Management of Lithium Toxicity
The management of lithium toxicity requires immediate discontinuation of lithium, supportive care, and in severe cases, hemodialysis to rapidly remove lithium from the body. 1
Assessment and Classification
- Lithium toxicity is classified into three patterns: acute (single large ingestion), acute-on-chronic (overdose during maintenance therapy), and chronic (most common, gradual accumulation during regular dosing) 2
- Severity is determined by serum lithium levels and clinical symptoms:
- Mild toxicity: 1.5-2.5 mEq/L
- Moderate toxicity: 2.5-3.5 mEq/L
- Severe toxicity: >3.5 mEq/L 3
Initial Management
- Immediately discontinue lithium administration upon suspicion of toxicity 1
- Perform gastric lavage for recent acute ingestions to prevent further absorption 1
- Correct fluid and electrolyte imbalances with IV fluids (normal saline) to enhance lithium excretion 1
- Monitor vital signs, neurological status, and cardiac function 2
- Obtain serial serum lithium levels to track elimination 4
Indications for Hemodialysis
- Serum lithium concentration ≥3.5 mEq/L (potentially lethal) 5
- Severe neurological symptoms regardless of lithium level 2
- Significant renal impairment limiting natural lithium clearance 3
- Failure to respond to conservative management 1
Hemodialysis Considerations
- Hemodialysis is more effective than peritoneal dialysis for lithium removal 6
- Continue hemodialysis until serum lithium levels are <1.0 mmol/L after redistribution 6
- Consider extended or repeated dialysis sessions due to post-dialysis rebound from tissue stores 3
- Both intermittent hemodialysis and continuous venovenous hemodialysis (CVVH) can be used, though intermittent hemodialysis provides faster clearance for large ingestions 7
Supportive Care
- Maintain adequate hydration to promote renal lithium clearance 1
- Monitor and manage neurological symptoms 2
- Provide respiratory support as needed 1
- Implement infection prophylaxis for patients with prolonged altered mental status 1
- Obtain regular chest X-rays to monitor for aspiration pneumonia 1
Monitoring During Recovery
- Continue monitoring serum lithium levels until consistently within therapeutic range 4
- Assess renal function regularly, as acute kidney injury may occur during toxicity 7
- Monitor for persistent neurological deficits, particularly cerebellar symptoms 2
- Evaluate for factors that precipitated toxicity (dehydration, medication interactions, renal impairment) 8
Prevention of Future Toxicity
- Temporarily discontinue lithium during intercurrent illness, planned IV contrast administration, or prior to major surgery 4
- Avoid concomitant use of NSAIDs, which can increase lithium levels 8
- Maintain adequate hydration, especially during illness 8
- Regular monitoring of lithium levels, electrolytes, and renal function 8
- Monitor lithium levels twice weekly during initial treatment until stabilized 9
- Educate patients and families about early symptoms of toxicity 1
Special Considerations
- Patients with chronic lithium toxicity often have more severe symptoms than those with acute toxicity, even at similar serum levels 5
- Chronic lithium users may develop nephrogenic diabetes insipidus, increasing risk of dehydration and subsequent toxicity 2
- Consider risk-benefit of continuing lithium after recovery from toxicity 7