Starting dose for lithium
Lithium Dosage Guide + Max Dose, Adjustments
Print SaveMedically reviewed by Drugs.com. Last updated on Feb 20, 2023.
Applies to the following strengths: 300 mg; 450 mg; 150 mg; 600 mg; 300 mg/5 mL
Usual Adult Dose for:
- Mania
- Bipolar Disorder
Usual Pediatric Dose for:
- Mania
- Bipolar Disorder
Additional dosage information:
- Renal Dose Adjustments
- Liver Dose Adjustments
- Dose Adjustments
- Precautions
- Dialysis
- Other Comments
Usual Adult Dose for Mania
Acute Control: 1800 mg/day
- Regular release formulations: 600 mg orally 2 to 3 times a day
- Extended release formulations: 900 mg orally 2 times a day
Long-term Control: 900 to 1200 mg/day
- Regular release formulations: 300 to 600 mg orally 2 to 3 times a day
- Extended release formulations: 600 mg orally 2 times a day
Comments:
- Regular release formulations should be given in the morning, afternoon, and nighttime (3 times a day dosing) or in the morning and at nighttime (2 times a day dosing).
- Extended release formulations should be given in the morning and at nighttime.
- Dosing must be individualized according to serum levels and the response to treatment.
- Alternative extended release formulation doses are 600 mg 3 times a day (acute control) and 300 mg 3 to 4 times a day (long-term control).
Uses:
- Treatment of manic episodes of bipolar disorder
- Maintenance treatment for individuals with bipolar disorder
Usual Adult Dose for Bipolar Disorder
Acute Control: 1800 mg/day
- Regular release formulations: 600 mg orally 2 to 3 times a day
- Extended release formulations: 900 mg orally 2 times a day
Long-term Control: 900 to 1200 mg/day
- Regular release formulations: 300 to 600 mg orally 2 to 3 times a day
- Extended release formulations: 600 mg orally 2 times a day
Comments:
- Regular release formulations should be given in the morning, afternoon, and nighttime (3 times a day dosing) or in the morning and at nighttime (2 times a day dosing).
- Extended release formulations should be given in the morning and at nighttime.
- Dosing must be individualized according to serum levels and the response to treatment.
- Alternative extended release formulation doses are 600 mg 3 times a day (acute control) and 300 mg 3 to 4 times a day (long-term control).
Uses:
- Treatment of manic episodes of bipolar disorder
- Maintenance treatment for individuals with bipolar disorder
Usual Pediatric Dose for Mania
12 years and older:
Acute Control: 1800 mg/day
- Regular release formulations: 600 mg orally 2 to 3 times a day
- Extended release formulations: 900 mg orally 2 times a day
Long-term Control: 900 to 1200 mg/day
- Regular release formulations: 300 to 600 mg orally 2 to 3 times a day
- Extended release formulations: 600 mg orally 2 times a day
Comments:
- Regular release formulations should be given in the morning, afternoon, and nighttime (3 times a day dosing) or in the morning and at nighttime (2 times a day dosing).
- Extended release formulations should be given in the morning and at nighttime.
- Dosing must be individualized according to serum levels and the response to treatment.
- Alternative extended release formulation doses are 600 mg 3 times a day (acute control) and 300 mg 3 to 4 times a day (long-term control).
- Maintenance therapy reduces the frequency of manic episodes and diminishes the intensity of the episodes.
Uses:
- Treatment of manic episodes of bipolar disorder
- Maintenance treatment for individuals with bipolar disorder
Usual Pediatric Dose for Bipolar Disorder
12 years and older:
Acute Control: 1800 mg/day
- Regular release formulations: 600 mg orally 2 to 3 times a day
- Extended release formulations: 900 mg orally 2 times a day
Long-term Control: 900 to 1200 mg/day
- Regular release formulations: 300 to 600 mg orally 2 to 3 times a day
- Extended release formulations: 600 mg orally 2 times a day
Comments:
- Regular release formulations should be given in the morning, afternoon, and nighttime (3 times a day dosing) or in the morning and at nighttime (2 times a day dosing).
- Extended release formulations should be given in the morning and at nighttime.
- Dosing must be individualized according to serum levels and the response to treatment.
- Alternative extended release formulation doses are 600 mg 3 times a day (acute control) and 300 mg 3 to 4 times a day (long-term control).
- Maintenance therapy reduces the frequency of manic episodes and diminishes the intensity of the episodes.
