SHARED CARE PRESCRIBING GUIDELINE
Shared Care Guideline: Prescribing Agreement
Oral Lithium for Affective Disorders
Section A: To be completed by the hospital consultant initiating the treatment
GP Practice Details:
Patient Details:
Name: ………………………………………
Name: ………………………………………………
Address: ……………………………………
Address: ……………………………………………
Tel no: ………………………………………
DOB: ……/………/…………
Fax no: ………………………………………
Hospital number: …………………………………
NHS.net e-mail: ……………………………
NHS number (10 digits): …………………………
Consultant name: ……………………………
Clinic name: ………………………………….
Contact details:
Address: .........................................................................................................................
Tel no: ……………………………………… Fax no: ………………………………………
NHS.net e-mail: ……………………………
Diagnosis:
Drug name & dose to be prescribed by GP:
……………………………………………………
…………………………………………………………….
Next hospital appointment: ……/……/……..
Dear Dr. ……………………..,
Your patient was seen on …../..…/………and I have started …………………………………………….(insert
drug name and dose) for the above diagnosis and are stabilised on this treatment. I am requesting your
agreement to sharing the care of this patient from …../.…./…….. in accordance with the attached Shared
Care Prescribing Guideline (Title: Oral Lithium for Affective Disorders) Please take particular note of
Section 2 where the areas of responsibilities for the consultant, GP and patient for this shared care
arrangement are detailed.
Patient information has been given outlining potential aims and side effects of this treatment and lithium
booklet supplied. The patient has given me consent to treatment possibly under a shared care prescribing
agreement (with your agreement) and has agreed to comply with instructions and follow up requirements.
.
The following investigations have been performed on ……/……/……… and are acceptable for shared care.
Please monitor………...........every ………..
Test
Result
Test
Result
Lithium level
U&E (Na, Ca, Cr & eGFR)
TFT (T4, TSH)
Weight (or BMI)
Latest blood results attached (tick)
Other relevant information: ………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
Section B: To be completed by the GP and returned to the hospital consultant as detailed in Section A
above
Please sign and return your agreement to shared care within 14 days of receiving this request
Tick which applies:
□ I accept sharing care as per shared care prescribing guideline and above instructions
□ I would like further information. Please contact me on:……………………….
□ I am not willing to undertake shared care for this patient for the following reason:
……………………………………………………………………………………………………………….
GP name: ………………………………………….……….
GP signature: ………………………………………………Date: …/…/…..
Date original approved: February 2004
Date next review due: Feb 2015
Date last review approved: Feb 2013
1
SHARED CARE PRESCRIBING GUIDELINE
working in partnership with
SHARED CARE PRESCRIBING GUIDELINE
Oral Lithium for Affective Disorders
NOTES to the GP
The expectation is that these guidelines should provide sufficient information to enable GPs to be confident
to take clinical and legal responsibility for prescribing this drug.
The questions below will help you confirm this:
 Is the patient’s condition predictable or stable?
 Do you have the relevant knowledge, skills and access to equipment to allow you to monitor treatment
as indicated in this shared care prescribing guideline?
 Have you been provided with relevant clinical details including monitoring data?
If you can answer YES to all these questions (after reading this shared care guideline), then it is appropriate
for you to accept prescribing responsibility.
If the answer is NO to any of these questions, you should not accept prescribing responsibility. You should
write to the consultant within 14 days, outlining your reasons for NOT prescribing. If you do not have the
confidence to prescribe, we suggest you discuss this with your local Trust/specialist service, who will be
willing to provide training and support. If you still lack the confidence to accept clinical responsibility, you still
have the right to decline. Your PCT pharmacist will assist you in making decisions about shared care.
It would not normally be expected that a GP would decline to share prescribing on the basis of cost.
