Tag Archives: lithium toxicity

A Missed Dose

In the last 28 years I have not skipped or missed a dose of medication.

Wednesday night as I huddled in the ER (for the second time in two weeks) the team of doctors and nurses surrounding me looked started as I told them this fact. I guess it never occurred to me that this might be unusual in any way, but in an emergency room where they’re relatively used to patients with mental illness suddenly stopping their medication and sailing into big episodes that might be landing them there… well, I quickly felt that the staff probably did not believe me.

It is true, though. And while most people would try to praise this as an act of good self control or healthy living I fear that the truth is actually somewhere in the realm of the opposite.

You see… when I was 17 I was taking an antidepressant that (little did I know) was slowly dissolving any semblance of sanity I had left at the time. Despite the fact that it was making me worse and worse, I took it religiously. At the time I was being treated for obsessive compulsive disorder, and frankly there were many things in my life that I needed to do religiously or I firmly believed I would die very suddenly.

I have always been the sort of person that once a routine has been established I have a very very hard time deviating from that routine, even when it is harming me. For the last several months, for example, I have eaten one large fried egg over medium and a slice of buttermilk toast for breakfast every day (at least, every day that I could eat). There are times when I struggle with the notion that I probably shouldn’t eat so many eggs (hello cholesterol), but the best I can do when I feel really ballsy is switch out the buttermilk toast for an english muffin. Not eating this breakfast is… well… wrong.

Anyway, at 17, taking said antidepressant religiously and spiraling into a very dark, weird place I was quickly in an psychiatric inpatient hospitalization situation. Within 24 hours I became outrageously ill, and I’m talking the most ill I had ever felt in my life up to (and even after) that point. Eight hours of uncontrollable vomiting and dry-heaving, and dizziness to the point of being unable to even dress myself.

This also happened to be the time when one of the nurses decided to display an abuse of power, laughing at my sudden illness, yelling at me, accusing me of having an eating disorder, and refusing to help me for several hours. By the time I was able to deduce that I was having withdrawals from my usual medication regimen, the damage was already done, and the fear this experience had instilled in me took root very firmly.

I could not and would not ever stop taking any medication suddenly for any reason again if it was in my power, and the paranoia and fear that manifested from this situation has often swung me into the danger zone in the opposite direction. What I mean is that while I don’t feel compelled to stop taking my medication suddenly (or act cavalier about keeping up with taking it), I have become even more obsessive and paranoid about taking these pills. To top it off, I’ve had many instances of not being able to remember if I took them or not, and then accidentally taking them several times over just in case I had forgotten.

Realistically this doesn’t provide a much more safe environment, and suffice it to say that withdrawal of many drugs is probably extremely preferable to overdose.

I had been feeling really rough on wednesday, a lot of the dizziness and nausea from the week previous had returned. By the time I took my dosage of lithium for the night, I vomited it back up in a matter of minutes.

Though I had already been advised earlier in the day to go to the ER by my doctor to receive intervenes nausea medication and fluids, it wasn’t until the panic of suddenly being lithium free for the first night in four years set in that I was heading straight for the hospital. I was certain that if I didn’t feel horribly sick already (and I did) I was headed for a night of fire and brimstone.

By the time I got to the ER I was hitting patches of uncontrollable crying. I was terrified, and even though the seasoned internet sage reported I would likely only experience mental and mood symptoms from the missed dose, the way my body reacts to medications (or lack thereof) has been significantly different than the norm in almost every situation. I had no way to know what might happen next.

So the doctors dealt with the nausea and the fluids, and when I brought the idea of “missing” (or losing, rather) my lithium dose that night the doctor instinctively told me to take it again when I got home.

Now, given my history, this is something I had already considered myself. However, I had been pretty dehydrated for a week or so and I was concerned because dehydration can lead to lithium toxicity. When I said this to the doctor, I also mentioned that I have already experienced lithium toxicity before and wouldn’t like to do it again. His conclusion was that they would check my lithium levels in the blood they had already taken earlier when I checked in.

Thirty minutes later he walked into my room and commented that my lithium levels were a bit higher than he expected. He advised I wait until the next night to continue with my lithium.

Among the papers I was given when I headed home for the night was the lab report that included my lithium level. It was nearly twice my regular level.

When I read that I was immediately glad I had gone to the ER and not just taken the lithium again. If I had, I would have undoubtedly experienced lithium toxicity, as I was nearly there already. For the first time I felt grateful for having vomited… and I can’t help but feel slightly mystified at the possibility that my body was rejecting the excess lithium all on its own.

I am now back on track with my medications and working with a GI specialist to try to pinpoint the source of my stomach issues. It is a little funny how not eating can make eating something as basic as plain white rice taste amazing!

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.