A 55-year-old man has been on lithium for 15 years for bipolar disorder. His serum creatinine is 1.8 mg/dL, GFR 45 mL/min. What is the MOST appropriate management?

• A Stop lithium immediately and switch to valproate
• B Add amiloride to counteract lithium-induced nephropathy
• C Continue same dose with annual creatinine monitoring only
• D Reduce lithium dose, more frequent monitoring of renal function and lithium levels, consider switching if deterioration continues ✓

Explanation

Chronic lithium nephropathy is well recognised, causing tubular dysfunction and glomerulosclerosis. With GFR 45 mL/min (CKD stage 3b), lithium should be dose-reduced and levels monitored more frequently (every 1–3 months). Abrupt discontinuation risks manic relapse and is not always necessary at this stage. If GFR continues to decline or drops below 30 mL/min, switching to an alternative mood stabiliser is considered. Amiloride reduces lithium-induced nephrogenic diabetes insipidus but does not halt glomerulosclerosis.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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