The patient’s best interests are always paramount
Date first prepared: January 2004
Date reviewed: January 2013
Date review approved: February 2013
Next review date: February 2015
Prepared by:
Carl Holvey, Principal Pharmacist SWLStG MH Trust
Approved by:
S W London Mental Health Prescribing Forum (January
2013)
S W London & St Georges Mental Health NHS Trust
Drug & Therapeutics Committee (Feb 2013)
Participating Primary Care Organisations
Kingston CCG
Dr Anthony Hughes, GP on behalf of Medicines
Management Committee
Seema Buckley, Chief Pharmacist
Richmond CCG
Dr Darren Tymens, Associate Medical Director
Emma Richmond, Head of Medicines
Management
Merton CCG
Dr Andrew Otley, Mental Health Lead
Brigitte van der Zanden, Chief Pharmacist
NHS Wandsworth
Dr Gillian Ostrowsky, Associate Medical Director
Nick Beavon, Chief Pharmacist
Sutton CCG
Dr Chris Kears, Mental Health Lead
Brigitte van der Zanden, Chief Pharmacist
Participating Hospital Trusts
SWL & St. George’s Mental Health Trust
Helen Miller (DTC Chair & Consultant Psychiatrist)
Dianne Adams (DTC secretary & Chief Pharmacist)
Date original approved: February 2004
Date next review due: Feb 2015
Date last review approved: Feb 2013
2
SHARED CARE PRESCRIBING GUIDELINE
ORAL LITHIUM FOR AFFECTIVE DISORDERS
1.
CIRCUMSTANCES WHEN SHARED CARE IS APPROPRIATE
 Prescribing responsibility will only be transferred when the consultant and the GP are in agreement
that the patient’s condition is stable or predictable.
 The patients will only be referred to the GP once the GP has agreed in each individual case and the
hospital will continue to provide prescriptions until successful transfer of responsibilities as outlined
below.
 The hospital will provide the patient with a minimum initial supply of 2 weeks therapy.
2.
AREAS OF RESPONSIBILITY
In general the various responsibilities will be shared as outlined below, but for an individual patient
there may be some variation in the detail (e.g. on who does which blood tests) but this must be clearly
agreed between the consultant and GP
Consultant
GP

Formulate diagnosis and initiate
 Prescribe specific dosage, form and brand of lithium ensuring
treatment plan
monitoring results indicate it is safe to do so, adjusting dosage as
required. If liquid is prescribed note, SWLStG uses only the
 Follow mental Health Trust guidelines
for prescribing and monitoring lithium
high strength lithium citrate liquid (1018mg/5ml, 400mg
therapy
lithium carbonate = 5ml of this strength).
 Provide verbal and written information
 Measure lithium plasma levels every 3 months in accordance
to the patient and answer their questions
with NICE guidelines (or at any other time if signs of toxicity) and
about lithium
send a copy of the results to the CMHT.
 Establish willingness for adherence to
 If monitoring results not available at the time of prescribing,
lithium treatment (to avoid abrupt
prescribe only a limited supply (e.g. maximum 14 days) and
cessation of treatment)
arrange for blood tests.
 Perform baseline checks of physical
 If patient refuses blood tests, prescribe only a limited supply
health (including body weight and ECG),
(e.g. maximum 14 days) and discuss urgently with CMHT. Patients
renal and thyroid function, serum calcium,
who have the capacity to decide and who refuse 3 monthly blood
creatinine, eGFR and sodium (recorded in
levels, may encounter problems with obtaining supplies from
the electronic care notes). FBC should be
community pharmacies. Appendix 1 of this document may be
done if indicated.
useful to aid this communication.
 Initiate lithium treatment and establish
 Measure thyroid function and renal function every 6 months in
desired dose / blood level
accordance with NICE guidelines and send a copy of the results to
 Provide lithium treatment pack to
the CMHT.
patient containing lithium information
 Update the patient’s lithium record book with all results and
booklet, lithium alert card and lithium
changes in treatment when presented by patient
record book, and complete with relevant
 Perform annual health checks including record of body weight in
details
accordance with NICE guidelines (including serum calcium)
 Check on going monitoring of lithium
 Monitor mental state
occurs
 Monitor adherence to medication
Communicate to GP:
 Assess for signs of adverse effects
 Dosage, form & brand of lithium to be
 Be alert for medicines that interact with lithium; if any are added,
prescribed (this must be specified in all
stopped or have their dosage changed re-check the lithium level
correspondence, prescriptions and the
and observe for any signs of toxicity or of relapse of symptoms.
patient’s lithium record
 Contact mental health community team or medicines
 Current lithium plasma level
information for advice on: dosage adjustment to maintain lithium
 Desirable plasma level range to be
level, management of adverse effects or patients who refuse blood
maintained
tests.
 Frequency of follow-up appointments
 Refer patient back to CMHT if concerns over mental state or
with CMHT and communicate treatment
concerns over poor compliance with treatment and of physical
changes to the GP promptly within Trust
health issues that affect dosing or treatment.
recommended times.
