ponse [see dosage and administration ( 2.6 ), warning and precautions ( 5.3 )] examples: hydrochlorothiazide, chlorothiazide, furosemide non-steroidal anti-inflammatory drugs (nsaid) clinical impact: nsaid decrease renal blood flow, resulting in decreased renal clearance and increased serum lithium concentrations. intervention: more frequent serum lithium concentration monitoring. reduce lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: indomethacin, ibuprofen, naproxen renin-angiotensin system antagonists clinical impact: concomitant use increase steady-state serum lithium concentrations. intervention: more frequent monitoring of serum lithium concentration. reduce lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: lisinopril, enalapril, captopril, valsartan serotonergic drugs clinical impact: concomitant use can precipitate serotonin syndrome. intervention: monitor patients for signs and symptoms of serotonin syndrome, particularly during lithium initiation. if serotonin syndrome occurs, consider discontinuation of lithium and/or concomitant serotonergic drugs [see warnings and precautions ( 5.6 )]. examples: selective serotonin reuptake inhibitors (ssri), serotonin and norepinephrine reuptake inhibitors (snri), monoamine oxidase inhibitors (maoi) nitroimidazole antibiotics clinical impact: concomitant use may cause lithium toxicity due to reduced renal clearance. intervention: more frequent monitoring of serum lithium concentration. reduce lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: metronidazole acetazolamide, urea, xanthine preparations, alkalinizing agents clinical impact: concomitant use can lower serum lithium concentrations by increasing urinary lithium excretion. intervention: more frequent serum lithium concentration monitoring. increase lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: acetazolamide, theophylline, sodium bicarbonate methyldopa, phenytoin and carbamazepine clinical impact: concomitant use may increase risk of toxic effects of these drugs intervention: monitor patients closely for symptoms of toxicity of methyldopa, phenytoin, and carbamazepine. iodide preparations clinical impact: concomitant use may produce hypothyroidism. intervention: monitor patients for signs or symptoms of hypothyroidism [see warnings and precautions ( 5.7 )]. examples: potassium iodide calcium channel blocking agents (ccb) clinical impact: concomitant use may increase the risk of neurologic adverse reactions in the form of ataxia, tremors, nausea, vomiting, diarrhea and/or tinnitus. intervention: monitor for neurologic adverse reactions. examples: diltiazem, nifedipine, verapamil atypical and typical antipsychotic drugs clinical impact: reports of neurotoxic reactions in patients treated with both lithium and an antipsychotic, ranging from extrapyramidal symptoms to neuroleptic malignant syndrome, as well as reports of an encephalopathic syndrome in few patients treated with concomitant therapy [see warnings and precautions ( 5.5 )]. intervention: monitor for neurologic adverse reactions. examples: risperidone, haloperidol, thioridazine, fluphenazine, chlorpromazine, perphenazine, clozapine neuromuscular blocking agents clinical impact: lithium may prolong the effects of neuromuscular blocking agents. intervention: monitor for prolonged paralysis or toxicity. examples: succinylcholine, pancuronium

patients treated with lithium and an antipsychotic. monitor routinely for changes to cognitive function ( 5.5 ) • hypothyroidism and hyperthyroidism: monitor thyroid function regularly ( 5.7 ) • hypercalcemia and hyperparathyroidism: associated with long-term lithium use. monitor serum calcium ( 5.8 ) 5.1 acute lithium toxicity the toxic concentrations for lithium (≥1.5 meq/l) are close to the therapeutic range (0.8 to 1.2meq/l). some patients abnormally sensitive to lithium may exhibit toxic signs at serum concentrations that are considered within the therapeutic range [see boxed warning, dosage and administration ( 2.6 )] . lithium may take up to 24 hours to distribute into brain tissue, so occurrence of acute toxicity symptoms may be delayed. diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination may be early signs of lithium toxicity, and can occur at lithium concentrations below 2.0 meq/l. at higher concentrations, giddiness, ataxia, blurred vision, tinnitus and a large output of dilute urine may be seen. serum lithium concentrations above 3.0 meq/l may produce a complex clinical picture involving multiple organs and organ systems, coma, and eventually death. serum lithium concentrations should not be permitted to exceed 2.0 meq/l. neurological signs of lithium toxicity range from mild neurological adverse reactions such as fine tremor, lightheadedness, and weakness; to moderate manifestations like apathy, drowsiness, hyperreflexia, muscle twitching, and slurred speech; and severe manifestations such as clonus, confusion, seizure, coma and death. cardiac manifestations involve electrocardiographic changes, such as prolonged qt interval, st and t-wave changes and myocarditis. renal manifestations include urine concentrating defect, nephrogenic diabetes insipidus, and renal failure. respiratory manifestations include dyspnea, aspiration pneumonia, and respiratory failure. gastrointestinal manifestations include