3 Clinical psychopharmacology3.4 Therapeutics
3.4.3 Monitoring efficacy and tolerability
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Written by Resident Doctor Committee · Published
Every review
At each review, assess symptoms, daily function, adherence, adverse effects and the person's wishes.
Urgent symptoms override any schedule: collapse, seizure, significant rash, jaundice, fever with rigidity, chest pain, confusion or worsening suicidality.
Lithium
Before starting
Baseline checks are weight, renal function, electrolytes, calcium, thyroid function and full blood count, with pregnancy assessed where relevant.
An electrocardiogram (ECG) is part of the baseline work-up, because lithium affects cardiac conduction and repolarisation.
Plasma levels
Take routine levels 12 hours after the dose.
Phase | Frequency |
|---|---|
Until stable | Weekly |
First year | Every three months |
After the first year, most adults | Every six months |
After the first year, higher-risk groups | Every three months |
Higher-risk groups are older adults and people with interacting medicines, renal concerns, poor adherence or control, or higher levels.
Review weight, renal function, calcium and thyroid function at least six-monthly.
Toxicity
The AMDISEN scale grades the clinical severity of lithium toxicity.
Suspected toxicity needs immediate assessment and an urgent level, without waiting for the routine trough.
Serious toxic symptoms can occur without a strikingly high level.
Antipsychotics
Measure | Schedule |
|---|---|
Weight | Weekly for 6 weeks, then at 12 weeks, 1 year and annually |
Pulse, blood pressure, glucose or glycated haemoglobin | Baseline, 12 weeks, 1 year, then annually |
Lipids with clozapine or olanzapine | Every three months in the first year, then yearly |
Abnormal movements | Baseline and regularly during titration |
Clozapine
Clozapine is dispensed only after registration with a monitoring service and valid blood results.
Fever, sore throat or infection needs urgent assessment and a blood count.