Initiating and monitoring lithium in bipolar I with suicide risk (MEQ)

(i) Offer lithium. Long-term RCTs/meta-analyses support lithium for bipolar relapse prevention (Geddes). BALANCE: lithium monotherapy and lithium–valproate combination both beat valproate monotherapy for any mood episode in bipolar I — so valproate alone is not an evidence-equivalent default. Cipriani 2013: lithium reduces suicides and all-cause deaths versus placebo in mood-disorder RCTs — highly relevant after a serious attempt. Frame as gold-standard maintenance with monitoring, not "too dangerous to discuss."[1][2][3]

(ii) Pre-start and consent. Baseline U&E/creatinine/eGFR, TFT, calcium, weight, pregnancy test when relevant, ECG if indicated; full drug history including OTC NSAIDs. Consent: narrow therapeutic index, need for 12-hour troughs and organ bloods, common effects (tremor, polyuria, weight), toxicity red flags, sick-day rules for severe vomiting/diarrhoea/dehydration, contraception/pregnancy plans. Confirm service can deliver monitoring.[4][6][7]

(iii) Initiation and TDM. Start low (e.g. lithium carbonate 250–500 mg/day product-dependent), titrate using clinical response and 12-hour trough levels at steady state. Maintenance scaffold often about 0.6–0.8 mmol/L; individualise. Early denser levels then regular level + eGFR/TFT/calcium calendar per local protocol (principles: more frequent early and after any clearance change).[6][7]

(iv) Interactions. Advise stopping casual ibuprofen; prefer paracetamol for simple analgesia if appropriate; warn that NSAIDs, ACEI/ARB, thiazides and dehydration raise lithium levels and can cause chronic toxicity. Provide written list and GP communication.[5][6]

(v) Toxicity. Stop lithium and precipitants; ABC; IV isotonic saline if volume depleted; serial levels, renal panel, ECG. Charcoal does not bind lithium. EXTRIP: ECTR recommended in severe poisoning and when impaired kidney function coexists with high concentration, or decreased consciousness/seizures/life-threatening dysrhythmias irrespective of level; HD preferred; watch rebound.[5][6]