The influence of external sodium and potassium on lithium uptake by primary brain cell cultures at "therapeutic" lithium concentration

Drug-Drug Interactions Between Lithium and Cardiovascular as Well as Anti-Inflammatory Drugs

INTRODUCTION

Lithium is the gold standard in treating bipolar affective disorders. As patients become increasingly older, drug-drug interactions leading to decreased excretion of lithium represent a key issue in lithium safety. As no study considered the effect of comedications on lithium serum concentration in combination, we aimed to quantify the impact of drugs affecting renal blood flow and function and thus potentially interacting drugs (diuretics, ACE inhibitors, AT1 antagonists, and non-steroidal anti-inflammatory drugs) on lithium serum levels in addition to age, sex, and sodium and potassium serum levels as well as renal function.

METHODS

Retrospective data of lithium serum levels were analyzed in 501 psychiatric inpatients (2008-2015) by means of linear regression modelling.

RESULTS

The number of potentially interacting drugs was significantly associated with increasing serum levels of lithium in addition to the established factors of age, renal function, and sodium concentration. Additionally, absolute lithium levels were dependent on sex, with higher values in females. However, only NSAIDs were identified to increase lithium levels independently.

DISCUSSION

Routine clinical practice needs to focus on drugs affecting renal blood flow and function, especially on NSAIDs as over-the-counter medication that may lead to an increase in lithium serum concentration. To prevent intoxications, clinicians should carefully monitor the comedications, and they should inform patients about possible intoxications due to NSAIDs.

Role of Counterion in the Adsorption Behavior of 1:1 Ionic Surfactants at Fluid Interfaces-Adsorption Properties of Alkali Perfluoro-n-octanoates at the Air/Water Interface

Equilibrium surface tension (σ_e) versus bulk concentration (c) isotherms of aqueous, surface-chemically pure solutions of various alkali perfluoro-n-octanoates were measured at 295 K. These 1:1 ionic surfactant systems belong to the pseudo nonionic ones. Evaluating the different σ_e vs log c isotherms by basic adsorption equations reveals that they follow ideal surface behavior. The novelty of this investigation exists in the fact that the surface area demand per molecule adsorbed calculated from the experimental σ_e vs log c isotherms is identical to that of the hydrated alkali cation. Thus, as long as the counterion's cross-sectional area is greater than that of its amphiphilic anion, the amphiphile's total surface area demand will exclusively be governed by that of its alkali counterion. This, in turn, means that the counterion is nonrandomly bound to the amphiphilic anion in the adsorption layer. Furthermore, the size of the hydrated alkali counterion in the adsorption layer does not differ from that in the bulk phase.

Astrocytic alkalinization by therapeutically relevant lithium concentrations: implications for myo-inositol depletion

RATIONALE

One theory for therapeutic effects of the lithium ion (Li+) in bipolar disorder is that myo-inositol, needed for phospholipase C-mediated signaling, is depleted by Li(+)-induced inhibition of inositolphosphate hydrolysis or of myo-inositol uptake, an effect demonstrated in cultured mouse astrocytes at high myo-inositol concentrations. In contrast, myo-inositol uptake is inhibited at low concentrations, reflecting that it occurs both by the high-affinity Na(+)-dependent myo-inositol transporter (SMIT) and the lower-affinity H(+)-dependent inositol transporter (HMIT). Increased intracellular pH (pHi) stimulates SMIT but inhibits HMIT, suggesting that the effect of Li+ could be caused by intracellular alkalinization. In this study, we therefore investigated Li+ effects on intracellular pH in astrocytes, measured by 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein (BCECF) fluorescence.

RESULTS

Chronic treatment with the therapeutically relevant Li+ concentration of 1 mM for 2 or 3 weeks increased pHi by approximately 0.10, whereas 0.5 mM was ineffective, and 2 mM caused a larger increase. The alkalinization resulted from acute stimulation of the Na+/H+ exchanger (NHE) by extracellular Li+, demonstrated after acid load with NH4Cl. In response to continuous stimulation, NHE1 mRNA was down-regulated, but protein was not.