nausea, vomiting, and bloating. no specific antidote for lithium poisoning is known. early symptoms of lithium toxicity can usually be treated by reduction or cessation of lithium, before restarting treatment at a lower dose 24 to 48 hours later [see overdosage ( 10 )] . the risk of acute toxicity is increased with a recent onset of concurrent illness or with the concomitant administration of drugs which increase lithium serum concentrations by pharmacokinetic interactions [see drug interactions ( 7 )] . additional risk factors for acute lithium toxicity include acute ingestion, age-related decline in renal function, volume depletion and/or changes in electrolyte concentrations, especially sodium and potassium. dose requirements during the acute manic phase are higher to maintain therapeutic serum concentrations and decrease when manic symptoms subside. the risk of lithium toxicity is very high in patients with significant renal or cardiovascular disease, severe debilitation or dehydration, or sodium depletion, and for patients receiving prescribed medications that may affect kidney function, such as angiotensin converting enzyme inhibitors (ace inhibitors), diuretics (loops and thiazides) and nsaids. for these patients, consider starting with lower doses and titrating slowly while frequently monitoring serum lithium concentrations and signs of lithium toxicity. to reduce the risk of acute lithium toxicity during treatment initiation, facilities for prompt and accurate serum lithium determinations should be available before initiating treatment [see boxed warning, dosage and administration ( 2.6 )] . advise patients and caregivers to watch for signs of early toxicity and to discontinue lithium and immediately inform their health care provider if they occur. 5.2 lithium-induced polyuria chronic lithium treatment may be associated with diminution of renal concentrating ability, occasionally presenting as nephrogenic diabetes insipidus, with polyuria and polydipsia. the concentrating defect and natriuretic effect characteristic of this condition may develop within weeks of lithium initiation. lithium can also cause renal tubular acidosis, resulting in hyperchloremic metabolic acidosis. such patients should be carefully managed to avoid dehydration with resulting lithium retention and toxicity. this condition is usually reversible when lithium is discontinued, although for patients treated with long-term lithium, nephrogenic diabetes insipidus may be only partly reversible upon discontinuation of lithium. amiloride may be considered as a therapeutic agent for lithium-induced nephrogenic diabetes insipidus. 5.3 hyponatremia lithium can cause hyponatremia by decreasing sodium reabsorption by the renal tubules, leading to sodium depletion. therefore, it is essential for patients receiving lithium treatment to maintain a normal diet, including salt, and an adequate fluid intake (2500 to 3000 ml) at least during the initial stabilization period. decreased tolerance to lithium has also been reported to ensue from protracted sweating or diarrhea and, if such occur, supplemental fluid and salt should be administered under careful medical supervision and lithium intake reduced or suspended until the condition is resolved. in addition, concomitant infection with elevated temperatures may also necessitate a temporary reduction or cessation of medication. symptoms are also more severe with faster-onset hyponatremia. mild hyponatremia (i.e., serum na > 120 meq/l) can be asymptomatic. below this threshold, clinical signs are usually present, consisting mainly of changes in mental status, such as altered personality, lethargy, and confusion. for more severe hyponatremia (serum na < 115 meq/l), stupor, neuromuscular hyperexcitability, hyperreflexia, seizures, coma, and death can result. during treatment of hyponatremia, serum sodium should not be elevated by more than 10 to 12 meq/l in 24 hours or 18 meq/l in 48 hours. in the case of severe hyponatremia where severe neurologic symptoms are present, a faster infusion rate to correct serum sodium concentration may be needed. patients rapidly treated or with serum sodium <120meq/l are more at risk of developing osmotic demyelination syndrome (previously called central pontine myelinolysis). occurrence is more common among patients with alcoholism, undernutrition, or other chronic debilitating illness. common signs include flaccid paralysis, dysarthria. in severe cases with extended lesions patients may develop a locked-in syndrome (generalized motor paralysis). damage often is permanent. if neurologic symptoms start to develop during treatment of hyponatremia, serum sodium correction should be suspended to mitigate the development of permanent neurologic damage. 