What is the management of supra-therapeutic lithium levels, presenting as confusion and coarse tremor, in a 75-year-old man with Bipolar Affective Disorder (BPAD)?

From the Guidelines

Immediate discontinuation of lithium and hospitalization for close monitoring is crucial in managing a 75-year-old man with bipolar affective disorder presenting with confusion and coarse tremor due to a supra-therapeutic lithium level of 2.5 mmol/L. The patient's symptoms, such as confusion and coarse tremor, are indicative of lithium toxicity, which can occur at doses close to therapeutic concentrations, as noted in the study on treatment of central disorders of hypersomnolence 1. Key steps in management include:

• Discontinuing lithium immediately to prevent further toxicity
• Initiating intravenous hydration with normal saline at 100-150 mL/hour to enhance lithium excretion, while carefully monitoring fluid status to avoid overload, especially in an elderly patient
• Checking serum electrolytes, renal function, and lithium levels every 4-6 hours to closely monitor the patient's condition
• Considering hemodialysis in severe cases with levels above 2.5 mmol/L or significant symptoms
• Providing supportive care, such as treating symptoms like tremor with low-dose benzodiazepines like lorazepam 0.5-1mg as needed Once the patient stabilizes and lithium levels normalize, reassessment of the medication regimen is essential, considering alternative mood stabilizers like valproate or atypical antipsychotics like quetiapine, as the study suggests the importance of monitoring and adjusting treatment based on patient response and potential side effects 1. It is also critical to investigate the cause of toxicity to prevent recurrence, including medication review, renal function assessment, and patient education about maintaining adequate hydration, highlighting the importance of regular monitoring of serum lithium concentrations and the patient's clinical state, as recommended in the guideline 1.

From the FDA Drug Label

The risk of lithium toxicity is increased by: ... Acute ingestion ... Impaired renal function ... Changes in electrolyte concentrations (especially sodium and potassium) Monitor for signs and symptoms of lithium toxicity. If symptoms occur, decrease dosage or discontinue lithium treatment. Diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination may be early signs of lithium intoxication, and can occur at lithium concentrations below 2 mEq/L Serum lithium concentrations above 3 mEq/L may produce a complex clinical picture involving multiple organs and organ systems. Central Nervous System: tremor, muscle hyperirritability, hypertonicity, ataxia, choreoathetotic movements, hyperactive deep tendon reflex, extrapyramidal symptoms including acute dystonia, cogwheel rigidity, blackout spells, epileptiform seizures, slurred speech, dizziness, vertigo, downbeat nystagmus, incontinence of urine or feces, somnolence, psychomotor retardation, restlessness, confusion, stupor, coma

Management of supra-therapeutic lithium levels:

• The patient is presenting with symptoms of lithium toxicity, including confusion and coarse tremor, at a lithium level of 2.5.
• Discontinue lithium treatment immediately to prevent further toxicity.
• Monitor the patient's vital signs, electrolyte levels, and renal function closely.
• Supportive care should be provided to manage symptoms and prevent complications.
• Consultation with a nephrologist or a toxicologist may be necessary to guide management. 2 2

From the Research

Management of Supra-Therapeutic Lithium Levels

• A 75-year-old man with bipolar disorder (BPAD) presenting with confusion and coarse tremor due to supra-therapeutic lithium levels of 2.5 requires immediate medical attention.
• The management of supra-therapeutic lithium levels involves stopping lithium therapy and providing supportive care, such as hydration and monitoring of vital signs 3.
• In patients with severe lithium toxicity, hemodialysis may be necessary to rapidly reduce lithium levels.

Lithium Therapy in BPAD

• Lithium is a first-line pharmacotherapy for the treatment of BPAD, but its use requires careful monitoring of serum lithium levels to avoid toxicity 4.
• The efficacy of lithium in preventing manic episodes is well-established, but its effectiveness in preventing depressive episodes is less clear 4.
• Combination therapy with other mood stabilizers, such as valproate or lamotrigine, may be necessary to achieve optimal treatment outcomes in patients with BPAD 4.

Risks and Benefits of Lithium Therapy

• Lithium therapy is associated with several risks, including nephrotoxicity, neurotoxicity, and teratogenicity 3, 5.
• The benefits of lithium therapy in patients with BPAD include its efficacy in preventing manic episodes and its potential to reduce the risk of suicide 4, 6.
• The risks and benefits of lithium therapy must be carefully weighed in each patient, and regular monitoring of serum lithium levels and renal function is necessary to minimize the risk of toxicity 3, 5.

Treatment Outcomes in BPAD

• Treatment outcomes in patients with BPAD vary widely, and the choice of therapy depends on several factors, including the severity of symptoms, comorbidities, and patient preferences 6, 7.
• Lithium monotherapy is effective in some patients with BPAD, but combination therapy with other mood stabilizers or antipsychotics may be necessary to achieve optimal treatment outcomes 4, 6.
• Adjunctive benzodiazepines may not significantly affect clinical outcomes in patients with BPAD, but their use should be carefully monitored due to the risk of dependence and withdrawal 7.