CONCLUSIONS

Chronic treatment with pharmacologically relevant Li+ concentrations increases pHi in astrocytes, creating conditions for decreased uptake of high myo-inositol concentrations and increased uptake of low concentrations. The pharmacological relevance of this effect is supported by literature data suggesting brain acidosis in bipolar patients and by preliminary observations that carbamazepine and valproate also increase pHi in astrocytes. Stimulation of NHE1-stimulated sodium ion uptake might also trigger uptake of chloride ions and osmotically obliged water.

The uptake of Li+ into human 1321 N1 astrocytomas using 7Li NMR spectroscopy

The uptake of Li+ ions into human 1321 N1 astrocytomas cultured on the surface of microcarrier beads was followed by 7Li NMR spectroscopy. The intracellular and extracellular 7Li resonances were separated by the use of dysprosium tripolyphosphate as a shift reagent. Excellent spectra were obtained from which the uptake of Li+ was found to be approximately ten times faster than that into human erythrocytes using the same technique and a steady-state intracellular Li+ concentration was observed within 60 min. The low intracellular Li+ concentration attained, relative to the extracellular concentration, indicates the presence of an efflux mechanism in astrocytomas that actively transports Li+ against its concentration gradient. The intracellular volume was estimated by quantitative 23Na NMR spectroscopy and the viability of the cells was confirmed by 31P NMR spectroscopy.

In vivo NMR spectroscopy of lithium-7 in humans

The pharmacokinetics of lithium uptake was measured by 7Li NMR spectroscopy at 24.83 MHz in vivo in the brain and muscle of a normal subject and a patient suffering from bipolar affective disorder, using a modified General Electric Signa clinical magnetic resonance imaging system. Comparison was made to standard phantoms to estimate Li concentrations. The levels of Li in brain and muscle were similar, were typically less than the level in serum, and generally tracked the level in serum. The Li level at steady state in the brain of a patient suffering from schizoaffective disorder was measured over a 7-month period. Substantial variation was seen, which showed some correlation with serum level. Serum level peaked about 2 h after a single 300-mg dose at steady state, and muscle level, immediately thereafter. Brain level peaked considerably later at 4 h. Localized in vivo 7Li NMR spectroscopy was demonstrated by acquisition of a 125-cm3 DRESS slice from the occipital region in less than 7 min.

Stimulation of cell membrane sodium transport activity by lithium: possible relationship to therapeutic action

Because lithium is extruded from cells by means of coupled exchange for external sodium (Na+-Li+ countertransport), we hypothesized that clinical treatment with this agent could lead to significant augmentation of net cellular sodium influx. We therefore directly measured sodium influx in vitro using erythrocytes (RBCs) from 27 depressed bipolar patients. When cells were loaded with sufficient lithium to maximally stimulate Na+-Li+ countertransport activity (5.1 mmoles/1 RBCs), there was a significant 44% increase in mean sodium influx. To approximate clinical conditions more closely, we also studied sodium influx in a subset of eight subjects after loading cells with 0, 0.40, 0.66, and 1.55 mmoles lithium/1 RBCs. Over this range of lithium concentrations, sodium influx increased progressively. In separate experiments, we found that RBC sodium content measured in eight subjects did not change significantly during a 4-week course of lithium treatment. Thus, excess cellular sodium during such treatment may be extruded by increased activity of the membrane Na+-K+ pump, which has electrogenic properties and thereby could augment the membrane potential. In the nervous system, such an effect could stabilize cell membranes electrophysiologically, and possibly affect processes, such as behavioral sensitization or kindling, proposed to have a role in the development of recurrent affective disorders.

A review of the biochemical and neuropharmacological actions of lithium

The pharmacological actions central to the therapeutic effects of lithium have not yet been established, despite almost 40 years of clinical use and scientific investigation. We review the biochemical and neuropharmacological data relating to this problem and attempt to identify profitable areas for further research.

The use of sodium and potassium to reduce toxicity and toxic side effects from lithium

Studies in rats find that the animals develop toxic side effects at serum levels which are therapeutic for man. Most of the toxic effects were prevented by feeding sodium and potassium. The rats must ingest and excrete comparatively higher amounts of lithium than humans to maintain these levels. Sodium used alone has been shown to reduce side effects in man, but was found to reduce therapeutic effectiveness at fixed lithium dosages. Evidence is presented to suggest that therapeutic effectiveness can be maintained and toxic side effects and risk of toxicity reduced, by using both sodium and potassium, and by modestly raising the dosage of lithium.