5.4 lithium-induced chronic kidney disease the predominant form of chronic renal disease associated with long-term lithium treatment is a chronic tubulointerstitial nephropathy (ctin). the biopsy findings in patients with lithium induced ctin include tubular atrophy, interstitial fibrosis, sclerotic glomeruli, tubular dilation, and nephron atrophy with cyst formation. the relationship between renal function and morphologic changes and their association with lithium treatment has not been established. ctin patients might present with nephrotic proteinuria (>3.0g/dl), worsening renal insufficiency and/or nephrogenic diabetes insipidus. postmarketing cases consistent with nephrotic syndrome in patients with or without ctin have also been reported. the biopsy findings in patients with nephrotic syndrome include minimal change disease and focal segmental glomerulosclerosis. the discontinuation of lithium in patients with nephrotic syndrome has resulted in remission of nephrotic syndrome. kidney function should be assessed prior to and during lithium treatment. routine urinalysis and other tests may be used to evaluate tubular function (e.g., urine specific gravity or osmolality following a period of water deprivation, or 24-hour urine volume) and glomerular function (e.g., serum creatinine, creatinine clearance, or proteinuria). during lithium treatment, progressive or sudden changes in renal function, even within the normal range, indicate the need for revaluation of treatment. 5.5 encephalopathic syndrome an encephalopathic syndrome, characterized by weakness, lethargy, fever, tremulousness and confusion, extrapyramidal symptoms, leukocytosis, elevated serum enzymes, bun and fasting blood glucose, has occurred in patients treated with lithium and an antipsychotic. in some instances, the syndrome was followed by irreversible brain damage. because of a possible causal relationship between these events and the concomitant administration of lithium and antipsychotics, patients receiving such combined treatment should be monitored closely for early evidence of neurological toxicity and treatment discontinued promptly if such signs appear. this encephalopathic syndrome may be similar to or the same as neuroleptic malignant syndrome (nms). 5.6 serotonin syndrome lithium can precipitate serotonin syndrome, a potentially life-threatening condition. the risk is increased with concomitant use of other serotonergic drugs (including selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, triptans, tricyclic antidepressants, fentanyl, tramadol, tryptophan, buspirone, and st. john’s wort) and with drugs that impair metabolism of serotonin, i.e., maois [see drug interactions ( 7.1 )] . serotonin syndrome signs and symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). monitor all patients taking lithium for the emergence of serotonin syndrome. discontinue treatment with lithium and any concomitant serotonergic agents immediately if the above symptoms occur, and initiate supportive symptomatic treatment. if concomitant use of lithium with other serotonergic drugs is clinically warranted, inform patients of the increased risk for serotonin syndrome and monitor for symptoms. 5.7 hypothyroidism or hyperthyroidism lithium is concentrated within the thyroid and can inhibit thyroid synthesis and release which can lead to hypothyroidism. where hypothyroidism exists, careful monitoring of thyroid function during lithium stabilization and maintenance allows for correction of changing thyroid parameters, if any. where hypothyroidism occurs during lithium stabilization and maintenance, supplemental thyroid treatment may be used. paradoxically, some cases of hyperthyroidism have been reported including grave’s disease, toxic multinodular goiter and silent thyroiditis. monitor thyroid function before the initiation of treatment, at three months and every six to twelve months while treatment is ongoing. if serum thyroid tests warrant concern, monitoring should occur more frequently. 5.8 hypercalcemia and hyperparathyroidism long-term lithium treatment is associated with persistent hyperparathyroidism and hypercalcemia. when clinical manifestations of hypercalcemia are present, lithium withdrawal and change to another mood stabilizer may be necessary. hypercalcemia may not resolve upon discontinuation of lithium, and may require surgical intervention. lithium-induced cases of hyperparathyroidism are more often multiglandular compared to standard cases. false hypercalcemia due to plasma volume depletion resulting from nephrogenic diabetes insipidus should be excluded in individuals with mildly increased serum calcium. monitor serum calcium concentrations regularly. 5.9 unmasking of brugada syndrome there have been postmarketing reports of a possible association between treatment with lithium and the unmasking of brugada syndrome. brugada syndrome is a disorder characterized by abnormal electrocardiographic (ecg) findings and a risk of sudden death. lithium should be avoided in patients with brugada syndrome or those suspected of having brugada syndrome. consultation with a cardiologist is recommended if: (1) treatment with lithium is under consideration for patients suspected of having brugada syndrome or patients who have risk factors for brugada syndrome, e.g., unexplained syncope, a family history of brugada syndrome, or a family history of sudden unexplained death before the age of 45 years, (2) patients who develop unexplained syncope or palpitations after starting lithium treatment. 5.10 pseudotumor cerebri cases of pseudotumor cerebri (increased intracranial pressure and papilledema) have been reported with lithium use. if undetected, this condition may result in enlargement of the blind spot, constriction of visual fields and eventual blindness due to optic atrophy. consider discontinuing lithium if this syndrome occurs.