N.B. results of all tests and investigations should be copied by / to both consultant and GP
Patient and Carers responsibilities
Carry lithium book to required appointments and allow Health Care professionals involved in their care to see the
book.
Date original approved: February 2004
Date next review due: Feb 2015
Date last review approved: Feb 2013
3
SHARED CARE PRESCRIBING GUIDELINE
3.
COMMUNICATION AND SUPPORT
Hospital contacts:
Out of hours contacts & procedures:
(the referral letter will indicate named consultant)
ENTER CONTACT DETAILS OF
YOUR LOCAL CMHT
The on-call psychiatrist at your local hospital can be
contacted via the hospital switchboard:


Springfield 020 3513 6000
Tolworth 020 8390 0102
Tel:
Fax:
E-mail:
Specialist support/resources available to GP including patient information:
 Additional information on any aspect of lithium treatment is available from Mental Health Medicines
Information 020 3513 6829
 Patient information leaflets & lithium books for patients are available from Springfield Hospital Pharmacy
020 3513 6204.
 Information leaflets, choice of treatment for illnesses & illness leaflets (funded by SWLStG):
http://www.choiceandmedication.org/swlstg-tr/
4. CLINICAL INFORMATION
Place in Therapy:
Therapeutic summary:
Dose & route of administration:
Duration of treatment:
Monitoring Requirements:
The NPSA Patient Safety Alert
states that NHS providers “should
ensure that patients prescribed
lithium are monitored in
accordance with NICE guidance”
Date original approved: February 2004
Date next review due: Feb 2015
One of the drugs of first choice for established recurrent illness
instead-of or in addition to antipsychotics and/or antidepressants
as appropriate.
Treatment and prophylaxis in mood disorders – exact mechanism
of action unknown
Dose - established for each individual patient to produce the
desired blood level (usual therapeutic range 0.4 – 1.0mmol/l but
specific target level will be individual for each patient).
Route of administration – oral (see notes on formulations in
“practical issues” section below).
For prophylaxis, likely to be for several years
 General monitoring of the patient’s mental state, adherence to
treatment and for any adverse effects of their medication.
 Every three months*:(*NICE recommendations)
o lithium blood level (sample taken 12 hours after last
dose)
 Every six months*:
o measure thyroid function
o measure renal function
 Annually*:
o physical health check including measure of body
weight and serum calcium.
In addition, measure lithium blood levels if signs of toxicity or
relapse of illness appear, or if any medication is added / removed
which may affect lithium blood levels (See interactions section)
Request on each laboratory form that a copy of all results be
sent to both consultant & GP.
Date last review approved: Feb 2013
4
SHARED CARE PRESCRIBING GUIDELINE
Summary of adverse effects:
Adverse effect
Frequency
Management
(See summary of product characteristics
(SPC) for full list)
N.B. because of potential risk to
unborn child, women of childbearing age should be clearly
informed of the risks of pregnancy
and should be encouraged to
discuss with you any possible
pregnancy, plans to breastfeed (or
plans to conceive) as early as
possible.