Uses:
- Treatment of manic episodes of bipolar disorder
- Maintenance treatment for individuals with bipolar disorder
Renal Dose Adjustments
Mild to moderate renal dysfunction (CrCl 30 to 89 mL/min): Begin with lower doses and titrate slowly; closely monitor serum concentrations and signs/symptoms of lithium toxicity.
Severe renal dysfunction (CrCl less than 30 mL/min): Not recommended.
Any progressive/sudden change in renal function (even within the normal range): Reevaluate treatment.
Liver Dose Adjustments
Data not available
Dose Adjustments
Therapeutic drug monitoring/range:
- Acute episodes: 0.8 to 1.5 mEq/L, not to exceed 2 mEq/L
- Long-term control: 0.6 to 1.2 mEq/L
- Patients who are abnormally sensitive may exhibit toxicity at concentrations of 1 to 1.5 mEq/L.
Serum levels should be drawn immediately prior to the next dose (e.g., 8 to 12 hours after the previous dose).
- Acute episodes: Levels should be determined 2 times a week, and continued until the patient is stable.
- Long-term control: Levels should be assessed regularly.
- Serum levels should be monitored after any change in dose, concomitant medication, marked increase/decrease in routine physical activity, and/or in the event of concomitant disease.
Elderly patients: Begin at the lower end of the dosing range
Patients with significant cardiovascular disease, debilitation, dehydration, and/or sodium depletion and those receiving drugs that could affect kidney function: Begin with lower doses and titrate slowly; closely monitor serum concentrations and signs/symptoms of lithium toxicity.
Precautions
US BOXED WARNINGS:
LITHIUM TOXICITY:
- Lithium toxicity is closely related to serum lithium concentrations, and can occur at doses close to therapeutic concentrations.
- Facilities for prompt and accurate serum lithium determinations should be available before initiating therapy.
NARROW THERAPEUTIC INDEX:
- This drug should be considered a narrow therapeutic index (NTI) drug as small differences in dose or blood concentrations may lead to serious therapeutic failures or adverse drug reactions.
Recommendations:
- Generic substitution should be done cautiously, if at all, as current bioequivalence standards are generally insufficient for NTI drugs.
- Additional and/or more frequent monitoring should be done to ensure receipt of an effective dose while avoiding unnecessary toxicities.
Safety and efficacy have not been established in patients younger than 12 years.
Consult WARNINGS section for additional precautions.
Dialysis
Data not available
Other Comments
Administration advice:
- Extended/controlled/prolonged/sustained release tablet formulations should not be crushed or chewed.
- Take with food to decrease gastrointestinal side effects.
- This drug should be taken at the same time(s) each day.
Storage requirements:
- The manufacturer product information should be consulted.
General:
- Lithium toxicity is related to serum lithium levels, and may occur at doses close to therapeutic levels.
- Patients in the manic phase are better able to tolerate lithium; tolerance to lithium decreases when manic symptoms subside.
- Mania is characterized by pressure of speech, motor hyperactivity, reduced sleep requirements, flight of ideas, grandiosity, elation, poor judgment, aggressiveness, and/or hostility.
Maintenance therapy reduces the frequency of manic episodes and diminishes the intensity of the episodes.
Monitoring:
- Cardiac: ECG, especially in patients at risk of unmasking Brugada syndrome; cardiac function at baseline and at regular intervals thereafter
- Endocrine: Thyroid function at baseline and at regular intervals thereafter
- Metabolic: Lithium levels at baseline and at regular intervals thereafter
- Renal: Renal function tests (e.g., urinalysis, urine specific gravity, serum creatinine, creatinine clearance), especially in patients who develop polyuria and/or polydipsia
Patient advice:
- Patients should be told to seek immediate medical attention if signs/symptoms of Brugada syndrome, encephalopathic syndrome, or diabetes insipidus occur.
- Patients, family members, and/or caregivers should be instructed to discontinue therapy and immediately report any signs/symptoms of lithium toxicity, change in behavior, or suicidality.
- Inform patients that this drug may cause drowsiness and central nervous system disturbances, and they should avoid driving or operating machinery until the full effects of the drug are seen.
- Patients should be counseled on the importance of maintaining adequate salt and water intake.
- Advise patients to speak to their healthcare provider if they become pregnant, intend to become pregnant, or are breastfeeding.
Frequently asked questions
- What is a proper diet to go on with lithium?
