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So I was toxic on lithium for a minimum of two months last year (september/october), but likely even further than that, per my then therapist.  I was having difficulty with aphasia, and that's part of the toxicity symptoms.  My last therapist's belief was that I had chronic toxicity for at least a chunk of time prior to the very clear september/october piece.  I was only taking 900 mg. 

I landed in the hospital because of the toxicity, barely able to take care of myself (if at all).  I couldn't form complete sentences, failed a mental status exam, couldn't feed myself, etc.  The1 hospital almost committed me involuntarily because they didn't think I was able to sign myself in.  My mom gave them a stern talking to about the fact that I'd gone there on my own and trusted them to allow a voluntary admission.  She asked them to give me a bit more time and force fluids to see if it helped.  Fortunately it did.  that said, I still don't remember the first 3-4 days of that hospital stay. 

I was released on 600mg, rather than the 900mg.  I was terrified of ever raising it, but I agreed that my psychiatrist would raise it about two weeks ago because I was starting to have depressive symptoms again.  She bumped it to 750.  She had me get a blood level done and it was 0.5.  So she called me and asked me to raise it again--purely to get it into the "therapeutic range."  We'd been keeping it below that because of how sensitive my body was and the fact that I'd gone toxic at a slightly higher dose.

So she wants to raise it.  She asked if I'm functioning and that's hard to answer.  I quit my job because of its impact on my mental health (at her recommendation/close to requirement).  But I'm still functioning independently.  I'm job searching.  I don't feel wonderful, but I'm also terrified of toxicity.  I know that fluids matter a lot and I drink a ton of water at my current job.  I'm not sure if I'll be able to maintain that while I'm at home job-searching.  In theory I should be able to, but I was literally drinking 1-2 liters.  So I fear that if my liquids drop, my level will increase. 

Long way of getting to the question...do you do a lithium increase just because you're below the therapeutic level?  Or would you wait and see how it goes?  I'd personally like to see how it goes at the increased dose since it's only been two weeks.  But I don't know if I'm acting out of fear or out of reason.

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1 hour ago, dancesintherain said:

So I was toxic on lithium for a minimum of two months last year (september/october), but likely even further than that, per my then therapist.  I was having difficulty with aphasia, and that's part of the toxicity symptoms.  My last therapist's belief was that I had chronic toxicity for at least a chunk of time prior to the very clear september/october piece.  I was only taking 900 mg. 

I landed in the hospital because of the toxicity, barely able to take care of myself (if at all).  I couldn't form complete sentences, failed a mental status exam, couldn't feed myself, etc.  The1 hospital almost committed me involuntarily because they didn't think I was able to sign myself in.  My mom gave them a stern talking to about the fact that I'd gone there on my own and trusted them to allow a voluntary admission.  She asked them to give me a bit more time and force fluids to see if it helped.  Fortunately it did.  that said, I still don't remember the first 3-4 days of that hospital stay. 

I was released on 600mg, rather than the 900mg.  I was terrified of ever raising it, but I agreed that my psychiatrist would raise it about two weeks ago because I was starting to have depressive symptoms again.  She bumped it to 750.  She had me get a blood level done and it was 0.5.  So she called me and asked me to raise it again--purely to get it into the "therapeutic range."  We'd been keeping it below that because of how sensitive my body was and the fact that I'd gone toxic at a slightly higher dose.

So she wants to raise it.  She asked if I'm functioning and that's hard to answer.  I quit my job because of its impact on my mental health (at her recommendation/close to requirement).  But I'm still functioning independently.  I'm job searching.  I don't feel wonderful, but I'm also terrified of toxicity.  I know that fluids matter a lot and I drink a ton of water at my current job.  I'm not sure if I'll be able to maintain that while I'm at home job-searching.  In theory I should be able to, but I was literally drinking 1-2 liters.  So I fear that if my liquids drop, my level will increase. 

Long way of getting to the question...do you do a lithium increase just because you're below the therapeutic level?  Or would you wait and see how it goes?  I'd personally like to see how it goes at the increased dose since it's only been two weeks.  But I don't know if I'm acting out of fear or out of reason.

Dances ~  I was on Lithium for years.  I could never make it up into "the therapeutic range".  I trusted my body to dictate my dose. I understand your fears over toxicity.  I realize doctors feel comfortable when you are "in the range" to meet their standard of care issues, however, not everyone can even make it to the range and stay in it.  Lithium is soo variable, or at least that was my experience.  It depended upon the humidity (I live in a high humidity area), how much I perspired that day - related to exercise,  my daily hydration and stress level.  I too suffer from soo much depression that inked in while I was on Lithium.  With depression, for me anyway, when I went thru a mood change, which was often, I could take more Lithium temporarily but then once I got thru the situational depressive symptoms, I went back to my therapeutic dose.  So, my dose varied.  I am toying going back on Lithium, however, I have a goiter and thyroid issues and my endocrinologist would cringe if he thought I was even thinking of going back on this drug as Lithium does not like the thyroid gland. I think you are wise to allow your body to dictate your dose, good reasoning from my point of view.  

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Dances, I would be very worried about increasing it, especially if you’re afraid your fluid intake might drop. Also, personally I’d give it longer than two weeks for results. Lithium is pretty fast acting, but you’re going through huge changes, my pdoc believes that not everything can just be medicated away. Maybe wait til the dust settles a bit? 

I know what you mean about sensitivity, I take 600mg, drink tons of fluids, and my range is always .7-.8. 

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Open label study on dosing.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151672/

Following 6 weeks of lithium treatment, the remission rate for all patients was 62.0%. The plasma lithium levels did not impact the clinical response. However, subjects with higher blood lithium levels had an increased prevalence of nausea, restlessness, headaches and cognitive complaints. The results indicate that the lithium dose for the treatment of bipolar depression in an individual should be based on the clinical efficacy and side-effects. In the context of personalized psychiatric treatments, it is necessary to evaluate the therapeutic action of lithium with individual regimens in order to develop more tolerable and effective treatment approaches.

 

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