Lithium toxicity (signs:
Unknown
Stop lithium,
vomiting, diarrhoea,
polyuria, increased thirst,
coarse tremor, ataxia,
muscle pain / weakness,
drowsiness, confusion)
(affected by
dosage, drug
interactions,
physical
illness, salt &
fluid balance)
measure lithium blood
level urgently, rehydrate,
contact CMHT, DO NOT
force diuresis, consider
A+E referral
Impaired renal function
Unknown
contact CMHT
(identified by monitoring)
Impaired thyroid function
Unknown
contact CMHT
 ACE inhibitors and Angiotensin-II antagonists – increased
lithium blood level (monitor lithium closely until stabilised)
 Analgesics – decreased lithium excretion by azapropazone,
diclofenac, ibuprofen, indometacin, ketorolac (avoid concomitant
use), mefenamic acid, naproxen, parecoxib, piroxicam,
rofecoxib, and probably other NSAIDs (risk of lithium toxicitymonitor lithium closely until stabilised)
 Antidepressants – SSRIs may increase risk of CNS effects
 Antipsychotics – increased risk of EPSE / neurotoxicity with
clozapine, haloperidol, phenothiazines, sulpiride; increased risk
of ventricular arrhythmias with amisulpride, sertindole,
thioridazine
 Acetazolamide – increased lithium excretion (monitor lithium
closely until stabilised)
 Diuretics – decreased lithium excretion/increased lithium
blood level. Loop diuretics safer than thiazides (monitor lithium
closely until stabilised)
 Methyldopa – neurotoxicity without increased lithium blood
level (monitor patients for sign of toxicity)
(identified by monitoring)
Clinically relevant drug
interactions:
N.B. included are the “potentially
hazardous” interactions as listed in
the BNF – see BNF / SmPC for more
complete information
N.B. increased lithium plasma
level/decreased lithium excretion
brings the risk of lithium toxicity
N.B. the effect of adding these drugs
to lithium treatment is described here
– the opposite effect is likely if the
drug is withdrawn
N.B. care may also be needed if one
interacting drug is switched for
another (e.g. change in diuretic)
Practical issues:
Date original approved: February 2004
Date next review due: Feb 2015
Formulations of lithium
 Different brands and forms of lithium are likely to produce
different lithium blood levels
 The brand & formulation of lithium should remain unchanged
for a patient & should be specified on each prescription, in all
correspondence and on the patient’s lithium record card/book
 Take extra care when prescribing lithium in liquid form, as
different brands contain very different concentrations of lithium
(e.g. Li-Liquid (Rosemont) is available in 2 strengths)
 SwLSTG only uses 1018mg/5mL Lithium citrate liquid.
5mL of this liquid is equivalent to 400mg of lithium
carbonate (Li-liquid).
If the lithium level is outside the desired range for this patient
 If level is above 1.0mmol/l contact the patient to arrange
urgent assessment and to ensure that they take no more lithium
and monitored for signs of toxicity.
Otherwise:
 Confirm correct dosage is being prescribed / taken
 Confirm blood sample taken 12 hours post-dose
Date last review approved: Feb 2013
5
SHARED CARE PRESCRIBING GUIDELINE

Check for drug interactions (N.B. some over-the-counter
drugs may interact e.g. ibuprofen)
 Check hydration and salt intake or loss
 Assess physical & mental state of the patient
 Adjust the dosage if indicated and repeat level after 5-7 days
Potential risk in pregnancy
Because of the potential risk to the unborn child, women of childbearing age should:
 Be clearly informed of the risks of pregnancy
 Be encouraged to discuss with you any possible pregnancy
as early as possible
 Be encouraged to discuss with you any plans to conceive as
early as possible
 Contact Mental Health Medicines Information (020 3513
6829) or the Perinatal Mental Health Service for advice.
Key references:
Date original approved: February 2004
Date next review due: Feb 2015



NPSA Patient Safety Alert NPSA 2009/PSA005
“Using lithium safely” Drug & Therapeutics Bulletin 1999, 37, 22
“Lithium for maintenance treatment of mood disorders” (Cochrane
review), Burgess S et al In: The Cochrane Library, Issue 3, 2001
 British National Formulary March 2010, no 59
 NICE clinical guideline 38 - Bipolar Disorder, July 2006
 SwLSTG Lithium prescribing and monitoring. TWC21j.
Date last review approved: Feb 2013
6
SHARED CARE PRESCRIBING GUIDELINE
Date:
Psychiatric team to Insert GP Address
Insert unit/team/hospital address
& Telephone number
Dear Colleague,
RE: (APPENDIX 1): Healthcare professional letter regarding patients’ refusal of lithium
monitoring.
First name Surname – DOB – NHS number
Patients address
The above patient refuses to have three monthly monitoring of their lithium level (and or
other regular blood testing) as recommended by the National Institute of Clinical Excellence
and The National Patient Safety Agency. The patient will have at least yearly monitoring of
all the physical parameters.
The clinician below has discussed the risks of not complying with these tests, which are an
inability to check for side effects and toxicity due to lithium therapy. The patient has been
given written information regarding lithium but still refuses to have on going blood tests. Our
discussion is fully documented in the electronic care notes.
This patient therapeutically benefits from this treatment and considers the risk of not having
on going monitoring one worth taking.
In the opinion of the clinician below this patient has the capacity to make this decision and
requests that you continue to prescribe and/or supply lithium as described on the
prescription under the wishes of the patient.
Yours sincerely,
Clinician signature
Service user signature
Name of clinician & designation
Date original approved: February 2004
Date next review due: Feb 2015
Date last review approved: Feb 2013
7