Risk factors of thyroid abnormalities in bipolar patients receiving lithium: a case control study

Relevance of red blood cell Lithium concentration in the management of Lithium-treated bipolar and unipolar disorders: a systematic narrative review

BACKGROUND

Despite a variability in response and a narrow therapeutic index, Lithium (Li) remains the gold standard treatment for bipolar disorders (BD), and a treatment of choice for unipolar disorders (UD). Red blood cell Li concentration (RBCLiC) and red blood cell/plasma Li ratio (LiR) have been studied in many areas of mood disorders (such as acute or chronic Li efficacy, adherence, side effects (SE), intoxication management) as well as in several research domains. This systematic review aims to synthesize the existing literature.

METHODS

We conducted a systematic review, based on preferred reporting items for systematic reviews and Metanalysis (PRISMA) guidelines, of articles published between 1972 and February 2023, indexed in the following databases: EMBASE, MEDLINE, Cochrane Library. The search terms were combinations of the following headings: "Lithium AND Plasma AND Erythrocyte AND Mood disorders". The systematic review protocol was published to PROSPERO (CRD42023406154).

RESULTS AND CONCLUSION

Out of the 252 identified studies, 57 met the selection criteria. The articles investigated the interest of RBCLiC and other blood parameters (PLiC and LiR) in various areas: (i) disease management (31 articles) (compliance/adherence (5 articles), SE/toxicity (13 articles), prediction of Li response/therapeutic efficacy for acute episode or for relapse prevention (17 articles)), (ii) Li blood parameters as trait markers of mood disorders subtypes (UD, BDI, BDII) (16 articles), (iii) Li blood parameters as state markers of mood episodes (11 articles), (iv) factors influencing Li blood parameters (age, gender, ethnicity, dosage and duration of Li treatment, co-medications with other treatments, seasonality) associated with RBCLiC or LiR (24 articles), and (v) potential pathophysiological mechanisms (30 articles).

CONCLUSION

Overall, this review suggests that RBCLiC or LiR could be of interest for tolerance monitoring. However, the heterogeneity of methods and results, coupled with the limited amount of data, does not allow clear conclusions to be drawn in the other areas explored in this literature review. Given the potential interest in exploring brain Li pharmacokinetics (PK)s, this review calls for further research.

A Prospective Study of Adverse Drug Reactions in Patients with Bipolar Disorder in Psychiatry Outpatient Department of a Tertiary Care Hospital

INTRODUCTION

Bipolar disorder is a chronic, debilitating psychiatric disorder. Mood stabilizers and atypical antipsychotics are first line drugs for bipolar disorder. They have significant adverse effects.

AIM

The study was conducted with an aim to evaluate the pattern of occurrence of Adverse Drug Reactions (ADRs) in the patients with bipolar disorder and to assess their causality, severity and preventability.

MATERIALS AND METHODS

A prospective and observational study - carried out in the psychiatry outpatient department of New Civil Hospital, Surat for 15 months. All patients diagnosed with bipolar disorder and receiving pharmacotherapy were included. Udvalg for Kliniske Undersøgelser (UKU) side effect rating scale and Abnormal Involuntary Movement Scale (AIMS) were used for documenting ADRs and tardive dyskinesia, respectively. Assessment of causality, severity and preventability of recorded ADRs was done using Naranjo's algorithm and WHO-UMC scale, modified Hartwig and Seigel Scale and modified Schumock and Thornton scale, respectively. Descriptive statistics was used (percentage, mean±standard deviation) for presentation of demographics and other numerical data; Chi Square test and Fisher's exact test were used to assess association between variables. A p-value < 0.05 was considered significant.

RESULTS

A total of 703 ADRs were recorded from 175 patients. The most common ADRs observed were asthenia (11.95%) and sedation (10.24%). Majority of ADRs were mild on assessment with UKU scale. Mood stabilizers (59.46%) were most frequently associated with ADRs and lithium was most common single drug responsible. Upon causality assessment, majority of the reactions were probable (54.77% with WHO-UMC scale, and 56.33% with Naranjo's algorithm). The association of results between the two scales was statistically significant (p<0.001). Majority of ADRs (70.27%) were assessed as mild and 64.30% of the ADRs were not preventable.

