Treatment of "on-off" phenomena with lithium

Lithium-associated movement disorder: A literature review

In 1949, Cade described “sedative effects” after injecting guinea pigs intraperitoneally with lithium (LTM) carbonate. Based on his experiments, he began treating psychiatric patients with LTM. This literature review aims to evaluate the clinical epidemiological profile, pathological mechanisms, and management of LTM-associated movement disorder (MD). Relevant reports in six databases (Excerpta Medica, Google Scholar, Latin American and Caribbean Health Sciences Literature, Medline, Scientific Electronic Library Online, and ScienceDirect) were identified and assessed by two reviewers without language restriction from 1949 to 2021. A total of 250 reports containing 1100 individuals who developed MD associated with LTM were identified. The MDs encountered 148 parkinsonism (PKN), 114 dyskinesia (DKN), 97 myoclonus, 22 dystonia (DTN), 20 Creutzfeldt–Jakob-like syndrome, 11 akathisia, 10 restless legs syndrome (RLS) symptoms, 6 tics, 5 cerebellar syndromes, and 3 stuttering. In the subgroup of cases not clearly defined, there were 320 individuals with extrapyramidal symptoms, 135 with DTN, 37 with DKN, 24 with PKN, and 7 with RLS. Other 141 individuals were only described as presenting an abnormal involuntary movement without further explanation. The mean age was 53.06 years (standard deviation [SD]: 15.64) and the predominant sex was female, i.e., 56.20% (154/274). The mean LTM dose was 963.03 mg/day (SD: 392.03). The mean serum LTM level was 1.53 mEq/L (SD: 1.08). The median onset time was 3 months (1 day to 40 years). The mean recovery time was 0.94 months (SD: 0.87). 45.94% had a full recovery. LTM-induced MD was extensively reported in the literature. Only general terms were used in the majority of the reports. LTM polytherapy probably affected the identification of the MD cause.

Molecular actions and therapeutic potential of lithium in preclinical and clinical studies of CNS disorders

Lithium has been used clinically to treat bipolar disorder for over half a century, and remains a fundamental pharmacological therapy for patients with this illness. Although lithium's therapeutic mechanisms are not fully understood, substantial in vitro and in vivo evidence suggests that it has neuroprotective/neurotrophic properties against various insults, and considerable clinical potential for the treatment of several neurodegenerative conditions. Evidence from pharmacological and gene manipulation studies support the notion that glycogen synthase kinase-3 inhibition and induction of brain-derived neurotrophic factor-mediated signaling are lithium's main mechanisms of action, leading to enhanced cell survival pathways and alteration of a wide variety of downstream effectors. By inhibiting N-methyl-D-aspartate receptor-mediated calcium influx, lithium also contributes to calcium homeostasis and suppresses calcium-dependent activation of pro-apoptotic signaling pathways. In addition, lithium decreases inositol 1,4,5-trisphosphate by inhibiting phosphoinositol phosphatases, a process recently identified as a novel mechanism for inducing autophagy. Through these mechanisms, therapeutic doses of lithium have been demonstrated to defend neuronal cells against diverse forms of death insults and to improve behavioral as well as cognitive deficits in various animal models of neurodegenerative diseases, including stroke, amyotrophic lateral sclerosis, fragile X syndrome, as well as Huntington's, Alzheimer's, and Parkinson's diseases, among others. Several clinical trials are also underway to assess the therapeutic effects of lithium for treating these disorders. This article reviews the most recent findings regarding the potential targets involved in lithium's neuroprotective effects, and the implication of these findings for the treatment of a variety of diseases.

Lithium-induced neurotoxicity at serum lithium levels within the therapeutic range

OBJECTIVE

To report the occurrence of lithium-induced neurotoxicity and extrapyramidal symptoms at serum lithium levels within the therapeutic range.

CLINICAL PICTURE

On two occasions, a 73-year-old patient presented with symptoms of lithium-induced neurotoxicity and extrapyramidal symptoms when her serum lithium levels were within the therapeutic range.

TREATMENT AND OUTCOME

Both lithium-induced neurotoxicity and extrapyramidal symptoms resolved when lithium was withdrawn.

CONCLUSION

Even when serum lithium levels are within the therapeutic range, lithium-induced neurotoxicity may occur. Patients on neuroleptics and the elderly in particular may be more vulnerable to these side effects.

