Question from a Member:
What are your thoughts on colonoscopy preps [bowel preparation before colonoscopy] for patients on lithium? Both for 1 and 2-day preps.
Bowel preparation before colonoscopy
Colonoscopy is a very important medical procedure. For diagnostic colonoscopies, it is essential that fecal material be removed from the large intestine as completely as possible so that the colonic mucosa can be properly visualized. This is why the quality of bowel preparation is a major determinant of the effectiveness of a colonoscopy.
Bowel preparation includes a low-fiber diet that leaves little residue in the bowel, clear liquids, induction of bowel movements to clear out the bowel as much as possible, and, fasting before the procedure.
Note: Sodium phosphate for bowel preparation, which should not be used along with lithium, is no longer available in the United States.
Should lithium be temporarily stopped before a colonoscopy?
There is no clear guidance about what to do about lithium during bowel preparation. And, I am unaware of any guideline recommending that lithium should always be stopped before bowel preparation. Some endoscopy centers do note the possibility of lithium toxicity and suggest that holding the lithium may be considered (example).
Here’s what I think about this question:
1. Any situation in which electrolyte imbalance and/or dehydration could occur increases the risk of lithium toxicity.
2. Even though patients are told to drink plenty of fluids during bowel preparation to avoid dehydration, fluid and electrolyte imbalance can still occur.
This is why I recommend stopping lithium at least 24 hours before starting bowel preparation and resuming it soon after the procedure, when the person is eating and drinking to their usual extent, and hydration, electrolytes, and renal function are stable.
– Ask yourself: What is the harm if the patient misses lithium for two or three days? Compare this with the potentially serious consequences of lithium toxicity.
– My rule of thumb is that in ANY situation in which fluid and electrolyte balance is unstable and unpredictable, I would much rather err on the side of holding the lithium until the fluid and electrolyte situation is resolved.
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Lithium—Side effects—Miscellaneous
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References
Ott M, Stegmayr B, Salander Renberg E, Werneke U. Lithium intoxication: Incidence, clinical course and renal function – a population-based retrospective cohort study. J Psychopharmacol. 2016 Oct;30(10):1008-19. doi: 10.1177/0269881116652577. Epub 2016 Jun 14. PMID: 27307388; PMCID: PMC5036078.
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