Lithium, fatigue, athletic performance, dehydration
May 27, 2008
Fatigue and muscle weakness are commonly listed as possible side effects of lithium. But as far as I can tell, that’s as far as anyone takes the subject. The causal mechanisms aren’t discussed. Nor are possible management strategies. I had those side effects bad enough to be almost ready to quit lithium when I figured out what was going on. I was then able to eliminate the side effects with a very simple remedy. I am not making suggestions for anyone but this is my story and it may be interesting to those on lithium, their family and friends, and those with patients on lithium.
I began medial treatment for BPDII Dec 2006 with Lamictal, presumably because I was presenting with depression. The Lamictal modified the depression by making me irritable and agitated all the time. Whether this change of mood was due to the drug or the disease wasn’t clear initially. But by summer I’d had enough of agitation and irritability (despite a attempt to mitigate it with Seroquel) and wanted a change.
So I started lithium. We monitored side effects, plasma Li level and kidney function during the ramp up. I had the thirst at first but that went away. Otherwise, all OK.
But when I got to 900mg sustained release daily dose I started to feel fatigued, weak, lethargic, and sluggish. I was sleeping more: 9-10 hours at night plus naps in the day. I had no energy and continuously faced a strong urge to lie down on the couch. My mood was affected: I was unhappy, irritable, and mean. And my athletic performance was dismal. This was very disturbing.
I am a male, early 40’s, and a cyclist. I do long distance cycling and a little bit of racing. I am relatively good; I finished Boston-Montreal-Boston 2006 in 70hr 34min, around the top 25% in an event that attracts cyclists from all over. I finished the 2006 400km Boston Brevet in 15hr 37min first out of 54 riders, 5 min faster than the next finisher. So before I started BPD treatment, I was a decent athlete. And please trust me that I have a good idea of what kind of baseline performance I can expect.
My performance on the bike in Nov and Dec was bad. I felt tired, my legs ached, I was having no fun and I was slow. My performance was off by 30-40% in terms of power*. I was embarrassed when I went out with the buddies. I didn’t enjoy cycling. My ambitions for 2008 seemed questionable.
It seemed like I was facing a choice between lithium and cycling. If so, it was fairly clear that lithium would lose since cycling has done more for my heath and mental wellbeing than any psychodrug.
Then in early Jan 2008 it started to get better. I was thrilled. I was not back to my previous performance but I was not far off. I had some good fast rides with the troop and things looked well. My shrink, who had no idea what had been causing the fatigue, agreed with me when I said: perhaps it was an initial thing and my body had adapted. But then in Feb the fatigue returned.
In Mar, while I was still feeling bad, I stopped taking lithium for one week to see what would happen. By the end of that week I was significantly improved, not fully recovered but noticeably better. When I started the lithium again I was back where I was.
I make a note of my weight regularly and the sheet is on the bathroom wall. So it was obvious when my body weight jumped up by 2.5% when I stopped lithium, stayed there for the week and then jumped back down where it was when I resumed taking lithium.
But it was a couple of weeks before a likely explanation dawned on me. My hypothesis was that lithium was causing dehydration and that dehydration was causing my symptoms of fatigue and weakness.
So I started drinking more. I was already drinking a lot relative to typical civilians but I stepped it up. I now drink 4-5liter H2O a day (roughly a pint every 90min) when not exercising. When cycling this goes up to about 0.75 – 1liter/hr depending on temperature and effort. When I get up at night to pee, I drink some more. I felt better already the day after I started drinking like this. The symptoms were gone.
Well, almost. Occasionally I have a day when I feel the side effects again. I attribute it to falling behind on my drinking.
I’ve discussed this with my shrink, who accepts the dehydration theory, and at length with my GP. He has several patients on lithium and explained to me how it affects the kidneys.
Lithium encourages the kidneys to drain clean water out of the blood. Technically, they say that it inhibits the kidneys’ ability to concentrate urine. That’s true but that doesn’t explain the dehydration. Better started: lithium inhibits the kidneys’ ability to concentrate urine AND boosts urination. So, for example, if you are dehydrated and on lithium, you can still pee plenty of pale or clear urine. For an athlete, this is tremendously important to understand.
Like many endurance sportspeople, I was in the habit of estimating hydration by monitoring urine color, volume and frequency. But on lithium this is misleading. As my GP explained, the only thing to go on is the sense of thirst. I make an effort to pay close attention to this. It’s a new habit and not so easy to learn but I think it works.
So that’s the end of my story. However, I’m still rather disappointed that I had to figure this out on my own. My shrink didn’t suspect dehydration as the cause of my symptoms. I found no clue despite hours of searching and reading online. I found mention of fatigue and muscle weakness and I found mention of the kidney effects and the need to drink enough but nothing that connected these – nothing to warn that lithium can cause dehydration that in turn can cause fatigue, muscle weakness, irritability and lethargy.
