Lithium drug monitoring during COVID-19 for stable adult patients

This page gives advice on monitoring and prescribing lithium during the COVID-19 pandemic.

General guidance on the management of medicines to treat mental health conditions during COVID-19 is available from the Royal College of Psychiatrists

Advice on other medicines with drug monitoring schedules during this time is here

Normal monitoring recommendations for lithium are:

  • thyroid function, renal function and weight check normally every 6 months; or every 3 months in at-risk patients (defined below)
  • once stable, serum lithium levels every 3 months for the first year then normally every 6 months thereafter; or continue every 3 months in at-risk patients (defined below)

During the COVID-19 pandemic, recommendations are:

  • If patients are not in the at-risk category (defined below) then monitoring intervals can be extended by up to 3 months; however, patients must keep in good physical health and maintain good fluid intake and should resume normal monitoring intervals as soon as possible and safe to do so
  • If patients are in the at-risk category (defined below) then their normal monitoring interval should be continued and extension is in most circumstances inappropriate

At-risk patients are defined as: 

  • Elderly (> 65 years)
  • Have received less than 12 months treatment
  • Renal impairment (eGFR < 60ml/min)
  • Impaired thyroid function at last test
  • Raised calcium levels at last test
  • Poor symptom control or suspected poor adherence
  • Last serum lithium > 0.8mmol/L
  • Recent (i.e. since last blood test) introduction or removal of interacting medications (See BNF for exhaustive list. Key interacting medications include, NSAIDs, ACEi, ARB and thiazide diuretics)

For patients with COVID-19 symptoms, recommendations are: 

  • If patient does not have symptoms of lithium toxicity, continue lithium but take lithium serum level and U&Es
  • If patient has symptoms of lithium toxicity WITHOLD lithium, take URGENT lithium serum level and U&Es
  • Symptoms of lithium toxicity include: diarrhoea, vomiting, tremor, mental state changes, or falls
  • Advise patients to maintain their fluid intake and not to take over-the-counter NSAIDs (e.g. ibuprofen), but to take paracetamol instead.

This page was developed in conjunction with Professor David Taylor, Director of Pharmacy at the Maudsley Hospital; and Peter Pratt, Specialist Mental Health Pharmacy Advisor at NHSEI.  We are hugely grateful for their input.