Effects of lithium on electrical activity and potassium ion distribution in the vertebrate central nervous system

Three different regions of the vertebrate central nervous system maintained in vitro (frog spinal cord, guinea pig olfactory cortex and hippocampus) have been used to investigate how Li+ influences membrane potential, membrane resistance, action potentials, synaptic potentials and the transmembrane K+-distribution of neurons and glial cells. In view of the therapeutic action of Li+ in manic-depressive disease, a special effort was made to determine the threshold concentration for the actions of Li+ on the parameters described above. It was observed that Li+ induced a membrane depolarization of both neurons and glial cells, a decrease of action potential amplitudes, a facilitation of monosynaptic excitatory postsynaptic potentials and a depression of polysynaptic reflexes. The membrane resistance of neurons was not altered. Li+ also induced an elevation of the free extracellular potassium concentration and a decrease of the free intracellular potassium concentration. Furthermore, in the presence of Li+ a slowing of the recovery of the membrane potential of neurons and glial cells, and of the extracellular potassium concentration after repetitive synaptic stimulation was observed. The threshold concentrations for the effects of Li+ were below 5 mmol/l in the frog spinal cord and below 2 mmol/l in the guinea pig olfactory cortex and hippocampus. The basic mechanism underlying the action of Li+ may be an interaction with the transport-function of the Na+/K+ pump.

Transport pathways for lithium ions in neuroblastoma x glioma hybrid cells at 'therapeutic' concentrations of Li+

The pathways of Li+ transport in neuroblastoma X glioma hybrid cells were studied at 2 mM external Li+. Five components of Li+ transport were identified. (1) A Na+-dependent Li+ countertransport system mediating Li+ transport in both directions across the plasma membrane. This transport pathway is insensitive to ouabain or external K+. It shows trans-stimulation (i.e. acceleration of Li+ extrusion by external Na+ and stimulation of Li+ uptake by internal Na+) and cis-inhibition (i.e. reduction of Li+ uptake by external Na+). (2) The Na+-K+ pump mediates Li+ uptake but not Li+ release in cells with physiological Na+ and K+ content. Li+ uptake by the pump in choline media is inhibited by both external Na+ and K+. In Na+ media, external K+ exhibits a biphasic effect: in concentrations up to about 1 mM, K+ accelerates, and at higher concentrations, K+ inhibits Li+ uptake by the pump. (3) Li+ can enter the voltage-dependent Na+ channel. Li+ uptake through this pathway is stimulated by veratridine and scorpion toxin, the stimulation being blocked by tetrodotoxin. Residual pathways comprise (4) a saturable component, which is comparable to basal Na+ uptake, and (5) a ouabain-resistant component promoting Li+ extrusion against an electrochemical gradient in choline media. The mechanisms for Li+ extrusion described here possibly explain how neuronal cells maintain the steady-state ratio of internal to external Li+ below 1 during chronic exposure to 1-2 mM external Li+.

Lithium entry into neural cells via sodium channels: a morphometric approach

Rat cerebral cortical explants prepared from 18-day-old embryos were grown for 18 days in vitro. Cultures were exposed to Na+, Li+ and choline+ media, respectively, in the presence or absence of tetrodotoxin and/or veratridine, and processed for electron-microscopy. Veratridine (50 microM) induced an increase in summated and mean areas of neuronal profiles in Na+- and Li+-media but not in the choline+-medium: the summated perimeters did not change. The mean value of the neuronal form factor was significantly elevated following exposure to veratridine in a Na+- or Li+-dependent manner, indicating that the shape of the sectioned neuronal elements shifted towards an (ideal) circle. Qualitative assessment revealed an increased electron-lucency of the cytoplasm of neuronal profiles in Na+- and Li+-media containing veratridine. The veratridine-induced neuronal changes were inhibited by simultaneous addition of tetrodotoxin (1 microM) to the media. In the case of the glial cells, the values of the summated area and form factor did not change in the various experimental groups. The area of the extracellular space per unit area of sections significantly decreased in the Na+- and Li+-media following veratridine exposure; this did not occur in the choline+-medium. The results indicate a considerable swelling of the neuronal elements, reflecting cation, Cl- and water uptake following prolonged sodium channel activation in the presence of Na+ or Li+ ions. The quantitative ultrastructural data strongly suggests an entry of Li+ ions into cultured rat cerebral cells via sodium channels.

