What is the management of lithium toxicity?

From the Guidelines

Lithium toxicity should be managed with immediate discontinuation of lithium and supportive care, including aggressive IV fluid administration and monitoring, with hemodialysis indicated for severe cases. The management of lithium toxicity is crucial to prevent morbidity and mortality, and it requires a comprehensive approach. For mild toxicity, stopping lithium and ensuring adequate hydration with intravenous fluids may be sufficient, as seen in clinical practice guidelines that emphasize the importance of monitoring and managing patients on potentially nephrotoxic agents like lithium 1.

Key Considerations

• Discontinuation of lithium is the first step in management
• Supportive care, including IV fluids, is essential for enhancing lithium excretion
• Monitoring of electrolyte levels, particularly sodium, is crucial to prevent worsening of toxicity
• Hemodialysis is indicated for severe toxicity, neurological symptoms, or renal failure
• Continuous cardiac monitoring is necessary due to the risk of arrhythmias

Management Strategies

• Mild toxicity: stopping lithium and ensuring adequate hydration
• Moderate to severe toxicity: hospital admission, intensive monitoring, and aggressive IV fluid administration
• Severe toxicity: hemodialysis and close monitoring of electrolyte levels and cardiac function It is essential to evaluate the cause of toxicity before considering lithium reinitiation or switching to an alternative medication, as this can help prevent future episodes of toxicity. Regular monitoring of GFR, electrolytes, and drug levels is recommended for patients taking lithium, as emphasized in guidelines for the management of chronic kidney disease 1.

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 2

From the Research

Management of Lithium Toxicity

The management of lithium toxicity involves several approaches, including:

• Supportive measures
• Hemodialysis in severe cases
• Use of sodium polystyrene sulfonate (SPS) to reduce absorption and enhance elimination of lithium

Treatment Guidelines

Available treatment guidelines for lithium intoxication have been evaluated, and it was found that:

• Most guidelines lack essential information or provide potentially hazardous information
• Clarity, presentation, and applicability of guidelines are relatively poor
• Regular updates of treatment guidelines are necessary to incorporate new information 3

Role of Hemodialysis

Hemodialysis is often recommended to treat lithium poisoning, but:

• There is no evidence from randomized controlled trials to support or refute the use of hemodialysis in the management of patients with lithium poisoning 4
• Observational studies show similar outcomes in patients managed with or without hemodialysis
• Hemodialysis may be necessary in cases of severe lithium intoxication, particularly when serum lithium levels are above the therapeutic range 5, 6

Alternative Treatments

Sodium polystyrene sulfonate (SPS) has been shown to:

• Reduce lithium half-life and promote lithium elimination in chronic intoxications
• Be a potential adjunct to supportive measures and hemodialysis in the treatment of lithium overdose 7

Patient Care

Patients with lithium toxicity require immediate and appropriate care, including:

• Monitoring of serum lithium levels and renal function
• Supportive measures to manage symptoms and prevent complications
• Consideration of hemodialysis or alternative treatments in severe cases 5, 6, 7, 3, 4