuprofen (what my dentist had suggested would be my “best option” to help me heal quickly). Despite my groggy concern, this particular pharmacist told me it would be fine to mix lithium and ibuprofen, as long as I didn’t take “too much.”

At home I reconsidered the situation.

“I am in so much pain,” I thought, “and what could one or two little ibuprofen do? I mean, doctors keep nagging me about taking it and that pharmacist said it would be ok… maybe I should just take a couple.”

It was not exactly the most sane or rational moment I’ve ever had.

No, I didn’t slip into a coma (but I’m not saying that isn’t a possibility when mixing these drugs), I didn’t have any seizures (again, that is a possible sign of severe lithium toxicity). Basically, I got lucky. My lithium levels were bumped up to the early stages of toxicity with symptoms similar to the ones I had the first time. It was a weird and scary place to be, and despite my general brain confusion at the time I had the wits to toss out the rest of the ibuprofen.

I know how difficult it can be to keep things straight when it comes to psychiatric medications, especially in situations when they aren’t improving our rationality or our thoughts are clouded by pain or mood swings. I was pretty shaken by my experience and how quickly I was effected, especially since I had been told by so many doctors I would be fine. When it comes to NSAIDS and lithium, here are a few things you can do to avoid my mistake!

  1. If you keep NSAIDS in your home (for a partner, roommate, or relative’s use) store them in a separate area from your usual medications. This can help keep you from taking them by mistake.
  2. If you see a doctor who suggests “ibuprofen”, “NSAIDS”, or “an anti-inflammatory” to treat your pain, speak up! Remind them that you take lithium and cannot mix those drugs and ask if there is anything else they can suggest.
  3. If you are looking for an over the counter pain reliever, those containing acetaminophen (like Tylenol) can often be an option (as it doesn’t react the way an NSAID does with lithium), though these drugs have their own set of associated risks. Be sure to ask your doctor what is right for you.
  4. Educate yourself! Doing your best to understand the medications you take and how they effect you can potentially keep you from a life-threatening situation. If you have unexpected symptoms after making a change in diet, exercise/exertion, medication, or illness, there may be changes in your lithium level and you should contact your prescribing doctor.
  5. Protect yourself. You are the gatekeeper, the one who decides what things enter your body and what things don’t make the cut. Likewise, doctors can be overworked, distracted, or not have a lot of knowledge about psychiatric medications or disorders, so even if you are seeing someone you trust, it is ok to get a second opinion or do more research before ultimately adhering to their advice. If something seems wrong about the advice you’ve been given (or the medicine you’ve been prescribed) always, always ask about it.

After experiencing a minor level of lithium toxicity from taking an NSAID I thought it was important for me to share my experience and let people know that there are a lot of conflicting opinions about mixing lithium and NSAIDS, as far as from the doctors, pharmacists, and dentists I’ve seen. Many of the medications taken for psychiatric disorders are very potent, and it is extremely important to take note of the risks and interactions between them. Knowledge is a huge tool when it comes to the success of our health and welfare, and taking an active interest in your treatment and treatment options (for mental and physical health) is extremely important.

20 responses to “Lithium and NSAIDS

  1. Very well written. I didn’t realize NSAIDS were taboo for lithium. I don’t take Lithium but have considered asking my doctor to switch me to it because it’s so much cheaper than my current mood stabilizer

  2. I had no idea that lithium couldn’t be taken with NSAID’s. I have taken a heavy dose of Celebrex twice a day for the last two months and used to take Naprosyn before that. I will be getting in touch with my pdoc!

    • I think the issue is more of a “shouldn’t”, especially when taken impulsively (because it can raise the lithium level). Is it an issue when taken daily and the lithium level is being monitored by your doctor? Probably not, so sorry to scare you! Over a long period of time the change NSAIDS have on the lithium level stabilizes, it isn’t the same as hitting a big spike for taking it once or twice. Hope that makes sense!

      • I see. After some Googling, it did appear that lithium and NSAID’s should not be taken together. I will be asking my pdoc. In your next related post, you might want to try and be a little clearer (or maybe I am foggy-headed, I dunno).

  3. If you don’t mind, I’d like to play devil’s advocate here and say the dentist and doctors are right. There are warnings written everywhere not to take NSAIDs with lithium, but just as Rose (the commenter above) does, I take NSAIDs for pain every day with lithium, and it’s fine. I’ve never gone into lithium toxicity. I do agree that if you’re already taking a very high dose of lithium, it is possible, but that’s mostly because you’re not drinking enough water! Water is the best and only cure for avoiding lithium toxicity. And NSAIDs are much better for your liver than Tylenol, especially if you have take something on a regular basis. You have to listen to your own body, that’s what my doctor says. If you’re taking NSAIDs with lithium and you feel fine–then don’t sacrifice the NSAIDs just because someone’s telling you not to take them.

    • If you are taking them every day, your lithium level is still remaining stable -just higher than it might have been before. This is different than suddenly taking an NSAID after never having taken one on lithium, because levels can spike, making a previously stable lithium level unstable.

      I’m glad we can agree that we each need to know our own bodies and need to make our own decisions regarding what we need!