The effects of kainic acid and 6-hydroxydopamine lesions, metal ions and GTP on in vitro binding of the D-2 dopamine agonist, [3H]N-0437, to striatal membranes

The kinetic and pharmacological profiles of the potent and selective D-2 dopamine agonist 2-(N-propyl-N-2-thienylethylamino)-5-hydroxytetralin ([3H]N-0437) have recently been described. This report concerns the effects of chemical lesions and metal ions on the radioreceptor binding of [3H]N-0437. Kainic acid lesions reduced the maximum number of binding sites (Bmax) in the rat striatum by 50%. The affinity of [3H]N-0437 for dopamine receptors was reduced by half. 6-Hydroxydopamine lesions had no measurable effect on the Bmax or on the KD. Of the physiological metal ions tested only Na+ had a significant effect on the binding. Sodium ions reduced the affinity of [3H]N-0437 for striatal receptors from 5.0 +/- 1.1 nM to 8.4 +/- 0.3 nM. In addition GTP lowered the Bmax from 1121 +/- 44 to 868 +/- 84 fmol/mg protein. The trace ions Li+ and Mn2+ had no effect at a concentration of 3.0 mM, while the exogenous ion Hg2+ at the same concentration prevented the specific binding of [3H]N-0437. Together, the results suggest that [3H]N-0437 labels both pre- and postsynaptic receptors, although postsynaptic receptors are labelled preferentially. Moreover, there is an indication that GTP shifts the affinity state of the D-2 receptor from high to low, while Na+ seems to be an allosteric inhibitor.

Treatment of Parkinson's disease with agents other than levodopa and dopamine agonists: controversies and new approaches

Parkinson's disease is associated with a variety of neurotransmitter disturbances which may be further altered by its treatment with dopamine agonists. Based on this information a wide range of pharmacological approaches have been used in search of newer treatment alternatives and in hopes of reducing complications of long-term levodopa use. This paper reviews the various therapies which have had some success in the management of Parkinson's disease, other than levodopa and dopamine agonists. Special emphasis is placed on the many unresolved questions and controversies that exist in this area of neuropharmacology.

Lithium does not interact with haloperidol in the dopaminergic pathways of the rat brain

Prophylactic treatment with lithium has been reported to prevent haloperidol-induced dopamine (DA) receptor supersensitivity. If such an effect exists, then lithium may be useful in the prevention of tardive dyskinesia, which is related to the neuroleptic-induced DA hyperfunction. In the experiments reported here chronic lithium administration had no effect on DA synthesis or utilization in the nigrostriatal, mesolimbic, or mesocortical DA pathways in the rat brain. Similarly, lithium had no effect on the increase in DA metabolism induced by the acute administration of haloperidol. Also, chronic lithium treatment failed to modify the biochemical tolerance which developed after prolonged administration of the neuroleptic drug. Supersensitivity of the presynaptic DA receptors, which was induced by prolonged exposure to haloperidol, likewise was unaffected by prophylactic lithium treatment. We conclude that lithium does not affect changes in DA metabolism or receptor supersensitivity induced by haloperidol. These results do not support the use of lithium in neurological disorders that may be related to neuroleptic-induced DA receptor supersensitivity.

A review of clinical trials of lithium in neurology

Lithium has been put to clinical trials in no less than fifteen neurological disorders. They are Huntington's chorea, tardive dyskinesia, spasmodic torticollis, Tourette's syndrome, L-dopa induced hyperkinesia and the "on-off" phenomenon in parkinsonism, organic brain disorders secondary to brain-injury, drug induced delusional disorders, migraine and cluster headache, periodic hypersomnolence, epilepsy, meniere's disease and periodic hypokalemic paralysis. This paper gives a brief summary of the clinical trials with lithium salts reported in the literature. There are encouraging results on the use of lithium in cluster headaches, cyclic form of migraine and hypomanic mood disorders due to organic brain disorders. The trials with lithium and amitriptyline in tardive dyskinesia needs independent confirmation. The effect of lithium on seizure disorders needs to be addressed too.

Problems of levodopa treatment

This article reviews the side-effects of levodopa therapy in Parkinson's disease. First the pharmacokinetic aspects of levodopa are dealt with. Then the side-effects are successively discussed. Finally the therapeutic possibilities for the side-effects will be covered. An attempt has been made to give both proponents and opponents of a certain therapy their due to make it clear to the reader that for the time being uniform therapeutic recommendations are not always possible. The typical characteristics and circumstances of every individual patient should be considered before any advice can be given.