Endurance Athlete and Triathlete Concerned about Taking Lithium
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Q:  Endurance Athlete and Triathlete Concerned about Taking Lithium

Dr. Phelps,
I read your helpful comments on lithium and sodium and why a person who takes lithium needs to stay hydrated. However, I am a little bit curious about being an endurance athlete. I just began my lithium treatment and I am also a triathlete. I spend hours every day sweating and training. I understand that I will need to increase my fluid intake and possibly my intake of sodium chloride.

However, I am still worried. Is my medication going to make it impossible for me to compete in high endurance races that require me to exercise for hours on end, often all day? This prospect worries me because exercise is a part of my life and I don't know if I want to give it up. I am willing to adjust or do anything required to keep training.

Thank you very much!

Dear Mark --

Exercise is clearly a good antidepressant, and I think it may be a fairly good "mood stabilizer" as well (based on watching what happens to some of my patients when orthopedic limitations interfere with their habitual levels of exercise, for example).  So I'm definitely in favor of keeping a high level of exercise in the mix of treatment tools.

I'll bet if you were to surf around this and other bipolar support group sites you will find other endurance athletes who are taking lithium for bipolar disorder.  Perhaps, using a somewhat more anonymous Internet e-mail address than the one from which you wrote here, you might query some endurance training websites or blogs, looking the other way around (start with all the endurance athletes, look for those who are taking lithium for bipolar disorder).

Most importantly, working with your physician and monitoring your lithium levels should -- theoretically at least -- just about eliminate any concerns that you have about your lithium level while training.  Learn your typical baseline lithium: first thing in the morning after an evening dose is the most routine; sometimes a pure "trough level" just prior to your next daily dose is used. (don't worry about the units.  You can become a master of the numbers even without knowing exactly what a milliequivalent is).  If you discover that the lithium level which works well enough to get good symptom control is 0.7 or less, then you are unlikely to get in trouble with a lithium increase when dehydrated.  Conversely, if your level is closer to 1.0, you are closer to potential "lithium toxicity", and dehydration during training could cause some trouble.

Of course you would want to be familiar with manifestations of "lithium toxicity", especially the mild ones which might signal that something was starting to happen.  Just so that you know (you are going to look on your own, or are you have?), I will include the more severe symptoms as well, from the emedicine site (translations in brackets are mine):

         Mild-to-moderate toxicity

o    Generalized weakness

o    Fine resting tremor [a mild shaking, not a big flapping]

o    Mild confusion

         Moderate-to-severe toxicity

o    Severe tremor

o    Muscle fasciculations [muscles rippling on their own]

o    Choreoathetosis [a slow twisting involuntary motion]

o    Hyperreflexia [you might feel this as being "jumpy]

o    Clonus [muscles locking up tight]

o    Opisthotonos [a rigid arching of the back]

o    Stupor

o    Seizures

o    Coma

Then, you might ask your doctor to help arrange a lithium blood level to be drawn right after you have had a significant work out.  You could even do this several times, increasing to a workout that was designed to simulate "race pace" under dehydrating circumstances, such as high temperature or humidity.  In other words, if under controlled circumstances you can determine that your lithium level is still under good control (under 1.1, for example, with none of the above signs) when going at full tilt, that should be reassuring so that you can really go for it in a race and not worry.

I suspect that what you will find, if you are careful about hydration while underway, is that your lithium levels are not increasing very much.  Of course, don't forget that a shifting of fluid and electrolytes in your bloodstream will continue for hours after you finish a workout, so don't lower your guard too soon.

Finally, I should note that one of my patients recently took my discussion of hydration so seriously that she ended up getting way too much fluid on board and lowering her blood sodium to the point that she got mild confusion symptoms from doing so.  Her lithium level was still extremely low at the time.  Thereby proving that it is possible to overdo it in the other direction as well. If your psychiatrist does not have time for checking multiple levels, your primary care doctor might be willing to do so.  They get pretty interested in blood levels and electrolytes, often more than the psychiatrist.  If you are fortunate enough to have an internist who is an exercise in that, then you've got it made

Good luck with all that, and with your training.

Dr. Phelps

Published November, 2008


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