Lithium therapy in patients on dialysis: A systematic review.

BACKGROUND: Lithium is a first-line pharmacotherapy for the treatment of bipolar disorder, but long-term use is associated with nephrotoxicity. However, as dialysis effectively eliminates lithium, it remains a pharmacotherapeutic option for patients on dialysis. This systematic review seeks to evaluate the dosing, safety, efficacy, and monitoring of lithium in patients receiving dialysis. METHOD: A PubMed database search performed May 5th, 2020, identified 535 article titles. After exclusion criteria were applied, a total of 15 articles were included in this systematic review. RESULTS: In 18 patients receiving dialysis, lithium was primarily used for the treatment of mood disorders. The majority of patients received 300-900 mg lithium carbonate thrice-weekly following dialysis, but several alternative lithium salts and dosing strategies were utilized. The pharmacokinetic properties of lithium in dialysis are not well understood and can be complicated by a serum lithium "rebound effect" following dialysis, due to a two-compartment volume of distribution. Additionally, presence of residual diuresis in some patients may be reason to administer lithium more frequently than thrice-weekly following dialysis. Lithium was shown to be an effective pharmacotherapy in all patients, with many demonstrating rapid improvement after drug initiation. Five patients experienced an adverse event on lithium, but only one patient required lithium discontinuation. CONCLUSION: Lithium may be used in patients on dialysis, with close monitoring of pre-dialysis serum lithium concentrations for at least two weeks after treatment initiation, followed by a lower frequency after stabilization to ensure therapeutic concentrations and reduce toxicity risk.

Donepezil-related intractable hiccups: a case report.

This case report describes a man with intractable hiccups probably caused by donepezil. The patient's symptoms were not responsive to commonly used medications for hiccups, but they were improved and completely relieved upon donepezil dose deescalation and discontinuation. We report two occasions in which the discontinuation of donepezil resulted in hiccup resolution and three occasions in which initiation of donepezil was associated with the onset of hiccups. This report contributes to the growing body of literature that describes an association between centrally acting medications and intractable hiccups.

Rationale for iloperidone in the treatment of posttraumatic stress disorder.

Multiple controlled efficacy studies are available to support the use of psychotropic medications in the treatment of posttraumatic stress disorder symptoms. Iloperidone, a recently approved atypical antipsychotic, has yet to be evaluated in such a manner. This unique agent has the highest affinity of all antipsychotics toward alpha-1 receptors. Antagonism of central nervous system alpha-1 receptors has been implicated in certain aspects of posttraumatic stress disorder, as evidenced by the beneficial role of prazosin in treating nightmares. Additional reduction in hypervigilance may occur through blockade of dopamine receptor D2 and serotonin receptors in the 5-HT2 family. Further investigation of iloperidone is warranted in the treatment of patients with posttraumatic stress disorder due to its unique receptor binding profile.

Exploring the potential effect of polypharmacy on the hematologic profiles of clozapine patients.

INTRODUCTION: Clozapine, an atypical antipsychotic with documented efficacy in the management of treatment-resistant schizophrenia, is associated with the risk of adverse hematological outcomes. Of particular concern are reductions in white blood cells (WBC) and absolute neutrophil counts (ANC). Individuals who display moderate leukopenia (3000/mm(3) > WBC ≥ 2000/mm) upon initiation of clozapine therapy are at increased risk of developing agranulocytosis, defined as an ANC less than 500/mm. Complications of agranulocytosis can be severe and include increased risk of infection and mortality. OBJECTIVES: The primary objective of this study was to examine data on clozapine recipients who experienced adverse drug reactions (ADRs) related to decreases in WBC or ANC and ascertain whether other drugs and/or drug interactions had played a role. The analysis included multiple classes of medications. METHODS: A retrospective chart review was performed of open and closed medical records of all inpatient recipients of clozapine at a state psychiatric center between January 1, 2004 and June 30, 2011. Laboratory records of patients prescribed clozapine were examined for abnormal WBC counts or ANC. A hematological ADR was considered to have occurred if there was a substantial drop in either WBC or ANC or mild or moderate leukopenia or granulocytopenia. Each episode was analyzed for medications that might have contributed to the ADR. Data were collected for all scheduled and STAT medications started at any point during the clozapine patient's hospitalization. The following seven medication groups, based on the Therapeutic Classification System of the American Hospital Formulary System (AHFS), were chosen for analysis because they were consistently used in the majority of the patient population: antihistamines, anti-infectives, autonomic agents, cardiovascular agents, antipsychotics, vitamins, and gastrointestinal agents. Pearson correlation coefficients were calculated to identify associations between the presence of hematological ADRs and medications administered concomitantly with clozapine. RESULTS: The following significant correlation coefficients were found between the use of a class of medications and the occurrence of a hematological ADR: antiinfective agents 0.409 (p < 0.01), gastrointestinal agents 0.329 (p < 0.01), and autonomic agents 0.309 (p < 0.01). In the subset of patients who were prescribed a proton-pump inhibitor or ranitidine concomitantly with clozapine, 24/26 (96%) experienced a hematological ADR. CONCLUSIONS: Autonomic agents, anti-infective agents, and proton pump inhibitors and other gastrointestinal agents were all associated with hematological ADRs when co-prescribed with clozapine. Medications from these classes should be initiated cautiously in patients being treated with clozapine to avoid precipitous drops in ANC or WBC that may increase the risk of agranulocytosis.