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Lithium should be ‘treatment of choice’ for bipolar disorder

Lithium should be used more widely for bipolar disorder, say the authors of a new analysis that shows that many of the safety concerns over the use of the drug are unwarranted.

NICE guidelines on bipolar disorder recommend a choice of lithium, olanzapine or valproatea for the long-term treatment of bipolar disorder, but safety concerns over lithium have led to a reduction in its use.

Current guidance from the BNF warns that any patient taking lithium should be assessed for renal and thyroid function every six months, and that the drug should be avoided in the first trimester of pregnancy.

However, this systematic review and meta-analysis of 385 studies looking at lithium found little evidence for a decrease in renal function or congenital malformations.

Patients taking lithium had reduced urinary concentrating ability (by 15% of normal maximum), the rate of hypothyroidism was increased about six-fold in those taking lithium, compared with placebo, and they gained more weight than those taking placebo (odds ratio 1.89). 

However, there was little evidence for a reduction in renal function and absolute risk of renal failure – only 18 of 3,369 patients received renal replacement – and ‘no significant evidence' for an increased rate of congential malformations, alopecia or skin disorders.

Corresponding author Professor John Geddes, professor of epidemiological psychiatry at University of Oxford said their study and others suggested that lithium should be more widely used

He said: ‘The present clinical recommendation is to avoid lithium in pregnancy. Our review suggests a sounder approach would be to explain the uncertainty of risk to women of childbearing age, before continuation or stopping of lithium therapy.'

An accompanying editorial concludes that this research reaffirms the role of lithium as a ‘treatment of choice' for bipolar disorder.

The Lancet 2012, published online 20 January


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