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.


* 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.

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35 Responses to “Lithium, fatigue, athletic performance, dehydration”

  1. Terra said

    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)

  2. thefsb said

    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.

  3. Nile said

    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.

  4. thefsb said

    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.

  5. […] 8, 2008 Since I published my fairly optimistic May 27 2008 post on this topic, I’ve a few observations and thoughts to […]

  6. Miranda said

    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.

  7. Chris said

    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.

  8. thefsb said

    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: https://thefsb.wordpress.com/2009/03/25/recovering-from-lithium/

  9. […] warmed up around the end of June and possibly related to some remaining diabetes insipidus (i.e. my kidneys aren’t working as well as they should) from my problems in […]

  10. Do you have a web feed I can save? I searched around but couldn’t

  11. thefsb said

    @Marketta Bouquin: No, I don’t think I do.

  12. Caroline said

    Um… Actually this water-drinking thing is the FIRST (along with unchanged salt intake) that your shrink or doc should tell you and is a major “duh” among responsible patients. What isn’t responsible is experimenting with going on and off your medication without physician direction or at least approval. That can have true consequences.

  13. Gail Schonfeld said

    I am specifically interested in the impact of lithium and other mood stabilizers on tennis players. The lithium seems to interfer with coordination and movement in tennis. Any ideas? I am referring to tennis in elite competitive players.

    • thefsb said

      Check out the side effect consumer info for Li. “tremor”, “involuntary twitching or muscle movements”, “loss of coordination” are there. I don’t recall experiencing these.

      Nothing like it on the list for Divalproex, though that list is no less terrifying.

      And so on down the list of “mood stabilizers”.

    • Chris Fallows said

      Gail,

      When it comes to the effects of Lithium it doesn’t seem to matter whether you’re an elite tennis player or a person with an IQ of 145: the medication interferes with cognition and this will, naturally, effect any type of motor activity arising from the brain. I have taken it on and off (mostly off, for the above reason) for nearly thirty years and am only staying on a much-reduced dose of it because the withdrawal process is too difficult and time-consuming. As Roger Whitaker notes in his recent book “Anatomy Of An Epidemic” psychotropic medication will also cause long-term deterioration in functioning, so their game is not likely to improve.

      • thefsb said

        Chris, generally I am sympathetic to Whitaker’s arguments, which are, I think broadly accepted now. But I’m weary of your sweeping last sentence.

        It seems likely there is at least one case in which non-use of psychotropic medication can cause long-term deterioration in functioning.

        Credible research points to a feature of BPD such that it gets worse over the course of an individual’s life in relation to the number of BP episodes. Each episode, it seems, causes damage to the brains mood regulation functions, making the individual more susceptible to further episodes.

        So some experts, e.g. Husseini Manji at NIH, see stabilization as the top priority in treatment. Moreover, Li and valproate (and neither, pace Whitaker, will make any pharmaco. rich) have both been shown to have a protective value against the brain damage I mentioned, even to support regeneration of the atrophied neurons.

    • Amy said

      Did you ever find out about lithium & tennis? I am having trouble. Used to be very competitive. Lots of trouble w/ toss for serving.

      • thefsb said

        No have no specific knowledge of lithium effects for tenis players. But hand tremor is always noted as a common side effect. I imagine that could affect play. Have you noticed hand tremor?

        My problem side effect was dehydration and I had to choose between cycling and lithium. When it comes to drugs with side effects, we have to make our own decisions considering overall quality of life.

        For some people, relatively low doses of lithium are sufficient. Perhaps there’s a dose that’s effective for you but low enough to give you back your control.

  14. Chris Fallows said

    Hi, thanks for your reply. What you refer to, an individual’s repeated episodes causing further damages, termed the “kindling effect,” has actually itself been disproved (this is now accepted by psychiatry as a disproved theory). As an aside, it is possible that the lower functioning caused by medications such as Lithium can itself create a condition or state that leads to a more full-blown episode (impaired functioning can make anyone depressed).

    The question of stability depends on how you define it. Is it simply going for an extended period of time without being hospitalized? Reduced symptoms–by how much? I realize that for those of us who have already been on these meds questions like these can tend to be merely theoretical, as, by my growing understanding, the medications may have altered brain receptors to the degree that it is either difficult or impossible to get off the stuff.

    I realize I’m also a bit out of place commenting in a blog that is dedicated to high-performance athletics. Just one important thought, if I could, I would like to exit with: the use of psychotropic medications taught a generation of people to rely on something outside themselves for control of their mind. I believe we can regain that control, first with the belief that we can.

