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. 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 steps to manage elevated lithium levels in a patient are:
- Discontinue the drug and inform the physician if early symptoms of lithium toxicity occur
- Reduce or cease dosage of the drug to treat early symptoms of lithium toxicity, and resume treatment at a lower dose after 24 to 48 hours
- For severe cases:
- Perform gastric lavage
- Correct fluid and electrolyte imbalance
- Regulate kidney functioning
- Use urea, mannitol, or aminophylline to increase lithium excretion
- Consider hemodialysis for rapid removal of the ion in severely toxic patients
- Provide infection prophylaxis, perform regular chest X-rays, and preserve adequate respiration 1
From the Research
Managing elevated lithium levels requires prompt intervention based on severity, with a focus on preventing morbidity, mortality, and improving quality of life. For mild toxicity (1.5-2.0 mEq/L), discontinue lithium immediately and increase fluid intake to 3-4 liters daily to enhance renal clearance. For moderate toxicity (2.0-2.5 mEq/L), hospitalization is necessary with IV normal saline at 150-200 mL/hour to promote lithium excretion, while monitoring electrolytes, renal function, and lithium levels every 4-6 hours. Severe toxicity (>2.5 mEq/L) or neurological symptoms requires ICU admission and consideration of hemodialysis, particularly when levels exceed 4.0 mEq/L or in patients with renal impairment, as highlighted in a study from 2. Supportive care includes addressing seizures with benzodiazepines (lorazepam 2-4 mg IV), managing arrhythmias, and correcting electrolyte imbalances. Once stabilized, lithium should be reintroduced cautiously if still indicated, starting at lower doses (150-300 mg daily) with more frequent monitoring, considering the patient's clinical presentation and serum lithium level, as discussed in 3 and 4. It's also important to note that sodium polystyrene sulfonate may be used to reduce plasma lithium concentrations after chronic lithium dosing, as shown in studies 5 and 6. However, the most recent and highest quality study 4 emphasizes the need to treat clinical lithium toxicity based on symptoms rather than just serum levels, especially in patients with renal impairment. Key considerations in managing elevated lithium levels include:
- Discontinuing lithium and enhancing renal clearance for mild toxicity
- Hospitalization and IV saline for moderate toxicity
- ICU admission and possible hemodialysis for severe toxicity or neurological symptoms
- Supportive care for seizures, arrhythmias, and electrolyte imbalances
- Cautious reintroduction of lithium at lower doses with frequent monitoring if still indicated.