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Lithium and Antihypertensive Medication: A Potentially Dangerous Interaction

A 62-year-old woman with hypertensive stage 3 chronic kidney disease and a long history of bipolar II disorder was hospitalized for progressive mental status change. A baseline serum creatinine was 1.3 mg ⁄ dL (normal, 0.8–1.2 mg ⁄ dL) and estimated glomerular filtration rate was 42 cc ⁄ min. Her hypertension had been well controlled while taking hydrochlorothiazide 25 mg daily for more than 5 years. Up until 5 years prior to admission the patient had multiple psychiatric hospitalizations, but since that time had achieved good stabilization on lithium carbonate 300 mg twice a day with a lithium level of 1.10 mEq ⁄ L (therapeutic, 0.3–1.3 mEq ⁄ L) 2 months prior to admission. There was no history of drug or alcohol abuse. She had a rash caused by carbamazepine and failed therapy with valproic acid and olanzapine. Approximately 6 weeks prior to admission, with systolic blood pressures consistently 142 to 154 mm Hg, lisinopril 10 mg was added. A month later the patient’s husband observed her to be weaker. It took longer for her to speak and she had more speech and movement hesitations. During the few days prior to admission, her voice appeared more strained and she seemed stiffer. Her thought process was noticeably slowed. Thinking that she was experiencing a bipolar exacerbation, her husband brought her to see her psychiatrist who referred the patient to the emergency department. On examination in the emergency department, her blood pressure was 126 ⁄62 mm Hg with a heart rate of 98 beats per minute and she was in no acute distress. She was able to follow some commands slowly and hesitatingly, but was also restless in bed and getting up on her hands and knees. Her eyes were frequently closed. The patient did not verbalize to the examiner but by report had a few normal sentences with a nurse. Another examiner noted her to be able to very slowly state her name and birth date. She was not fully cooperative, but was not stiff. Ataxia was noted, and moderate assistance for standing was required. Serum creatinine was 2.5 mg ⁄dL and lithium level was 2.88 mEq ⁄L. Emergent hemodialysis with a bicarbonate bath was prescribed, and hydrochlorothiazide, lisinopril, and lithium were held. Shortly after hemodialysis her lithium level was 0.65 mEq ⁄L, rising to 1.27 mEq ⁄L 6 hours later, and a second hemodialysis was ordered. Eight hours following the second dialysis treatment, the patient’s lithium level was 0.77 mEq ⁄L. She was discharged on the fifth hospital day, back to baseline independent function, with a serum creatinine level of 1.6 mEq ⁄L. Three months later the patient had a serum creatinine level of 1.2 mg ⁄dL, a blood pressure of 132 ⁄78 mm Hg on amlodipine 5 mg daily, and a lithium level of 0.77 mEq ⁄L on lithium carbonate 300 mg twice daily.