More about lithium
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Patient resources
- Drug Information
- Lithium (Advanced Reading)
- Lithium Capsules and Tablets
- Lithium Controlled-Release and Extended-Release Tablets
- Lithium Syrup and Oral Solution
Other brands
Eskalith, Lithobid, Eskalith-CR
Professional resources
- Prescribing Information
Related treatment guides
- Bipolar Disorder
- Cyclothymic Disorder
- Borderline Personality Disorder
- Cluster Headaches
Further information
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.
Medical Disclaimer
Dosing Tips: Lithium for Bipolar Disorder
Chris Aiken, MD, and Kellie Newsome, PMH-NP, discuss how to dose lithium for the treatment of bipolar disorder.
PSYCHPEARLS POSCAST
In a recent podcast, the presenters listed 4 mood stabilizers that stand out in bipolar disorder treatment. In this podcast, Dr Aiken and Ms Newsome will discuss how to dose one of them: lithium.
Transcript (edited for clarity).
Kellie Newsome, PMH-NP: Dr Aiken, how do you start a patient on lithium?
Chris Aiken, MD: I start patients on lithium very slowly. This is a medication that is meant to work for the long term. It is not that effective for acute episodes, so there's no reason to rush it. Patients are often afraid of lithium; it has kind of a bad reputation out there, which isn't necessary because it's relatively well tolerated. For example, it has a chance of causing sedation around 1 in 28 patients, compared with 1 in 5 or 1 in 10 for most other mood stabilizers.
It is also a little friendlier when it comes to weight gain and cognitive side effects than many of the other mood stabilizers.
If you start lithium too quickly, the patient is liable to stop it because of one big side effect: nausea. That is the one you need to prepare them for. Nausea shouldn't be a reason to stop lithium, because it almost always gets better with time. So if you can just get your patient through that whether it's using ondansetron or ginger tablets or taking it after food or raising the dose real slowly, it'll pay off in the long term.
Generally, I'll start with 300 mg at night and raise it by 300 mg each week until I reach 900 mg, at which point, I'll check the level. If the patient is on a drug that interacts with lithium, such as hydrochlorothiazide, or if they're older or frail or afraid of side effects, I'll start lower cutting all of those doses in half. Of course, if your patient is actively manic or you're trying to keep them out of the hospital, you might go faster with this.
Kellie Newsome, PMH-NP: Do you give lithium all at night or twice a day.
Chris Aiken, MD: Lithium is often dosed twice a day, but I think that's out of convention rather than science. Its half-life is 24 hours so there's no reason to do that. And in a few long term studies, patients actually had lower rates of renal problems if the lithium was dosed entirely at night rather than twice a day. It seems that the kidneys do better when they get a bolus of lithium at night, rather than spread evenly throughout the day.
Kellie Newsome, PMH-NP: So what if you're using a high dose? Wouldn't you need to spread that out?
Chris Aiken, MD: First of all, the dose doesn't really matter in lithium; it's the blood level. So that is a good question though, what if the blood level is high, would we need to spread that out. Nobody knows the answer to that. But what I do is if the blood level is going above 0.8, I will spread it out and give a little bit of the dose in the morning.
The reason is that we do have long term studies where if lithium level is kept at 0.8 or below, there is much lower risk of renal problems. So we don't know for sure, but I'm hedging my bets and saying let's try to keep that level, less than 0.8 throughout the day to save the kidneys.
Kellie Newsome, PMH-NP: Lithium comes in several forms, instant release, lithobid, and eskalith. Which one do you prefer?
Chris Aiken, MD: Generally, I'll use lithobid, but each has its advantage. Lithobid and eskalith are the extended released versions, and they're going to cut most of the side effects in half so they're better tolerated overall. However, if the patient has constipation, that often improves with the instant release, whereas diarrhea and nausea tend to improve with the controlled release. Another reason you might use the instant release is if you're starting real low like 150 mg, that dose only comes as an instant release, and eskoleth. I can't see much reason to prefer eskoleth over lithobid, other than the tablet size, which does matter to patients.
Most patients, rather take 2 pills than 3. And since eskoleth comes as a 450 often use 2 of those rather than 3 of the lithobids, once they get to the dose of 900.
Kellie Newsome, PMH-NP: Once you get to 900 and you check the level, what levels are you actually looking for?
Chris Aiken, MD: This is something we have a lot of research on so there are good numbers to know here. The target level for lithium is 0.6, to 0.8 for depression as well as for the maintenance phase. You want to keep it in that sweet spot. If the patient has active mania, you should go up to 0.8 to 1.2. But you might want to bring it down after they've recovered, again to save the kidneys. Children by the way require the same levels as adults, but if the patient is over 65, they might need levels that are 20% to 30% lower than the ones I just quoted for an interesting reason. In older age, the brain tends to absorb more of the lithium, so they actually get a good therapeutic effect at a slightly lower dose.