�¢ severe renal impairment (clcr < 30 ml/min): avoid use of lithium ( 2.8 ) 2.1 pre-treatment screening before initiating treatment with lithium, renal function, vital signs, serum electrolytes, and thyroid function should be evaluated. concurrent medications should be assessed, and if the patient is a woman of childbearing potential, pregnancy status and potential should be considered. 2.2 starting dosage consider medical conditions and drug interactions that would affect lithium dosage and administration [see warnings and precautions ( 5.1 ), drug interactions ( 7.1 )]. in the absence of medical conditions and concomitant medications that would suggest starting at a lower dose, the recommended starting dose in adults is: • capsules: 300 mg three times daily obtain serum lithium concentration assay after 4 days, drawn 12 hours after the last oral dose. adjust daily dosage based on serum lithium concentration and clinical response. fine hand tremor, polyuria and mild thirst may occur during initial therapy for the acute manic phase, and may persist throughout treatment. transient and mild nausea and general discomfort may also appear during the first few days of lithium administration. these adverse reactions may subside with continued treatment, concomitant administration with food, temporary reduction or cessation of dosage. 2.3 dosage for acute treatment of manic episodes in bipolar i disorder titrate to serum lithium concentrations between 0.8 and 1.2 meq/l, which may be achieved in adults with: • capsules: 600 mg, two to three times daily obtain serum lithium concentrations regularly until the serum concentration and clinical condition of the patient has stabilized [see dosage and administration ( 2.6 )] . adjust daily dosage based on serum lithium concentration and clinical response. 2.4 dosage for maintenance treatment of bipolar i disorder titrate to serum lithium concentrations between 0.8 and 1 meq/l, which may be achieved in adults with: • capsules: 300 mg to 600 mg, two to three times daily monitor the patient's clinical state and serum lithium concentrations regularly [see dosage and administration ( 2.6 )] . adjust daily dosage based on serum lithium concentration and clinical response. 2.5 dosage recommendations in pediatric patients 12 to 17 years of age dosage recommendations for lithium in patients 12 years and older are similar to that of adults [see use in specific populations ( 8.4 )] . 2.6 serum lithium monitoring blood samples for serum lithium determination should be drawn immediately prior to the next dose when lithium concentrations are relatively stable (i.e., 12 hours after the previous dose). total reliance must not be placed on serum concentrations alone. accurate patient evaluation requires both clinical and laboratory analysis. in addition to regular monitoring of serum lithium concentrations for patients on maintenance treatment, serum lithium concentrations should be monitored after any change in dosage, concurrent medication (e.g., diuretics, non-steroidal anti-inflammatory drugs, renin-angiotensin system antagonists, or metronidazole), marked increase or decrease in routinely performed strenuous physical activity (such as an exercise program) and in the event of a concomitant disease [see boxed warning, warnings and precautions ( 5.1 ), drug interactions ( 7.1 )] . patients abnormally sensitive to lithium may exhibit toxic signs at serum concentrations that are within what is considered the therapeutic range. geriatric patients often respond to reduced dosage, and may exhibit signs of toxicity at serum concentrations ordinarily tolerated by other patients [see use in specific populations ( 8.5 )] . 2.7 dosage adjustments during pregnancy and the postpartum period if the decision is made to continue lithium treatment during pregnancy, monitor serum lithium concentrations and adjust the dosage as needed in a pregnant woman because renal lithium clearance increases during pregnancy. avoid sodium restriction or diuretic administration. to decrease the risk of postpartum lithium intoxication, decrease or discontinue lithium therapy two to three days before the expected delivery date to reduce neonatal concentrations and reduce the risk of maternal lithium intoxication due to the change in vascular volume which occurs during delivery. at delivery, vascular volume rapidly decreases and the renal clearance of lithium may decrease to pre-pregnancy concentrations. restart treatment at the preconception dose when the patient is medically stable after delivery with careful monitoring of serum lithium concentrations [see warnings and precautions ( 5.1 ) and use in specific populations ( 8.1 )] . 2.8 dosage adjustments for patients with renal impairment start patients with mild to moderately impaired renal function (creatinine clearance 30 to 89 ml/min evaluated by cockcroft-gault) with dosages less than those for patients with normal renal function [see dosage and administration ( 2.2 )] . titrate slowly while frequently monitoring serum lithium concentrations and monitoring for signs of lithium toxicity. lithium is not recommended for use in patients with severe renal impairment (creatinine clearance less than 30 ml/min evaluated by cockcroft-gault) [see use in specific populations ( 8.6 )] .