  15. Nick M. Martin said

    This is a very helpful post. I was diagnosed with BPII almost a decade ago, which was treated with Serzone and small dosages of depakote, until my blood work started to show signs of liver toxicity. After several other drugs (including a significant increase of depakote, I experienced severe cognitive dysfunction and weight gain, although my frequency of rapid cycling decreased significantly. I was able to reduce the weight gain for almost a year with the help of an athletic trainer, but it remained a reoccurring problem the minute I reduce exercise.

    Finally, I attended a conference where the Director of a university mental health clinic (who was bi-polar herself) espoused the value of Lithium. I slowly segued off of the remaining drugs and transitioned to the Lithium. While rapid cycling remains relatively stable, the levels of fatigue have continued to increase, matching levels similar to those reported by thefsb.I had been lifting wegihts and doing aerobic exercise about 5 times a week; I was however needing almost 9 hours of sleep and frequent naps to get through a day. This was complicated by a vitamin B12 deficiency which increased cycles of “being awaken” after 11pm, thus reducing night time sleep and forcing my need for naps during the day. I had been taking Provigil to help offset the effects which worked in the beginning and afterward, lessened in their effectiveness.

    The explanation here, is helpful, and one that I will try and report back on. I havent been able to do a full work out in months; this past summer, I focused on South Beach Diet which helped me to loose weight, but now building muscle tone and aerobic capacity are my next goals. I am hoping that the water here is the key to improving this symptom.

  16. C Wilson said

    I agree this a helpful–and very validating post. In addition to hydration, I seek the best quality of life by maintaining myself with the most minimal Li possible (but ready to up it if start to swing). Another thing Li effected is my ability to read like i used to–I simply don’t read books or research like I did. And the effects on my creativity or any passion is another concern. One of the common effects of Li is constant but subtle movement of the eyes which tires them and makes it hard to focus–eyes tire quickly. Thanks.

  17. Karen said

    Oh my God! My serve toss is exactly the thing I have the most trouble with! I am beginning to understand why I can’t seem to get my tennis game back…I’ve been on Li for 20+ years. In fact as I write this I’m flat on my back with Lithium “Poisoning” (Not really) for playing 3 tennis matches in one week in which I was dripping sweat. I tried to keep up with the Gatorade. Pedialyte is also supposed to be good. The third match I knew I shouldn’t have played, I didn’t feel right and I was ready to quit within 20 minutes…dumb. Now I’m in bed trying to drink lots of Gatorade and too tired to go buy Pedialyte : ). It will pass.

  18. DK said

    I am a 3 handicap golfer and avid crossfitter. I supplement an electrolyte drink daily, especially during heavy workouts, and drink 1 liter of coconut water or Gatorade. I have experienced no I’ll affects to athletic performance or coordination. I am on 900 mg lithium and 100 mg lamictal.

    • thefsb said

      It’s good to hear that you tolerate those meds well. Hydration with electrolytes will certainly help.

      But is it enough? It is for you at that Li dose and doing your activities. It wasn’t for me, at my dose doing my activities. (I was disappointed because I liked the way Li made me feel, shrinkologically speaking.) We can expect such differences from one person to another.

      Assuming that your Li dose is sufficient to be effective, it’s cool that it hasn’t impaired your game considering the other common side effects.

      Gatorade is an acceptable fallback in a pinch but I encourage people to avoid it in general. There are plenty of better ways to deliver water and electrolytes, either with or without some sugar or complex carbs. Here’s what I do…

      I’m now racing road and track and I race and train about 10-12 hours per week. For training rides under 2 hours I just take water and I get enough salts in my food. For longer rides I take pocket food (real food that I like – not commercial sports products) and I may supplement with Hammer Endurolytes http://www.hammernutrition.com/products/endurolytes.elt.html if I think I need it. For races over 90 minutes I may try to add some more sugar during the event using maybe gels or Skratch Labs Exercise Hydration Mix http://www.skratchlabs.com/collections/drinks/products/exercise-hydration-mix.

      Check out the Skratch Labs stuff as an alternative to Gatorade. It’s far too expensive but it’s the best of it’s kind.

  19. Andrea said

    I just found your blog. I was diagnosed with Bipolar I when I was 19 and now I’m 45. I took lithium for about 20 years and am now off of it. It really didn’t work well for me and greatly affected my weight, sports performance, and physical health in negative ways. I am so happy to be off of it. After years of therapy and recovery I am down to 200 mg. Lamictal and 100 mg. Seroquel – both taken at bedtime. I’m doing well. Looking back, I realize that lithium never controlled my symptoms as well as these medications.

