Lithium in man. Serum electrolytes and glucose after a single lithium load

Lithium-associated hypercalcemia and hyperparathyroidism: A systematic review and meta-analysis

OBJECTIVES

We aimed to review and summarise the existing human literature on the association between lithium and hyperparathyroidism.

METHODS

A systematic literature search was carried out according to PRISMA guidelines (last search 27 February 2024), using MEDLINE, Web of Science, Embase and the Cochrane Library. A meta-analysis was performed to determine the prevalence of lithium-associated hypercalcemia (LAHca) in lithium-treated patients.

RESULTS

The pooled prevalence of LAHca based on total calcium and ionised calcium was comparable, at 3.17% and 4.23%, respectively. Calcium, and PTH if the patient is hypercalcaemic, is insufficiently measured in lithium-treated patients in clinical practice. Lithium use is associated with higher calcium and PTH levels, as well as a higher incidence of hyperparathyroidism. There is a high prevalence of multiglandular disease in lithium-associated hyperparathyroidism (LAH), with a pooled prevalence of 51.28%. Parathyroid surgery and cinacalcet are effective treatments for LAH. Regarding lithium discontinuation, there is anecdotal but conflicting evidence suggesting that it can result in the resolution of LAH in selected cases.

CONCLUSIONS

Lithium treatment increases the risk of hyperparathyroidism, a treatable complication with a pooled prevalence of around 4%, compared to 0.5% in the healthy population.

Diurnal variation of blood glucose during lithium treatment

Plasma glucose was analysed during a 24-hour period in 62 lithium-treated patients. Compared with 59 normal control persons and 80 psychiatric controls the lithium-treated patients with neutral mood had higher maximum glucose and higher mean plasma glucose. Depressed lithium-treated patients had lower mean plasma glucose than the neutral lithium-treated patients. Depressed patients among the psychiatric controls did not differ from the neutral patients in this group with respect to plasma glucose.

Affective disorders, diabetes mellitus and lithium

There appears to be an association between affective disorders and diabetes mellitus independent of the use of lithium in treatment. Prior studies have suggested that lithium treatment may impair glucose tolerance or produce frank diabetes in certain patients. Metabolic complications of the diabetic state, such as hyperosmolality and salt depletion increase lithium absorption and the risk of toxicity even at generally acceptable serum levels. The management of patients with diabetes and affective disorders on prophylactic lithium is discussed.

Lithium effects: relation to lithium dose and to plasma peak levels

In a 24-hour study, plasma peak lithium was determined in manic-melancholic patients who routinely had their entire lithium dose at night. A correlation analysis was undertaken of the relation of plasma peak level and the dose of lithium to a number of lithium induced changes: Increase in urine volume, weight gain, decrease in plasm phosphate, increase in plasma magnesium, decrease in plasma urea, increase in plasma alkaline phosphatase, increase in urinary pH. Only the changes in plasma phosphate and in urine pH were significantly correlated to the peak value of plasma lithium. The increase in urine volume was significantly correlated to the dose of lithium.

Lithium treatment and glucose tolerance in manic-melancholic patients

Intravenous glucose tolerance was measured in manic-melancholic patients given one daily lithium-dose for relapse prevention. It was found that glucose tolerance was increased for some hours after each lithium administration. In the first week of treatment glucose disposal rate was increased up to 12 h after lithium ingestion. In long-term treated patients glucose tolerance was increased 2 h after administration but not 12 h after. Fasting glucose was increased 2 h after lithium administration in long-term treated patients. Concomitant changes in lactate triglycerides, free-glycerol and electrolytes were measured in serum.

Repression of a lithium pump as a consequence of lithium ingestion by manic-depressive subjects

The lithium pump in human erythrocyte membranes, which is responsible for extrusion of lithium against a concentration gradient, has been found to be reversibly repressed during periods of lithium carbonate administration. The pump activity of patients prior to lithium therapy is not different from controls. The onset of repression may require several days to several weeks and occurs at specific individual threshold levels of lithium carbonate dosage. Reactivation of the lithium pump occurs sometime after the dosage is discontinued. We postulate that repression of the lithium pump results from systemically available factors which alter membrane structure, and suggest that is such changes also occur in the central nervous system, they may provide insight into one means by which lithium produces its psychotropic affects.

Lithium effects on diurnal rhythm of calcium, magnesium, and phosphate metabolism in manic-melancholic disorder

The diurnal rhythm of plasma phosphate, calcium, and magnesium was studied in 34 lithium treated patients, in 42 other psychiatric patients, and in 47 healthy persons. Seventeen blood samples were drawn from each person during the 24-hour period. Lithium was given at 10 p.m. and in the next few hours plasma phosphate decreased compared with the two control groups. In the same period plasma calcium showed a temporary increase, whereas plasma magnesium was increased during the whole 24-hour period. The lithium treated patients had a reduced urinary calcium excretion during the night, and an increased urinary magnesium excretion during the day, whereas no changes were found in urinary phosphate excretion.