lways possible to reliably estimate their frequency or establish a causal relationship to drug exposure. central nervous system : tremor, muscle hyperirritability (fasciculations, twitching, clonic movements of whole limbs), hypertonicity, ataxia, choreoathetotic movements, hyperactive deep tendon reflexes, extrapyramidal symptoms including acute dystonia, cogwheel rigidity, blackout spells, epileptiform seizures, slurred speech, dizziness, vertigo, downbeat nystagmus, incontinence of urine or faeces, somnolence, psychomotor retardation, restlessness, confusion, stupor, coma, tongue movements, tics, tinnitus, hallucinations, poor memory, slowed intellectual functioning, startled response, worsening of organic brain syndromes, myasthenic syndromes (rarely). eeg changes : diffuse slowing, widening of frequency spectrum, potentiation and disorganization of background rhythm. cardiovascular: conduction disturbance (mostly sinus node dysfunction with possibly severe sinus bradycardia and sinoatrial block), ventricular tachyarrhythmia, peripheral vasculopathy (resembling raynaud’s syndrome). ecg changes : reversible flattening, isoelectricity or rarely inversion of t-waves, prolongation of the qtc interval. gastrointestinal: anorexia, nausea, vomiting, diarrhea, gastritis, salivary gland swelling, abdominal pain, excessive salivation, flatulence, indigestion. genitourinary: glycosuria, decreased creatinine clearance, albuminuria, oliguria, and symptoms of nephrogenic diabetes insipidus including polyuria, thirst, and polydipsia. dermatologic: drying and thinning of hair, alopecia, anaesthesia of skin, chronic folliculitis, xerosis cutis, psoriasis onset or exacerbation, generalized pruritus with or without rash, cutaneous ulcers, angioedema. autonomic nervous system: blurred vision, dry mouth, impotence/sexual dysfunction. miscellaneous: fatigue, lethargy, transient scotoma, exopthalmos, dehydration, weight loss, leukocytosis, headache, transient hyperglycemia, hypomagnesemia, excessive weight gain, edematous swelling of ankles or wrists, dysgeusia/taste distortion (e.g., metallic or salty taste), thirst, swollen lips, tightness in chest, swollen and/or painful joints, fever, polyarthralgia, and dental caries. common adverse reactions: fine hand tremor, polyuria, mild thirst, nausea, general discomfort during initial treatment. ( 6 ) to report suspected adverse reactions, contact hetero labs limited at 1-866-495-1995 or fda at 1-800-fda-1088 or www.fda.gov/medwatch .