Chris Aiken, MD, is the Mood Disorders Section Editor for Psychiatric Times, the Editor in Chief of The Carlat Psychiatry Report,and the Director of the Mood Treatment Center. His written several books on mood disorders, most recently The Depression and Bipolar Workbook. He can be heard in the weekly Carlat Psychiatry Podcastwith his co-host Kellie Newsome, PMH-NP. The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for The Depression and Bipolar Workbookand from W.W. Norton & Co. for Bipolar, Not So Much.
Kellie L. Newsome, PMH-NP,is the cohost of the Carlat Psychiatry Podcast and is also a practicing Psychiatric Mental Health Nurse Practitioner in Winston Salem, NC, at the Mood Treatment Center. Raised in Tasmania, Australia, Kellie moved to the United States in 1998.
For more on this topic, see Top Mood Stabilizers for Bipolar Disorder.
Lithium is effective in bipolar affective disorder in children
In a new randomized, double-blind, placebo-controlled clinical trial, scientists from Johns Hopkins University (Johns Hopkins University), USA, proved that lithium is effective in the treatment of bipolar affective disorder, manic and mixed forms currents in children. They noted that lithium preparations are the gold standard and standard of therapy for bipolar disorder in adult patients, however, prior to this work, there have been no rigorous methodological studies on their effectiveness in pediatric practice. The results of the study are presented online in the journal Pediatrics.
Participants were 81 patients aged 7-17 years with diagnosed bipolar disorder with manic and mixed episodes. Of these, 53 patients took lithium preparations (Group 1), and the rest - placebo (Group 2). Their mental status was assessed using the Young Mania Rating Scale (YMRS) and the Children's Depression Rating Scale (Revised).
Initially, the appointment of psychostimulants during the work was excluded, however, after 4 weeks, participants with concomitant attention deficit hyperactivity disorder began to take drugs in this group. The initial dose of lithium was 600–900 mg/day, with only patients weighing <30 kg receiving 600 mg/day. The average weekly dose in participants aged 7-11 years was 1292 mg, 12-17 years was 1716 mg.
8 weeks after the start of the study, scientists analyzed the condition of the participants and, taking into account their age, gender and other factors, determined that patients in the 1st group felt significantly better than the representatives of the 2nd (p = 0.03) . So, patients of the 1st group on average scored 17.8 points on the YMRS scale (which in 32% of cases is half lower than at the beginning of the study), and the 2nd group - 22.3 points, which indicates the presence of pronounced signs of manic behavior . Considering the results obtained, the researchers noted that the therapeutic effect of lithium preparations in children with bipolar disorder was 5.
51 points. After assessing the condition of all patients using the Clinical Global Impression — Severity scale — CGI-S, the scientists noted that the severity of symptoms in participants in the 1st group decreased by 42%, and the 2nd — by 21% . Moreover, 26% of patients in group 1 and only 14% of patients in group 2 were diagnosed with disease remission during the 8th week of work.
Study leader Dr. Robert Findling noted that lithium was often associated with side effects. Thus, vomiting occurred in 45% of patients, nausea - in 43%, headache - in 36%, but none of them refused to participate in the work. To reduce the severity of such effects, participants were asked not to take drugs on an empty stomach and to use a higher dose in the evening. Side effects related to general metabolism were recorded. So, on average, the increase in body weight over the study period in patients of the 1st group was 0.9kg, and the 2nd - 1.2 kg. Scientists suggest that longer-term use of lithium preparations may contribute to impaired weight gain in children with the pathology under study.
In addition, the scientists noted that taking lithium preparations led to a statistically significant increase in the level of thyroid-stimulating hormone (p<0.001). It is known that lithium can affect the function of the thyroid gland, therefore, recommendations for prescribing such drugs to children should contain instructions for gradually reducing their dose or using hormone replacement therapy.
