I have been taking lithium 900 mg daily for five days and now have clammy hands, nausea, and loss of appetite; what should I do?

Immediate Action Required: Stop Lithium and Seek Emergency Evaluation

You need to stop taking lithium immediately and contact your prescribing physician or go to the emergency department today. Your symptoms—clammy hands, nausea, and loss of appetite after only 5 days on 900 mg daily—are concerning for early lithium toxicity, even though this is a relatively short treatment duration.

Why This Is Urgent

Your 900 mg daily dose is significantly higher than recommended starting doses. Guidelines indicate lithium should be initiated at 150 mg per day, with therapeutic blood levels of 0.2-0.6 mEq/L typically achieved with 150-300 mg daily 1. You are taking 3-6 times the recommended starting dose, which dramatically increases toxicity risk.

Early Warning Signs You're Experiencing

The FDA drug label explicitly identifies your symptoms as early signs of lithium toxicity 2:

• Nausea and vomiting (gastrointestinal symptoms)
• General discomfort and loss of appetite (anorexia)
• Clammy hands suggest autonomic dysfunction or early tremor manifestation

Critically, the FDA states these symptoms "may occur at lithium levels below 2 mEq/L" and can appear "during the first few days of lithium administration" 2. Toxicity can occur even at therapeutic or near-therapeutic blood levels, particularly in sensitive individuals 3, 4.

What Happens If You Continue

If untreated, early toxicity progresses to:

• Neurological deterioration: tremor, drowsiness, muscular weakness, lack of coordination, confusion, altered consciousness 2, 5
• Severe toxicity: ataxia, seizures, cardiac arrhythmias, acute kidney injury, coma 2, 6, 7
• Permanent neurological damage: cerebellar dysfunction can persist even after lithium discontinuation 6

Recent case reports document that gastrointestinal symptoms (nausea, vomiting, diarrhea) frequently precede neurological manifestations and may trigger dehydration, which further concentrates lithium levels and accelerates toxicity 3, 5.

Immediate Steps

1. Stop lithium now—do not take today's dose or any subsequent doses until evaluated

2. Contact your prescribing physician immediately to report symptoms

3. Go to the emergency department if:

   • Symptoms worsen
   • You develop confusion, severe weakness, tremor, or difficulty walking
   • You cannot reach your physician promptly
   • You experience vomiting or diarrhea (which causes dehydration and worsens toxicity)

4. At medical evaluation, you need:

   • Serum lithium level measurement
   • Renal function tests (creatinine, BUN)
   • Electrolyte panel
   • Assessment of hydration status

Why This Dosing Was Inappropriate

The evidence is unequivocal that elderly patients are particularly prone to neurotoxicity at higher lithium dosages 1, and even younger patients require careful dose titration. Your case illustrates a common prescribing error: starting at maintenance doses rather than initiating therapy gradually.

Proper Lithium Initiation Protocol

When lithium is restarted (if appropriate):

• Begin at 150 mg daily 1
• Monitor serum levels after 5-7 days
• Increase gradually only if levels are subtherapeutic and symptoms warrant
• Target therapeutic range: 0.6-1.2 mEq/L for acute treatment; 0.4-0.8 mEq/L for maintenance
• Never exceed 1.5 mEq/L 2

Critical Monitoring Going Forward

If lithium is continued after this episode:

• Baseline and regular monitoring of renal function, thyroid function, and serum lithium levels 8, 9
• Patient education about toxicity symptoms, hydration needs, and drug interactions 5, 10
• Avoid NSAIDs, diuretics, and ACE inhibitors without physician consultation—these dramatically increase lithium levels 8, 10
• Maintain adequate hydration; dehydration is a major precipitant of toxicity 5, 6

Common Pitfall to Avoid

Do not assume symptoms will "subside with continued treatment" as the FDA label suggests for mild initial side effects 2. While transient mild nausea can occur, your constellation of symptoms after such a high starting dose warrants immediate evaluation. The distinction between "expected initial side effects" and "early toxicity" is critical—when in doubt, check a lithium level.

The literature consistently shows that chronic toxicity from therapeutic dosing is more common than acute intentional overdose 6, 10, and your symptoms at day 5 suggest you may be particularly sensitive to lithium or that the dose is simply too high for initiation.