What is the management approach for lithium toxicity?

Management of Lithium Toxicity

For severe lithium toxicity (serum levels ≥3.5 mEq/L with significant symptoms, or any level with cardiovascular compromise), hemodialysis is the definitive treatment and should be initiated urgently. 1

Immediate Assessment and Stabilization

Discontinue lithium immediately upon recognition of toxicity, regardless of severity 2, 3. The clinical presentation guides management more than serum levels alone, as neurotoxicity can occur even at therapeutic levels 4, 5.

Identify Precipitating Factors

• Evaluate for dehydration, medication interactions (especially NSAIDs), renal impairment, or intercurrent illness that triggered toxicity 1
• Check electrolytes, particularly sodium, potassium, and magnesium 1
• Assess renal function immediately, as impairment both causes and results from lithium toxicity 6

Obtain Serial Lithium Levels

• Measure serum lithium concentration on presentation 7
• Repeat levels every 4-6 hours to track elimination and detect rebound after dialysis 1, 7
• Continue monitoring until levels remain stable below 1.0 mEq/L 1

Severity-Based Treatment Algorithm

Mild Toxicity (tremor, nausea, diarrhea, polyuria)

• Cessation or dose reduction alone is often sufficient 2, 3
• Resume treatment at lower dose after 24-48 hours if symptoms resolve 2
• Maintain adequate hydration 1

Moderate to Severe Toxicity

Initiate aggressive supportive care:

• Gastric lavage if presentation is within hours of acute ingestion 2, 3
• Correct fluid and electrolyte imbalances, particularly maintaining high-normal sodium levels to facilitate lithium exit from cells 3
• Preserve adequate respiration and provide infection prophylaxis 2

Hemodialysis Indications

Hemodialysis is indicated urgently for: 1

• Serum lithium ≥3.5 mEq/L with significant neurological or cardiovascular symptoms
• Any lithium level with significant cardiovascular compromise (symptomatic bradycardia, advanced AV block, refractory hypotension)
• Refractory toxicity despite conservative management
• Renal insufficiency preventing adequate lithium clearance 6

Hemodialysis Protocol

• Continue dialysis for 6-8 hours until serum level <1.0 mEq/L is achieved 1
• Critical: Measure lithium level 4-6 hours post-dialysis to assess for rebound from tissue redistribution 1, 6
• Repeat hemodialysis if rebound occurs or symptoms persist 6
• Hemodialysis is far superior to peritoneal dialysis, which should only be used if hemodialysis is unavailable 6, 8

Management of Specific Complications

Cardiovascular Manifestations

• Obtain ECG to assess for arrhythmias, QT prolongation, or conduction abnormalities 1
• Correct electrolytes (potassium and magnesium) as primary treatment for arrhythmias 1
• Avoid antiarrhythmics that prolong QT interval (amiodarone, sotalol) if QT prolongation is present 1
• For hypotension: administer IV fluids and vasopressors (norepinephrine preferred) 1
• Proceed urgently to hemodialysis if hypotension persists despite support 1

Renal Complications

• Monitor renal function tests frequently during treatment 7
• Recognize that renal insufficiency may persist; in one series, 5 of 17 patients with acute renal failure did not regain normal function 6
• Chronic lithium nephropathy may be a predisposing factor for toxicity 6

Treatments to Avoid

Do NOT use sodium chloride infusion as a specific treatment—it has no specific effect on lithium excretion and can cause dangerous hypernatremia 6, 8

Forced diuresis is minimally effective and requires unimpaired renal function, offering little advantage over supportive care alone 8

Special Populations and Considerations

High-Risk Patients

• Advanced age, pre-existing neurological disease, fever, or concurrent use of antipsychotics/antidepressants increase risk of neurotoxicity even at normal levels 4
• Neurotoxicity can be irreversible in some cases, with persistent neurological deficits despite lithium discontinuation 5

Prevention Strategies

• Temporarily suspend lithium during intercurrent illness, IV radiocontrast administration, bowel preparation, or prior to major surgery 1
• Avoid concomitant NSAIDs which increase lithium levels 1
• Maintain adequate hydration, especially during illness 1
• Regular monitoring of lithium levels, electrolytes, and renal function 9, 1

Patient and Caregiver Education

Educate about early warning signs requiring immediate medical attention: tremor, nausea, diarrhea, polyuria-polydipsia, slurred speech, or ataxia 1, 7. This allows for rapid intervention before severe toxicity develops.