CONCLUSION

ADRs are a frequent occurrence in patients with bipolar disorder which are mild in most cases. Incidence of ADRs can be decreased and compliance as well as quality of life of patient can be improved by early detection and management.

General pharmacokinetic/pharmacodynamic concepts of mood stabilizers in the treatment of bipolar disorder

Introduction:

Mood stabilizers are the recommended treatment for patients who receive a diagnosis of bipolar disorder. Because of the necessity of mood stabilizer treatment in patients with bipolar disorder and the extent of pharmacokinetic and pharmacodynamic principles involved, the purpose of this review is to summarize the pharmacokinetic principles of lithium in addition to the pharmacodynamics of lithium, carbamazepine, lamotrigine, and valproic acid/valproate.

Methods:

Practice guidelines, review articles, and clinical trials were located using online databases PubMed, CINAHL, IDIS, and Medline. Search terms included at least one of the following: bipolar disorder, carbamazepine, lamotrigine, lithium, mood stabilizers, pharmacokinetics, pharmacodynamics, valproate, and valproic acid. Online clinical databases Dynamed® and Lexicomp® were also used in the study.

Results:

Mood stabilizers collectively possess distinct qualities that are closely regarded before, during, and after therapeutic initiation. Individual patient characteristics, coupled with these observed traits, add to the complexity of selecting the most optimal neurologic agent. Each medication discussed uniquely contributes to both the maintenance and restoration of overall patient well-being.

Discussion:

Introduction of mood stabilizers into drug regimens is often done in the presence of an array of mitigating factors. Safety and efficacy measures are commonly used to gauge desired results. Careful monitoring of patients' responses to selected therapies is paramount for arriving at appropriate clinical outcomes.

Thyroid functions and bipolar affective disorder

Accumulating evidence suggests that hypothalamo-pituitary-thyroid (HPT) axis dysfunction is relevant to the pathophysiology and clinical course of bipolar affective disorder. Hypothyroidism, either overt or more commonly subclinical, appears to the commonest abnormality found in bipolar disorder. The prevalence of thyroid dysfunction is also likely to be greater among patients with rapid cycling and other refractory forms of the disorder. Lithium-treatment has potent antithyroid effects and can induce hypothyroidism or exacerbate a preexisting hypothyroid state. Even minor perturbations of the HPT axis may affect the outcome of bipolar disorder, necessitating careful monitoring of thyroid functions of patients on treatment. Supplementation with high dose thyroxine can be considered in some patients with treatment-refractory bipolar disorder. Neurotransmitter, neuroimaging, and genetic studies have begun to provide clues, which could lead to an improved understanding of the thyroid-bipolar disorder connection, and more optimal ways of managing this potentially disabling condition.

Association between mood stabilizers and hypothyroidism in patients with bipolar disorders: a nested, matched case-control study

OBJECTIVES

This study investigated whether lithium, carbamazepine, and valproate increased the risk for hypothyroidism using Taiwan's National Health Insurance Dataset.

METHODS

The sample included 557 bipolar disorder patients with incident hypothyroidism first diagnosed between 1998 and 2004, and 2,228 sex-, age-, and index date-matched bipolar disorder patients without hypothyroidism from 1996-2004. We compared the use of lithium, carbamazepine, and valproate before the onset of hypothyroidism between the two groups using a conditional logistical regression model.

