From the FDA Drug Label
The toxic levels for lithium are close to the therapeutic levels. It is therefore important that patients and their families be cautioned to watch for early symptoms and to discontinue the drug and inform the physician should they occur. Toxic symptoms are listed in detail under ADVERSE REACTIONS. Treatment: No specific antidote for lithium poisoning is known Early symptoms of lithium toxicity can usually be treated by reduction or cessation of dosage of the drug and resumption of the treatment at a lower dose after 24 to 48 hours. In severe cases of lithium poisoning, the first and foremost goal of treatment consists of elimination of this ion from the patient Treatment is essentially the same as that used in barbiturate poisoning: 1) gastric lavage, 2) correction of fluid and electrolyte imbalance and 3) regulation of kidney functioning. Urea, mannitol, and aminophylline all produce significant increases in lithium excretion. Hemodialysis is an effective and rapid means of removing the ion from the severely toxic patient Infection prophylaxis, regular chest X-rays, and preservation of adequate respiration are essential.
The management of lithium toxicity involves:
- Reduction or cessation of dosage to treat early symptoms
- Gastric lavage, correction of fluid and electrolyte imbalance, and regulation of kidney functioning in severe cases
- Use of urea, mannitol, and aminophylline to increase lithium excretion
- Hemodialysis as an effective means of removing the ion from severely toxic patients
- Infection prophylaxis, regular chest X-rays, and preservation of adequate respiration as essential measures 1
From the Research
Management of lithium toxicity requires immediate discontinuation of lithium and supportive care based on severity, with hemodialysis indicated for severe cases, as evidenced by the most recent study 2. The approach to managing lithium toxicity involves assessing the severity of the toxicity and providing appropriate supportive care.
- For mild toxicity (lithium levels 1.5-2.5 mEq/L), stopping lithium and ensuring adequate hydration with intravenous fluids may be sufficient, as supported by older studies 3, 4.
- Moderate to severe toxicity (levels >2.5 mEq/L) or patients with significant symptoms require hospital admission, intensive monitoring, and aggressive IV fluid therapy with normal saline at 150-200 mL/hour to enhance lithium excretion. Key considerations in the management of lithium toxicity include:
- Serial lithium level monitoring, with levels checked every 2-4 hours initially in severe cases, to assess the effectiveness of treatment and guide further management.
- Correction of electrolyte imbalances, particularly sodium, potassium, and calcium, which can impact the severity of lithium toxicity and the patient's overall clinical status.
- The use of hemodialysis, which is highly effective in removing circulating lithium, especially in severe cases or when there are significant neurological symptoms, renal failure, or a deteriorating clinical status despite supportive measures, as highlighted in 2.
- The potential role of other interventions, such as sodium polystyrene sulfonate, in enhancing lithium elimination, although this may be more relevant in specific contexts or as an adjunct to primary treatments, as discussed in 5.
- Psychiatric reevaluation after stabilization to determine the need for restarting lithium or choosing an alternative medication, emphasizing the importance of addressing the underlying psychiatric condition while minimizing the risk of further lithium toxicity.