OBJECT DRUGS

• Lithium (Eskalith)

PRECIPITANT DRUGS

NSAIDs:

• Diclofenac (Voltaren, etc.)
• Diflunisal (Dolobid)
• Etodolac (Lodine)
• Fenoprofen (Nalfon)
• Flurbiprofen (Ansaid, etc.)
• Ibuprofen (Motrin, etc.)
• Indomethacin (Indocin, etc.)
• Ketoprofen (Orudis)
• Ketorolac (Toradol, etc.)
• Meclofenamate
• Mefenamic acid
• Meloxicam (Mobic)
• Nabumetone (Relafen)
• Naproxen (Aleve, etc.)
• Oxaprozin (Daypro)
• Piroxicam (Feldene)
• Sulindac (Clinoril)
• Tolmetin (Tolectin)

Comment:

Lithium toxicity has been reported with concurrent NSAID therapy, although the magnitude of the effect is highly variable from patient to patient. The lithium toxicity can be severe, and there are many case reports of lithium toxicity following initiation of NSAIDs. In an epidemiologic study ACE inhibitors and loop diuretics were associated with a substantial increase in the risk of hospitalization due to lithium toxicity, but an association with thiazide diuretics and NSAIDs was not found. It may be that only predisposed patients develop lithium toxicity from NSAIDs; for example only some patients manifest substantial reductions in renal function following use of NSAIDs.

Class 3: Assess Risk & Take Action if Necessary

• Consider Alternative: Salicylates do not appear to have much effect on plasma lithium concentrations and can be considered as alternatives to NSAIDs. Sulindac (Clinoril) appears less likely than other NSAIDs to increase lithium concentrations, but isolated cases have been reported. Acetaminophen is not likely to alter lithium elimination.
• Monitor: Monitor for altered lithium effects if NSAIDs are initiated, discontinued, changed in dosage, or if the patient is switched from one NSAID to another. Note that—depending on the original lithium serum concentration—it may take up to several weeks for lithium toxicity to become manifest. Lithium toxicity may cause nausea, vomiting, anorexia, diarrhea, slurred speech, confusion, lethargy, coarse tremor, and in severe cases can cause seizures and coma.