A morphometric study of cultured rat cerebral synapses exposed to different cationic media

Quantitative techniques have been applied to compare the effects of high-K+, Mg2+ and Li+ media on the ultrastructure of cultured synapses alongside Na+-incubated controls. The explant cultures were prepared from 18-day-old embryonic rat cerebral cortices and maintained for 19 days in vitro. K+ -Stimulation for 25 min resulted in an increase in the mean perimeter and area of presynaptic terminals. Of these, the perimeter increase was the more pronounced, as indicated by a decrease in the value of the two-dimensional form factor. Reductions were also observed in the number of synaptic vesicles per presynaptic terminal, in the vesicle-terminal area ratio and in the synaptic vesicle density in an area adjacent to the presynaptic membrane, the latter two parameters being in positive linear correlation. The frequency of presynaptic cisternal/vacuolar profiles increased, and the synaptic curvature shifted in a positive direction. Synaptic length did not change following K+-exposure. Qualitative assessment indicated the presence of a network subjacent to the post-synaptic thickening and swelling of the postsynaptic ending after K+-stimulation. Incubation and fixation in Mg2+-media of two concentrations resulted in an increase in the number and area ratio of synaptic vesicles per terminal, and an elevation in the synaptic vesicle density in the higher Mg2+ concentration medium. Li+-treatment reduced the number of synaptic vesicles per terminal, the vesicle-terminal area ratio, and the vesicle density in the vicinity of the presynaptic membrane, while the synaptic curvature shifted in the positive direction. These changes were less pronounced than those characteristic of synapses in the K+ medium.

Lithium distribution across the membrane of motoneurons in the isolated frog spinal cord

Lithium sensitive microelectrodes were used to investigate the transmembrane distribution of lithium ions (Li+) in motoneurons of the isolated frog spinal cord. After addition of 5 mmol.1(-1) LiCl to the bathing solution the extracellular diffusion of Li+ was measured. At a depth of 500 micrometers, about 60 min elapsed before the extracellular Li+ concentration approached that of the bathing solution. Intracellular measurements revealed that Li+ started to enter the cells soon after reaching the motoneuron pool and after up to 120 min superfusion, an intra - to extracellular concentration ratio of about 0.7 was obtained. The resting membrane potential and height of antidromically evoked action potentials were not altered by 5 mmol.1(-1) Li+.

Indirect ultrastructural evidence for lithium uptake by cultured rat cerebral cells through the sodium channel

Cerebral cortices, prepared from 18-day-old rat embryos, were grown in explant cultures for 18 days. They were then incubated for 25 min in media of 3 types of cationic composition with and without tetrodotoxin and/or veratridine. Qualitative and quantitative ultrastructural observations revealed a considerable swelling of neuronal elements following veratridine exposure in both Na+ and Li+ media; this swelling was prevented by tetrodotoxin. By contrast, veratridine failed to induce swelling of neuronal profiles in a choline+ medium. The results indirectly indicate that Li+ ions enter cultured rat cerebral cells through the Na+ channels.

Acute and chronic effects of lithium in therapeutically relevant concentrations on potassium uptake into astrocytes

Potassium uptake into astrocytes in primary cultures was measured by the aid of 42K. Acute application of lithium in concentrations of 1 and 5 mM, but not 0.5 und 0.25 mM, exerted a significant inhibition of the potassium uptake rates. This effect is due to a partial impairment of the ouabain-sensitive part of the uptake into the cells caused by a lithium interaction with the extracellular K+-activated site of the Na+, K+-ATPase. After 14 days of exposure of the astrocytes to 1 mM lithium, the potassium uptake remained lower in the presence of lithium than in its absence. However, the cells had adjusted to the chronic presence of lithium by increasing their potassium uptake to such an extent that, during the exposure to 1 mM lithium, it was indistinguishable from that in cultures from the same batches grown in the absence of lithium and measured in the absence of this compound. The interference by lithium with potassium uptake into astrocytes may well be related to the inhibition of potassium clearance in the CNS described in the literature.