Treatment of Lithium Toxicity
The treatment of lithium toxicity primarily involves discontinuation of lithium, supportive care, and in severe cases, hemodialysis to rapidly eliminate lithium from the body. 1
Initial Management
- Immediately discontinue lithium administration upon suspicion of toxicity 1
- Perform gastric lavage if the ingestion was recent (within 1-2 hours) 1
- Correct fluid and electrolyte imbalances with IV fluids to maintain adequate hydration 1
- Monitor and regulate kidney function, as renal impairment can worsen lithium toxicity 1
Elimination Strategies
- For mild to moderate toxicity, cessation of lithium for 24-48 hours followed by resumption at a lower dose may be sufficient 1
- Urea, mannitol, and aminophylline can be administered to increase lithium excretion 1
- Hemodialysis is the most effective and rapid method for removing lithium in severe toxicity cases 1, 2
- Peritoneal dialysis may be considered as an alternative but less effective option for patients with impaired renal function 2
Monitoring During Treatment
- Obtain serial serum lithium levels to track elimination 3
- Monitor renal function tests (BUN, creatinine) frequently during treatment 3
- Regular assessment of vital signs and neurological status 4
- Infection prophylaxis, regular chest X-rays, and preservation of adequate respiration are essential 1
Special Considerations
- Avoid sodium overloading during treatment 2
- Be aware that neurotoxicity can persist or even develop despite normalization of serum lithium levels 5
- Do not restart lithium immediately after levels normalize in cases of significant overdose, as delayed neurotoxicity may occur 5
- Patients with chronic lithium toxicity may require more aggressive intervention than those with acute toxicity due to tissue accumulation 4
Prevention of Recurrence
- Regular monitoring of serum lithium concentrations is essential, especially during acute treatment phases 6
- Temporarily suspend lithium during intercurrent illness, planned IV radiocontrast administration, bowel preparation, or prior to major surgery 6
- Educate patients and caregivers about early signs of lithium toxicity (tremor, nausea, diarrhea, polyuria-polydipsia) 6, 3
- Conservative dosing and careful consideration when combining lithium with other medications 7
Pitfalls and Caveats
- There is no specific antidote for lithium toxicity 1, 2
- The therapeutic window for lithium is narrow, with toxic levels close to therapeutic levels 1
- Forced diuresis is only minimally more effective than withdrawal of treatment in patients with normal renal function 2
- Lithium should be discontinued during ECT treatment if clinically possible, as concurrent use has been associated with acute brain syndrome 8
- Delayed neurotoxicity can occur even after lithium levels have normalized, requiring careful monitoring before restarting lithium 5