NON PITTING TYPE PEDAL EDEMA WITH LITHIUM: A CASE REPORT Case Study PARVATHYPRIYA C., JESLYN MARY PHILIP, CHRISTEENA GEORGE, LAKSHMI R. Department of Pharmacy Practice, Amrita School of Pharmacy, Kochi, Amrita Vishwa Vidyapeetham, Amrita University, India Email: lakshmir@aims.amrita.edu Received: 24 Sep 2016 Revised and Accepted: 23 Nov 2016 ABSTRACT Objective: To report a case of lithium induced bilateral nonpitting pedal edema. Methods: The clinical data of a bipolar affective disorder patient with current episode of mania and psychotic symptoms who experienced bilateral non pitting pedal edema with lithium. Results: The patient was a 29 yr old female who developed bilateral non-pitting type pedal edema with lithium therapy with normal plasma lithium level (0.72mEq/l). She is a known case of bipolar affective disorder (BPAD) was admitted to psychiatry department with episode of mania with psychotic symptoms. She had history of drug induced hypersensitivity reaction with eosinophilia and systemic symptoms (DRESS) with oxcarbazepine and so the drug was discontinued and was started on tablet lithium 400 mg twice daily. On admission here, the dose of lithium was increased to 1200 mg/day. The patient gradually improved but she developed bilateral non-pitting pedal edema. Serum lithium concentration was normal and there were no other early symptoms of lithium toxicity. But as the patient's distress further increased with increasing pedal edema, it was decided to stop lithium altogether and to maintain the patient on tablet quetiapine 800 mg therapy for BPAD. Within one week of stopping lithium the edema on both her feet decreased significantly. Causality was assessed by naranjo causality assessment scale and a probable relationship was obtained between lithium and pedal edema with a score of 6. Conclusion: This case emphasises that regular physical examination and laboratory investigations are important for patients who are on lithium therapy. Clinicians should always be careful while initiating lithium treatment in a patient with respect to the initial dose and dose escalation even after a period of successful therapy with lithium, as minor dose escalation can cause major changes in the serum lithium concentration and thereby the patient’s tolerability to lithium. Keywords: Pedal edema, Lithium, Mania © 2017 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ijpps.2017v9i1.15353 INTRODUCTION Lithium is widely used to treat and prevent episodes of mania in bipolar disorder. It is a mood stabiliser. It is also used for the treatment of aggression, post-traumatic stress disorder, and conduct disorder in children and as an augmenting agent for antidepressants [1]. It is available as both immediate and extended release formulations. For treatment of acute mania, it is initiated at low doses of 300 mg three times daily or less, gradually increasing based on response and tolerability of patients. The daily dose can go up to 1800 mg in 3 to 4 divided doses. Lithium’s mechanism of action is not well understood. It mainly affects two intracellular signalling pathways namely inositol monophosphate and glycogen synthase kinase pathway. Through the action in inositol monophosphate pathway, it reduces intracellular inositol which can be the mechanism behind mood stabilising effect of lithium. By inhibition of glycogen kinase-3, it influences energy metabolism, neuroprotection and neuroplasticity [2]. In addition to its therapeutic role, it is important to monitor patients closely, to prevent occurance of side effects as lithium has got a narrow therapeutic index. A large proportion of patients experienced at least one episode of toxicity during chronic lithium therapy [3]. Most common side effects of chronic lithium therapy is hand tremors, polydipsia, polyuria, weight gain, diarrhoea and edema in face and legs [4]. Lithium can also cause various serious side effects like cardiac arrhythmias, circulatory shock, blackout spells, headache, psychomotor retardation, acne vulgaris, and exacerbation of psoriasis, hypothyroidism, diabetes insipidus, anorexia, gastritis, oliguria, leukocytosis and tremors [7]. Cases with lithium-induced pedal edema are significant as it can even occur in normal serum lithium concentration. Here we are discussing a case of lithium-induced bilateral pedal edema in a patient who has no hepatic renal or cardiovascular disease. Mechanism of this phenomenon is not well understood as laboratory investigations were all normal. Demers et al. postulates that edema can be due to a marked increase in sodium intake which may be induced in part by mania or reduction in sodium excretory capacity induced by lithium [5]. CASE REPORT A 29 y old female, k/c/o BPAD came with complaints of fever with rash for 2 d with a preceding history of starting new psychiatric medications 15 d prior to the episode. She was on tablet oxcarbazepine 900 mg, tablet quetiapine 600 mg, tablet zolpidem 10 mg and tablet clonazepam 1 mg, all for daily dosing. These medications were prescribed for a mood disorder, insomnia and to control psychotic symptoms associated with mania. On examination, she was found to have facial puffiness with rashes over the face and back. Initial lab investigations showed elevated SGOT of 41.8 IU/l (5- 35 IU/l), SGPT of 74.2 IU/l (5-45 IU/l), with absolute eosinophilia of 26.3% (1-8%). She was admitted with a provisional diagnosis of oxcarbazepine induced hypersensitivity reaction. For this she was started on symptomatic management with methylprednisolone, antihistamine and antipyretics and continued on her psychiatric medications except for oxcarbazepine which was suspected as the cause of her drug-induced hypersensitivity reaction. Dermatology consultation was sought and the same line of management was optioned. Psychiatry consultation was sought and doses of quetiapine and zolpidem were increased and also added tablet lithium 800 mg daily for management of mania. Her facial puffiness decreased markedly and her rashes decreased and she got discharged in a stable condition with the above-mentioned management. After one week she got admitted at the department of psychiatry due to an episode of mania with psychotic symptoms. She was continued on 20 mg of zolpidem and 700 mg quetiapine for insomnia and International Journal of Pharmacy and Pharmaceutical Sciences ISSN- 0975-1491 Vol 9, Issue 1, 2017