ponse [see dosage and administration ( 2.6 ), warning and precautions ( 5.3 )] examples: hydrochlorothiazide, chlorothiazide, furosemide non-steroidal anti-inflammatory drugs (nsaid) clinical impact: nsaid decrease renal blood flow, resulting in decreased renal clearance and increased serum lithium concentrations. intervention: more frequent serum lithium concentration monitoring. reduce lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: indomethacin, ibuprofen, naproxen renin-angiotensin system antagonists clinical impact: concomitant use increase steady-state serum lithium concentrations. intervention: more frequent monitoring of serum lithium concentration. reduce lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: lisinopril, enalapril, captopril, valsartan serotonergic drugs clinical impact: concomitant use can precipitate serotonin syndrome. intervention: monitor patients for signs and symptoms of serotonin syndrome, particularly during lithium initiation. if serotonin syndrome occurs, consider discontinuation of lithium and/or concomitant serotonergic drugs [see warnings and precautions ( 5.6 )]. examples: selective serotonin reuptake inhibitors (ssri), serotonin and norepinephrine reuptake inhibitors (snri), monoamine oxidase inhibitors (maoi) nitroimidazole antibiotics clinical impact: concomitant use may cause lithium toxicity due to reduced renal clearance. intervention: more frequent monitoring of serum lithium concentration. reduce lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: metronidazole acetazolamide, urea, xanthine preparations, alkalinizing agents clinical impact: concomitant use can lower serum lithium concentrations by increasing urinary lithium excretion. intervention: more frequent serum lithium concentration monitoring. increase lithium dosage based on serum lithium concentration and clinical response [see dosage and administration ( 2.6 )]. examples: acetazolamide, theophylline, sodium bicarbonate methyldopa, phenytoin and carbamazepine clinical impact: concomitant use may increase risk of toxic effects of these drugs intervention: monitor patients closely for symptoms of toxicity of methyldopa, phenytoin, and carbamazepine. iodide preparations clinical impact: concomitant use may produce hypothyroidism. intervention: monitor patients for signs or symptoms of hypothyroidism [see warnings and precautions ( 5.7 )]. examples: potassium iodide calcium channel blocking agents (ccb) clinical impact: concomitant use may increase the risk of neurologic adverse reactions in the form of ataxia, tremors, nausea, vomiting, diarrhea and/or tinnitus. intervention: monitor for neurologic adverse reactions. examples: diltiazem, nifedipine, verapamil atypical and typical antipsychotic drugs clinical impact: reports of neurotoxic reactions in patients treated with both lithium and an antipsychotic, ranging from extrapyramidal symptoms to neuroleptic malignant syndrome, as well as reports of an encephalopathic syndrome in few patients treated with concomitant therapy [see warnings and precautions ( 5.5 )]. intervention: monitor for neurologic adverse reactions. examples: risperidone, haloperidol, thioridazine, fluphenazine, chlorpromazine, perphenazine, clozapine neuromuscular blocking agents clinical impact: lithium may prolong the effects of neuromuscular blocking agents. intervention: monitor for prolonged paralysis or toxicity. examples: succinylcholine, pancuronium

fetal weight, increased fetal skeletal abnormalities, and cleft palate (mouse fetuses only) with oral doses of lithium that produced serum concentrations similar to the human therapeutic range. other published animal studies report adverse effects on embryonic implantation in rats after lithium administration. advise pregnant women of the potential risk to a fetus. the background risk of major birth defects and miscarriage for the indicated population(s) is unknown. in the u.s. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. clinical considerations dose adjustments during pregnancy and the postpartum period if the decision is made to continue lithium treatment during pregnancy, serum lithium concentrations should be monitored and the dosage adjusted during pregnancy. two to three days prior to delivery, lithium dosage should be decreased or discontinued to reduce the risk of maternal and/or neonatal toxicity. lithium may be restarted in the post-partum period at preconception doses in medically stable patients as long as serum lithium levels are closely monitored [see dosage and administration ( 2.7 ), warnings and precautions ( 5.1 )]. fetal/neonatal adverse reactions lithium toxicity may occur in neonates who were exposed to lithium in late pregnancy. a floppy baby syndrome including neurological, cardiac, and hepatic abnormalities that are similar to those seen with lithium toxicity in adults have been observed. symptoms include hypotonia, respiratory distress syndrome, cyanosis, lethargy, feeding difficulties, depressed neonatal reflexes, neonatal depression, apnea, and bradycardia. monitor neonates and provide supportive care until lithium is excreted and toxic signs disappear, which may take up to 14 days. consider fetal echocardiography between 16 and 20 weeks gestation in a woman with first trimester lithium exposure because of the potential increased risk of cardiac malformations. 8.2 lactation risk summary limited published data reports the presence of lithium carbonate in human milk with breast milk levels measured at 0.12 to 0.7 meq or 40 to 45% of maternal plasma levels. infants exposed to lithium during breastfeeding may have plasma levels that are 30 to 40% of maternal plasma levels. signs and symptoms of lithium toxicity such as hypertonia, hypothermia, cyanosis, and ecg changes have been reported in some breastfed neonates and infants. increased prolactin levels have been measured in lactating women, but the effects on milk production are not known. breastfeeding is not recommended with maternal lithium use; however, if a woman chooses to breastfeed, the infant should be closely monitored for signs of lithium toxicity. discontinue breastfeeding if a breastfed infant develops lithium toxicity. clinical considerations consider regular monitoring of lithium levels and thyroid function in a breastfed infant. 8.4 pediatric use dosage recommendations for lithium in patients 12 years and older are similar to that of adults [see dosage and administration ( 2.5 )]. safety and effectiveness of lithium in pediatric patients below the age of 12 years have not been established. 8.5 geriatric use clinical studies of lithium carbonate tablets did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. other reported clinical experience has not identified differences in response between the elderly and younger patients. in general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other treatment. lithium is known to be substantially excreted by the kidneys, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function. 8.6 renal impairment as lithium is eliminated primarily through the kidney, lithium renal clearance is decreased in patients with abnormal renal function, and the risk of lithium intoxication increases considerably in this setting. lithium should not be used in severe renal insufficiency (creatinine clearance less than 30 ml/min evaluated by cockcroft-gault), especially if the condition requires adherence to a low-sodium diet [see dosage and administration ( 2.8 )]. start patients with mild to moderately impaired renal function (creatinine clearance 30 to 89 ml/min evaluated by cockcroft-gault) with lower doses of lithium and titrate slowly while frequently monitoring serum lithium concentrations and for signs of lithium toxicity [see dosage and administration ( 2.8 )].