After I resolved the issue, I searched again armed with better queries and again found no sign that this is an understood problem. My shrink accepted the theory but it seemed new to her. Considering that one of the documented effects of dehydration (2% is enough) is mood disturbance (irritability is often recorded), this seems unreasonable. Aside from the physical symptoms, lithium is causing mood problems in some patients — needlessly.
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* This was estimated from heart rate. Properly prepared (rest, feeding, etc.), I can expect to be able to ride at average 165bpm for an hour. This was down to 130bpm. Taking my sitting heart rate as 55bpm, this indicates about 40% power loss.
Hey, found your blog thru the link from moodgarden.
I started DepakoteER in mid April. I used to work out about 2 hours a day, 5-6 days a week. When I started Depakote, I had the exact symptoms you described and I’ve practically turned into a couch potato. I wonder if it is the same thing? I’ll have to monitor my water intake. By the way, I’m a cyclist too..wouldn’t say “avid” cyclist, but it’s a part of my routine.
All the best, or as I say, “HUGS”
Terra (Ali at moodgarden)
Terra: you could try the trick of measuring your weight daily for a few days, then stop the depakote for a few days, continuing to measure weight daily, and then start depakote again continuing to measure your weight? if the weight steps up when you stop depakote and back down when you resume, your water content is the likely explanation. though your shrink might not approve of such experiments.
There’s an explanation of the kidney’s response to Lithium that goes as follows: “This is toxic! Excrete! Excrete Excrete!”
I suspect that this is a gross oversimplification – if not Just Plain Wrong – but it’s a useful aid to understanding. If you take Li, your kidneys rush to excrete more water and this overrides the normal control functions.
Pass notes on what the kidneys are for: they exist to maintain the correct concentrations of salts (K+, Na+, Ca2+ and Cl-) in your bloodstream, intertitial fluids and cellular fluid and – if the concentrations are within acceptable limits – the kidneys will monitor your blood pressure and work to keep a constant fluid volume on board.
Failing any of that will place a metabolic burden on every single cell in your body – some of them will work against osmosis and expend energy to maintain their internal environment in what is (now) a hostile external solution, others will be unable to do so and will suffer a decline in metabolic efficiency. Nerve cells, which operate by manipulating the concentrations of ions across their cell membranes, are particularly vulnerable.
Which is all a long-winded way of saying that dehydration is a Bad Thing, but also a very well-known one: the lack of awareness in your consultant is disturbing because homeostasis and kidney function are first-year pre-med and he is supposed to know this, understand this, live and breathe the knowledge of it all working together with the patient’s condition and the medications he prescribes.
The reason we have pre-med is to make a doctor something more that a list-response algorithm: more than ’see symptom X, prescribe drug Y’, he or she is supposed too see the symptoms and understand what is happening, prescribe the treatment and know exactly what it does to the systems of the body.
My advice to you would be: look up support groups and boards for people with diabetes insipidus – that’s the one with the lack of ADH and associated abnormalities in kidney function, NOT the glucose-and-insulin condition called diabetes mellitus – because there is a considerable overlap between their dehydration issues and yours. They may have strategies for living with the condition that are relevant to you.
Nile, that’s very useful info and helps my understanding. But there’s still something I don’t understand. You said “If you take Li, your kidneys rush to excrete more water and this overrides the normal control functions.” Removing water from the body seems counterproductive if the problem is an over-concentration of an additional salt, namely lithium carbonate. It seems to me that response would tend to increase concentration.
So would it be reasonable to think of this as follows? The body doesn’t have a specific mechanism for dealing with Li so, as salts are generally excreted in urine, the body simply increases the rate of urination, which is the mechanism it has available. And if the individual correspondingly increases water input then increased rate of flushing the Li out should follow.
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Thank you very much for your well articulated opinion, and research methods.
I slept yesterday from 4 PM to 8 AM, and would have slept longer, except the dog was hungry. It is 12:30pm now, and I have the(tried and failed 3x) strength to get out of bed, type, and search for the answer to the fatigue – is it the lithium? I see my psych in a week, so I will try your method of water and more water. I have been experiencing muscle weakness and general droopiness, besides the sleeping. I thank you for sharing this valuable information.
I take Lithium for Bipolar I and have been told by my pdoc to make sure NOT to overload with too much water, to drink fluids (he specifically recommended Gatorade) with electrolytes. When you drink too much water your kidneys will only excrete the water, not the Lithium, apparently, and you may then build up too high a level of Lithium, which can lead to toxicity. I would think that if you’re trying to avoid the fatiguing effect of Lithium you would also not want too high a level of Lithium, but that’s my supposition.
Chris, you may well be right. After I quit Li there was no doubt left that it was causing chronic dehydration and was therefore incompatible with my athletic activities. You may be interested in my recent update post here: http://thefsb.wordpress.com/2009/03/25/recovering-from-lithium/
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