Education Around Importance of Medication Monitoring Procedures Key at a Long-Term Care Psychiatric Facility

Discussion with medical staff at an inpatient long-term care state psychiatric facility can result in increased clinical awareness of lithium monitoring, according to a poster¹ presented at the American Society of Health-System Pharmacy 2023 Midyear Clinical Meeting and Exhibition.

Lithium, an antimanic drug indicated to treat acute mania and as a maintenance therapy for bipolar disorder is a high-risk medication, containing a boxed warning for the risk of lithium toxicity, even when a patient’s serum concentrations are within the therapeutic range. The drug requires extensive monitoring, including for estimated glomerular filtration rate, thyroid function, blood count, plasma lithium levels, and pregnancy.

To evaluate the use of lithium medication, as well as assess adherence to the standard monitoring parameters, researchers conducted a retrospective chart review at a single-center inpatient long-term care psychiatric facility. Electronic medical records were reviewed for each adult who received lithium therapy between January and March 2023, with patients categorized into 1 of 3 groups: 1, newly admitted patients continuing lithium therapy; 2, established patients initiated on lithium; and 3, established patients maintained on lithium.

Monitoring frequency, as well as baseline and ongoing lab studies, was dependent on the patient group.

Monitoring parameters included the following: white blood cell count, serum creatinine and calcium, thyroid stimulating hormone and free thyroxine, urine pregnancy test, electrocardiogram, and plasma lithium levels approximately 7±3 days after initiation or dose change and at monthly intervals.

In total, investigators identified 49 patients including 1 patient who was newly admitted and already prescribed lithium and 3 who were initiated on lithium during the study period; the remaining 45 patients were maintained on lithium therapy.

The researchers identified differences in thyroid stimulating hormone and basic metabolic panel monitoring, as well as in lithium levels found within the therapeutic range—or, if out of range, a progress note with a plan of action. In the maintenance group, fallouts were missing progress notes regarding out of range lithium levels; although these levels were out of range, they did not reach a toxic threshold. Additionally, urine pregnancy tests were obtained in only 50% (1 of 2) of applicable new lithium limitations. These fallouts were “spread among multiple prescribers, without trend.”

Complete blood counts and electrocardiograms were monitored appropriately across all groups.

“The results from this medication use evaluation highlight both successes as well as opportunities for improved lithium monitoring within this inpatient setting,” the researchers concluded. “Areas of opportunity include more frequent [thyroid stimulating hormone] and [basic metabolic panel] monitoring, consistent collection of urine pregnancy tests…and documentation of out of range serum lithium levels within the EHR.”

Reference

1. Golz T, Englett B, Holladay K, Chang K. Medication use evaluation of lithium in adults at a long-term state psychiatric facility. Presented at: American Society of Health-System Pharmacists 2023 Midyear Clinical Meeting & Exhibition; December 3-7, 2023; Anaheim, CA. Poster 4-061.