Q. Dear Anna, I am a young bipolar man who has been on some pretty heavy medications for about a year. I've switched so many times that my head is spinning, but I think I may have found the right combination with Lithium, (1200 mgs.) Seroquel (300 mgs.) and Lamictal (100 mgs.) To make a long story short, my last blood test showed all my organs to be healthy and intact, but that I was very close to going toxic. I believe the scale ends at 1.5 for the safety range, and I am at 1.3. I am concerned about that, about accidentally doing something to push myself over the line, and my current dosage is just right for me and shouldn't be lowered due to several manic episodes and a spending spree. Also, does smoking cigarettes affect the medication that much, because whenever I smoke my hands shake worse than usual. Any help you could give me about these concerns would be greatly appreciated. Thank you.

A. Ryan,

Thanks for writing in. Lithium toxicity can be very serious and is definitely something to be concerned about. I am not aware of any interactions between cigarette smoking and lithium, but I do feel it is something you might want to bring up with your physician at your next appointment. Too much nicotine can cause slight tremors in certain individuals because it is a stimulant and can be overdosed on just like any other drug.

During an acute manic episode, serum levels of lithium between 1.0 and 1.5 are generally recommended. However, once the acute episode passes, maintenance therapy generally requires levels a bit lower, from 0.8-1.2. Sensitive individuals can become toxic from levels much lower than that.

The most common cause of lithium toxicity is too little water. When you drink less, or perspire more than usual, your serum levels rise. If you drink too much they will lower. Be aware of any changes in activity that might result in toxicity (like starting a new exercise program) and be certain to drink plenty of water.

Be alert to the symptoms of toxicity, such as diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination. If you experience any of these symptoms, I suggest you phone your doctor or head to the emergency room.

Anna