  20. edunn said

    This has been very helpful, however, I’ve not been able to read all of the responses to thefsb’s initial documercial (blog). I too have always been an avid rider but not within competitive forums. It was usually to acquire my choice of what became a 37 year addiction. After that many years of enjoying sleepless nights, overhauling businesses and creating new departments, which were needed to maintain compliance with our unhealthy government I quit my drug of choice and was left with a brain that was “officially” drained. Now I get my chance to utilize the infamous, Lithium. This is fine but I am tired as #&(%! So all the years of learning to boost my water intake because of my drug of choice, will have paid off? I have always suffered the dehydration but it is not the same as it was with the speed use. Obviously because I am not using the speed. The only reason I quit is because it is illegible and I don’t want to go to “hell”. I have since suffered the lack of focus and energy loss that comes with it. The lithium has made me very, very, very, very tired. It has made me more tired than the lack of speed. So your blog is very useful for someone that seems to have very little in common with you yet far more than I would have ever considered before this moment.

  21. Liz said

    I feel so blessed to read this. I live in a very hot climate (central queensland, Australia) and I love riding. I am not competitive re: entering races or tris but I do a good 1.5 to 2 hour ride three times a week. Diagnosed with Bipolar II, two months ago, my psych has me on 900mg lithium/50mg seroquel and risperidone. I have noticed that it is like I am back at square one regarding riding. I am going up hills like a complete turtle and feel very despondant and upset as it’s like all my fitness has disappeared. I am a persistent person though and my riding mates are great and very understanding. I will now up my water level. See how I go. Your post have given me hope that all will be well and I can enjoy riding regardless of the medication I am on. Btw, I have suffered with this for 30 years before the proper diagnosis was given recently and there is NO WAY I am giving up the meds. I just don’t want to be back in that hell hole.

    • thefsb said

      The kidneys are weird. They normally work by removing fluid from the blood and putting most of it back while channeling a small amount to the bladder with metabolic waste. Li causes them to channel a lot more water to the bladder. So with Li they fail to concentrate urine and the bladder fills with the water you drink. Really annoying. So be careful. Don’t add electrolytes when you drink more water, stay at whatever mg/hr for the salts works for you now.

      But, Holy Cow, Liz, that’s a nasty cocktail for a B2 diagnosis. Two anti-psychotics? I’m not against appropriate use of shrink-meds but anti-psychotics are frightful. (In USA they are over-prescribed owing to the aggressive marketing tolerated here.) They are for treating psychosis, which, if the B2 diag is correct, you don’t have. The idea that they are mood-stabilizers is so 19-th century. Yes, they calm you down but so does hydrotherpy. Li on it’s own is very effective at treating and preventing mania.

      All medical treatment of chronic illness should be aimed at improving overall quality of life. Most people with a new diag go through years of drug-roulette (because literally nobody knows how to prescribe for these illnesses, and any professional who believes otherwise is suffering from one) so I urge you to collaborate with an MD to find, in due course, something more benign that works also for the lifestyle you enjoy.

      Good luck!

      And remember not to believe everything you read on the internet. Especially not me;) 🚴🏿

  22. Sandy Close said

    I liked your story. I have been on lithium for 28 years. I am 46 female. Very active in fitness. The fatigue still comes and goes with no explanation. I drink only water mostly. And remove all caffeine so I can monitor the fatigue. I cannot get a clear answer as to what long term lithium taking will do to the kidneys.

  23. Kim O. said

    I have been experiencing extreme fatigue and muscle weakness for the past couple of weeks. I am also on 900 mg. Eskalith. So you are saying that if you increase your water/liquid intake that the fatigue/weakness will stop? I’ve been on lithium for many years, but only low doses. Recently, I had to increase the lithium because of an episode. If I increase the water intake and it doesn’t solve the problem, then I may need to get my thyroid checked out. Lithium can cause hypothyroidism and damage to the kidneys. That’s why we have to have those blood levels taken so often. I will give this a try. I hope it works!

    I belong to an online support group for bipolars. Its the MDJunction support group. You may want to join for emotional, mental and spiritual collaboration..

  24. Katy said

    Wow, okay thank you for this! I just recently started Lithium, and have noticed a marked decline in my running performance. Today after running an unusually slow and sluggish long run, I made up my mind to ditch the lithium. But, now….after reading this… maybe I will give it a little more thought. I really don’t want to have to choose running or lithium.

    That’s awesome you did the hard work to get to the bottom of this. I so appreciate you sharing your story. Did you eventually find that some of these side effects (extreme thirst, and dehydration, etc.) subsided?

    • thefsb said

      Hi Katy, to answer your question: no, I did not find that the side effects subsided. After a lot of experimentation I could not find an acceptable balance and changed ℞. That said I would encourage anyone in your sort of situation to try to find your own way to live with lithium. Each case is different.

  25. allisononmymind said

    Thank u so much for posting this. I couldn’t explain my fatigue in my sport I attributed it to Lithium as it was the only change. Your post encourages me to drink more. I will see if that changes anything. Cross fingers it does. My urine was so smelly and yellow so it makes sense what you’re saying

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