RESULTS

Compared with patients who had never used any of the three mood stabilizers, patients were more likely to have hypothyroidism if they only used carbamazepine [odds ratio (OR) = 1.68; 95% confidence interval (CI): 1.07-2.65]; or comedication of lithium and valproate (OR = 2.40; 95% CI: 1.70-3.40), lithium and carbamazepine (OR = 1.52; 95% CI: 1.10-2.08), and three mood stabilizers (OR = 2.34; 95% CI: 1.68-3.25). There was a dose-response relationship between the number of mood stabilizers and risk for hypothyroidism (OR = 1.34, 95% CI: 1.21-1.49) and a significant interaction between lithium and valproate on the risk for hypothyroidism (p = 0.020).

CONCLUSIONS

Our findings indicate that lithium, carbamazepine, and valproate may increase the risk for hypothyroidism, particularly if combined, and suggest regular monitoring of thyroid function and monotherapy of mood stabilizers for treating patients with bipolar disorders.

Lithium and thyroid

One in 200 people receive lithium for treatment of bipolar disorder. The common clinical side effects of the drug are goitre in up to 40% and hypothyroidism in about 20%. Lithium increases thyroid autoimmunity if present before therapy. Treatment with levothyroxine is effective and lithium therapy should not be stopped. Lithium may cause hyperthyroidism due to thyroiditis or rarely Graves' disease. As lithium inhibits thyroid hormone release from the thyroid gland it can be used as an adjunct therapy in the management of severe hyperthyroidism. It also increases thyroidal radioiodine retention and may be effective in reducing administered activity in hyperthyroidism. There is no clinical benefit of lithium therapy in thyroid cancer. More research is required on the cellular proliferative effects of lithium as well as its impact on the immune system.

New airways for resuscitation?

Over the last 15 years supraglottic airway devices (SADs), most notably the classic laryngeal mask airway (LMA) have revolutionised airway management in anaesthesia. In contrast for resuscitation, both in and outside hospital, facemask ventilation and tracheal intubation remain the mainstays of airway management. However there is evidence that both these techniques have complications and are often poorly performed by inexperienced personnel. Tracheal intubation also has the potential to cause serious harm or death through unrecognised oesophageal intubation. SADs may have a role in airway management for resuscitation as first responder devices, rescue devices or for use during patient extraction. In particular they may be beneficial as the level of skill required to use the device safely may be less than for the tracheal tube. Concerns have been expressed over the ability to ventilate the lungs successfully and also the risk of aspiration with SADs. The only SADs recommended by ILCOR in its current guidance are the classic LMA and combitube. Several SADs have recently been introduced with claims that ventilation and airway protection is improved. This pragmatic review examines recent developments in SAD technology and the relevance of this to the potential for using SADs during resuscitation. In addition to examining research directly related to resuscitation both on bench models and in patients the review also examines evidence from anaesthetic practice. SADS discussed include the classic, intubating and Proseal LMAs, the combitube, the laryngeal tube, laryngeal tube sonda mark I and II and single use laryngeal masks.

Thyroid peroxidase autoantibodies in euthyroid subjects

Thyroid peroxidase (TPO) is a key enzyme in the formation of thyroid hormones and a major autoantigen in autoimmune thyroid diseases. Titers of TPO antibodies also correlate with the degree of lymphocytic infiltration in euthyroid subjects, and they are frequently present in euthyroid subjects (prevalence 12-26%). Even within the normal range for thyrotropin (TSH), TPO antibody titers correlate with TSH levels, suggesting that their presence heralds impending thyroid failure. Assays for serum TPO antibodies have become much more sensitive, and very low titers can be found in virtually all subjects. However, titers above an assay-dependent cut-off are a clear risk factor for hypothyroidism; in the Whickham survey the annual risk of developing hypothyroidism in TPO-positive women with normal thyrotropin levels was 2.1%. Measuring TPO antibodies in euthyroid subjects can be used to identify subjects with increased risk for hypothyroidism: e.g. as triage to measure thyrotropin. This could be done in women who wish to become pregnant and those with an increased risk per se who are pregnant (to predict first trimester hypothyroidism, and postpartum thyroid dysfunction), patients with other autoimmune diseases, subjects on amiodarone, lithium, or interferon-alpha, and in relatives of patients with autoimmune thyroid diseases.