1. Lithium side effects: 
-25%-100% chance of getting hypothyroidism after taking it for 10 years, but not worrisome because you can just give synthroid. In fact, this is even better because it drops TSH and depressed people with TSH < 1 have fewer depressive sx.
-Mechanism of action is via gpcr, tsh, also iodine competition.

-10% get renal insufficiency at 10 years. 

-Tremor can develop with therapeutic doses, but worsens with higher levels.

-Nephrogenic DI: via effects on vasopressin. 

-3 labs you get for someone on lithium- Cr, TSH, Li levels. 

2. Lithium & pregnancy: 

-Li levels can vary a lot in pregnancy because of relatively rapid changes in total body water content 

-Corticosteroids given to accelerate fetal lung development can worsen psychosis (mania and depression)

-Risk of ebstein's anomaly and ASD are highest in first trimester; after that point, it can cause transient neonatal hypothyroid and goiter. 

-Absolute risk of ebstein's anomaly is very, very low
-Watch out for pre-eclampsia, because if you tank someone's kidneys they won't be able to clear the lithium and it can quickly accumulate to toxic levels 

3. Lithium Toxicity: get an EKG, Cr, Li level. 

-Tremor (correlates with level) 

-Altered mental status

-Diarrhea

-Kidneys can shut down-- problematic because lithium is 90% renally cleared (10% gi tract). 

-2nd/3rd deg heart block. Immediately check EKG in someone with suspected Li tox. 

-Levels normally 0.8 to 1.2. Toxicity can start at 1.5. 

-If its mildly toxic you give fluids, if its bad you have to dialyze. 

-Li levels remain higher, longer in the brain than elsewhere in the body so it takes longer to get over those effects. 

-Most common reason for lithium tox is inadvertent dehydration, causing mild renal impairment, or the addition of new meds-- NSAIDs and diuretics. 

4. Suicide risk is lower with people who take lithium, compared with other drugs. 

5. Valproate: 

-sedating

-a/symptomatic transaminitis

-elevated ammonia (can happen out of the blue even if you have been taking this drug for a long time) 

-pancreatitis. 

-Risk of birth defects is 10-15%. This drug is contraindicated in women of childbearing age who are not on a reliable birth control. Period, fullstop. 

6. Carbamazepine: 

-autoinducer, induces own destruction so the levels will drop over time. 

-Causes direct BM suppression

-Hepatotox

-Rash 

-Can cause ataxia, blurred vision, 

-Treats bipolar, trigeminal neuralgia, migraines. 

7. Lamotrigine 

-Works really well for depressed stage of bipolar, doesn't induce mania

-10% will get a rash, 1% of those people will get SJS. Rash risk proportional to rate of drug increase, so titrate 25mg slowly to 200. 

-First signs of SJS will be in mucosa, hands, feet; tell your patients to watch out for blisters in their mouth. 

8. Augmentation strategies for depression: 

-Lithium

-Abilify

-Synthroid 

-Stimulants (addictive; use only in refractory depression, or in terminal patients)

9. Risk factors for worsening QT prolongation: 

-Low K

-Low Mg

-Low Ca

-Replenish electrolytes aggressively in people taking meds that prolong QT... otherwise you will send them into torsades. Poor form. 

-Other meds that prolong QT (amiodarone, tramadol)

-IV haldol is the worst at this, definitely do not use in someone who's QT is >500

10. Antipsychotics: 

-Higher potency - worse EPS side effects, less Anticholinergic

-Lower potency - better EPS, worse anticholinergic