mbryonic implantation in rats after lithium administration. advise pregnant women of the potential risk to a fetus. the background risk of major birth defects and miscarriage for the indicated population(s) is unknown. in the u.s. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. clinical considerations dose adjustments during pregnancy and the postpartum period if the decision is made to continue lithium treatment during pregnancy, serum lithium concentrations should be monitored and the dosage adjusted during pregnancy. two to three days prior to delivery, lithium dosage should be decreased or discontinued to reduce the risk of maternal and/or neonatal toxicity. lithium may be restarted in the post-partum period at preconception doses in medically stable patients as long as serum lithium levels are closely monitored [see dosage and administration ( 2.7 ), warnings and precautions ( 5.1 )]. fetal/neonatal adverse reactions lithium toxicity may occur in neonates who were exposed to lithium in late pregnancy. a floppy baby syndrome including neurological, cardiac, and hepatic abnormalities that are similar to those seen with lithium toxicity in adults have been observed. symptoms include hypotonia, respiratory distress syndrome, cyanosis, lethargy, feeding difficulties, depressed neonatal reflexes, neonatal depression, apnea, and bradycardia. monitor neonates and provide supportive care until lithium is excreted and toxic signs disappear, which may take up to 14 days. consider fetal echocardiography between 16 and 20 weeks gestation in a woman with first trimester lithium exposure because of the potential increased risk of cardiac malformations.

of muscle coordination, drowsiness, abnormal heart rhythm or muscular weakness occur [see warnings and precautions ( 5.1 )]. lithium-induced polyuria counsel patients on the adverse reactions related to lithium-induced polyuria, when to seek medical attention, and the importance of maintaining normal diet with salt and staying hydrated [see warnings and precautions ( 5.2 )]. hyponatremia counsel patients on the adverse reactions of hyponatremia, when to seek medical attention, the importance of maintaining a normal diet including adequate salt intake and staying hydrated [see warnings and precautions ( 5.3 )]. salt supplements and additional fluids may be required if excessive losses occur. serotonin syndrome caution patients about the risk of serotonin syndrome, particularly with the concomitant use of lithium with other serotonergic drugs including ssris, snris, triptans, tricyclic antidepressants, fentanyl, tramadol, tryptophan, buspirone, st. john's wort, and with drugs that impair metabolism of serotonin (in particular, maois, both those intended to treat psychiatric disorders and also others, such as linezolid) [see warnings and precautions ( 5.6 ) and drug interactions ( 7 )]. drug interactions advise patients that many drugs can interact with lithium and to inform their doctor and pharmacist if they are taking any over the counter medication, including herbal medication, or are started on a new prescription [see drug interactions ( 7 )]. somnolence tell patients that lithium may cause somnolence particularly when initiating treatment and to be cautious about operating vehicles or hazardous machinery, until they are reasonably certain that lithium treatment does not affect them adversely [see adverse reactions ( 6 )]. pregnancy advise pregnant women of the potential risk to a fetus and/or neonate [see use in specific populations ( 8.1 )]. lactation advise women that breastfeeding is not recommended during treatment with lithium [see use in specific populations ( 8.2 )]. manufactured for: camber pharmaceuticals, inc. piscataway, nj 08854 by: hetero labs limited jeedimetla, hyderabad - 500 055, india 2046707