Julia Kotikovich
| USAN accepted for use in the USA Included in preparations: list Pharmacological action Normothymic agent (normalizes mental state without causing general lethargy). At therapeutic concentrations, it blocks the activity of inosyl 1 -phosphatase and reduces the concentration of neuronal inositol, which is involved in the regulation of neuronal sensitivity. The beneficial effect of lithium in migraine may be due to changes in platelet serotonin and histamine concentrations. The antidepressant effect may be associated with an increase in serotonergic activity and a decrease in the regulation of the function of β-adrenergic receptors. PharmacokineticsAbsorbed from the gastrointestinal tract when taken orally. C max of the active substance in plasma is reached after approximately 9 hours. Does not bind to plasma proteins. Penetrates through the placental barrier, excreted in breast milk. Not metabolized. Excreted by the kidneys - 95%, with feces - less than 1%, with sweating - 4-5%. Indications of the active substance LITHIUM CARBONATEManic and hypomanic states of various origins, prevention and treatment of affective psychoses, prevention and treatment of affective disorders in patients with chronic alcoholism. Migraine, Meniere's syndrome, sexual disorders, drug addiction. Open list of ICD-10 codes
Dosing regimenThe dose is determined by the level of lithium concentration in blood plasma. Taken inside. For adults, the dose is 300-600 mg 3-4 times / day. The therapeutic concentration of lithium in plasma is 0.6-1 mmol / l. For children under 12 years old - 15-20 mg 2-3 times a day. The maximum daily dose of for adults when taken orally is 2.4 g. . From the side of the cardiovascular system: heart rhythm disorders. From the digestive system: dyspepsia. From the endocrine system: rarely - thyroid dysfunction. Others: increased thirst, hematopoietic disorders, leukocytosis, weight gain. Contraindications for useLeukemia, severe surgery, pregnancy, lactation. Use during pregnancy and lactation Contraindicated for use during pregnancy and lactation (breastfeeding). Use in impaired renal functionUse with caution in renal failure. Use in childrenLong-acting dosage forms should not be used in children under 12 years of age. Use in elderly patientsElderly patients require dosage adjustment. Special instructionsUse with caution in cardiovascular diseases (including AV blockade, intraventricular blockade), CNS diseases (including epilepsy, parkinsonism, organic lesions, schizophrenia), severe dehydration, infectious diseases, urinary retention, renal failure, as well as diabetes mellitus, hyperparathyroidism, thyrotoxicosis, psoriasis, in debilitated patients and hyponatremia of any etiology. Elderly and debilitated patients require dosage adjustment. Nausea and vomiting, early signs of lithium toxicity, may be masked by the antiemetic effect of some phenothiazines. During the first month of therapy, plasma lithium levels should be monitored weekly. Do not drink alcohol during treatment. Long-acting dosage forms should not be used in children under 12 years of age, do not alternate with other dosage forms. Influence on the ability to drive vehicles and mechanisms During the period of treatment, care should be taken when driving vehicles and engaging in other potentially hazardous activities that require increased attention and speed of psychomotor reactions. Drug interactionsWith simultaneous use with thiazide diuretics, indapamide, a rapid increase in the concentration of lithium in the blood plasma and the development of toxic effects are possible. With simultaneous use with ACE inhibitors, an increase in the concentration of lithium in the blood plasma and the development of toxic effects are possible; with NSAIDs - it is possible to increase the toxic effects of lithium; with iodine preparations - an increase in the risk of thyroid dysfunction is possible; with xanthine derivatives - it is possible to increase the excretion of lithium in the urine, which can lead to a decrease in its effectiveness. With simultaneous use with alprazolam, a clinically significant increase in the concentration of lithium in the blood plasma is possible; with acyclovir - a case of increased toxic effect of lithium is described; with baclofen - cases of increased hyperkinetic symptoms in patients with Huntington's chorea are described. With the simultaneous use of lithium carbonate with verapamil, drug interactions are unpredictable. With the simultaneous use of lithium carbonate with diltiazem, a case of psychosis has been described. Co-administration with haloperidol may increase extrapyramidal symptoms; with carbamazepine, clonazepam - neurotoxicity may develop. With simultaneous use with methyldopa, the development of the toxic effect of lithium is possible; with metronidazole - it is possible to increase the concentration of lithium in the blood plasma. When used simultaneously with sodium chloride, sodium bicarbonate, high sodium intake enhances lithium excretion, which may lead to a decrease in its effectiveness.    Copyright © · The Wright Initiative · Articles · Site Map 
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It also has antidepressant, sedative and antimanic effects. The effect is due to lithium ions, which, being antagonists of sodium ions, displace them from cells and thereby reduce the bioelectrical activity of brain neurons. Accelerates the breakdown of biogenic amines (the concentration of norepinephrine and serotonin in the brain tissues decreases). Increases the sensitivity of neurons in the hippocampus and other areas of the brain to the action of dopamine. Interacts with lipids formed during the metabolism of inositol. 
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When a stable concentration is reached, the control is carried out monthly, then 1 time in 2-3 months. 