  4. I’ve had a history of NSAIDs and Lithium. I’m diabetic and I have a history of pain in my feet. I’ve been taking Naproxen every day for some time. When my psych doc prescribed Lithium the first couple of tests showed a high level for the dosage I was taking. Both my doc and I did some research and came up with the same conclusion, the Naproxen was causing the elevated level. So, we moved the Lithium dosage around until it got to the right level.

    Then, about 3 months ago, I started getting bloody noses, it go so bad that I ended up in the emergency room because it wouldn’t stop. Both the ER doc and my Ear Nose and Throat doc told me to stop taking the Naproxen. After I did that, my Lithium levels dropped and my mood started to get unstable. I talked to my psych doc about it, told him what was going on, and we changed my dosage around until the levels were right again.

    I think it is possible to take an NSAID while taking Lithium but it should be closely monitored by a doctor.

    • Good point, and I agree. I was thinking a lot more about the more “impulsive” situations where NSAIDS come in (like the one I experienced) when I wrote this, so thank you for illustrating how they can effect lithium levels over a longer period of time!

  5. Thank you for your post. I do not take Lithium but have had my own horror story of a journey with NSAIDS.

    I finally put my foot down when the last NSAID perscription came back and I read the ingrediants. MISOPROSTAL!!!!!! (to treat missed miscarriage, to induce labor, and to induce abortion.)

    Be VERY aware of EVERY ingredient in every so called NSAID. They put scary stuff in there, and have ABSOLUTLY NO MANDATE TO TELL YOU!!!

    • Misoprostol (Cytotec) is a drug originally approved to prevent NSAID induced ulcers. The other use (abortifacient) came about by exploiting a side effect of the drug. If you are female, then you should have been very carefully counseled about the risks of taking Arthrotec (diclofenac + misoprostol), as in, use 2 forms of birth control, get a pregnancy test every month, etc. If you were not counseled, or did not read the literature that hopefully came with the medication, then your shock is understandable. There are many drugs which can have terrible effects if not used correctly by educated consumers. That does not make the drug itself bad, or evil, because many times the reason that drug is on the market is that it is the only one that is effective for its indications.

  6. Thank you so much for this post. Your blog is always extremely well written, intelligent, and informative. It’s been years since I was on lithium, but I do not recall ever having been told to avoid NSAIDs. Thank God I did not experience toxicity. Perhaps having bipolar type II my dosage was comparatively low. Lithium is effective and inexpensive (since it is an element), but potentially toxic. Thank you again for your always educational posts.

  7. Reblogged this on Kitt O'Malley and commented:
    Sarah Sullivan’s information article about the effect of NSAIDs on lithium toxicity:

  8. Johnny Ojanpera

    Reblogged this on Love Songs And Mood Swings and commented:
    This is great information.

  9. David Rochlin

    Various stories and studies in progress are suggesting that NSAID drugs might be a treatment for Bipolar, that Bipolar might be related to inflammation. Consequently, the interest in combining it with lithium carbonate is going to spike.

  10. I had a problem with Lithium toxicity when prescribed a medication for blood pressure and a regimen of 2 Aleve twice a day by my GP. I didn’t think to ask if they might interact with Lithium and she, obviously, didn’t know. When I went in for symptoms of toxicity, they treated me like I’d a stroke. I even mentioned that I took Lithium. Wouldn’t take my Lithium levels though I ask her to. She said it didn’t look like a drug interaction, but something neurological. Scared me to death. I thought I’d had a stroke. Couldn’t walk straight, couldn’t ride my bike, couldn’t taste anything but metallic, dizzy and disoriented. So so scary. Finally called my psychiatrist who asked what I was taking and ordered my levels checked. They were through the roof. I spent a night in the hospital being monitored and getting fluids. It was a nightmare. I tried to keep going to that Doctor for a year. Finally I had to change because I couldn’t trust her. It was a 20 year relationship. The lesson for me was that GPs don’t know psychiatric drugs. I had to learn the hard way. I honestly thought I was going to die.

  11. Thank You. You have really helped allot, easy to understand, great advice. 11 out of 10

  12. I am prescribed Naproxin daily for chronic pain and inflammation issues and have been taking it for quite some time. My pdoc has a list of the RX’s I take, and just gave me a prescription yesterday for Lithium, to replace my Depakote. I am very nervous to start taking the Lithium, it makes me very wary after reading about the drug interactions. I am going to contact my doc before I fill this prescription. I have heard so many scary things about this drug……ugh!

  13. I had lithium toxicity recently. No idea why I was taking it as I had been and prescribed. All of a sudden I got really sick, my level was just under lethal levels (I got really lucky).

    I was just diagnosed with a chronic moderate pain condition and the Dr. keeps trying to put me on NSAIDS saying short term is fine. I’m glad to be my own gate keeper. It is sad that we have to keep such close eye.

    Thanks for the post

  14. I have taken motrin with lithium, the 900mg prescription ones. And i never had a problem. It was only for a few days because of my tooth. Also other times I have taken the two without a problem. If you do not take motrin for long periods of time, you will be fine.I think people get too carried away with the no motrin thing, really.Chill out.

  15. I’ve Ben on lithium for a while now and have recently been prescribed apo naproxen 500mg and I’ve taken a few but am unsure if there the reason why I’m so sick right now I didn’t keep any food down or sleep. and I’m just wondering if it’s a symptom.

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