What are the treatment options for suspected lithium toxicity with symptoms of hyperlithemia?

Treatment of High Lithium Symptoms (Lithium Toxicity)

Immediately discontinue lithium and initiate hemodialysis for severe toxicity (serum levels ≥3.5 mEq/L with significant symptoms, severe neurological or cardiovascular symptoms at any level, or refractory toxicity despite conservative management). 1

Immediate Management Steps

Discontinue Lithium and Assess Severity

• Stop lithium immediately in all cases of suspected toxicity 2
• Evaluate for precipitating factors including dehydration, medication interactions (especially NSAIDs), renal impairment, or intercurrent illness 1
• Obtain serum lithium level, electrolytes (particularly potassium and magnesium), renal function, and ECG 1

Recognize Clinical Manifestations by Severity

Mild toxicity presents with:

• Tremor, nausea, diarrhea, polyuria-polydipsia 1
• Often manageable with cessation or dose reduction alone 3

Moderate to severe toxicity includes:

• Neurological: confusion, ataxia, seizures, altered mental status 4
• Cardiovascular: arrhythmias, ECG changes, hypotension, bradycardia, AV block, myocardial dysfunction 1
• Note that symptom severity does not always correlate with serum levels, especially in chronic versus acute intoxication 1, 5

Treatment Algorithm Based on Severity

Mild Toxicity

• Cessation or reduction of lithium dose is often sufficient 2, 3
• Resume treatment at lower dose after 24-48 hours once symptoms resolve 2
• Correct fluid and electrolyte imbalances 2

Moderate to Severe Toxicity

Initial supportive measures:

• Gastric lavage if recent acute ingestion 2, 3
• Aggressive IV fluid resuscitation to maintain hydration and support renal function 2, 5
• Correct electrolyte abnormalities, especially potassium and magnesium 1

Hemodialysis indications (urgent):

• Serum lithium ≥3.5 mEq/L with significant symptoms 1
• Severe neurological symptoms (seizures, coma, severe confusion) at any level 1
• Significant cardiovascular compromise (symptomatic bradycardia, advanced AV block, refractory hypotension) at any level 1
• Refractory toxicity despite conservative management 1
• Impaired or potentially impaired renal function with moderate-severe toxicity 6

Hemodialysis is the most effective and rapid means of lithium removal 2, 3, 6

Hemodialysis Protocol

• Continue dialysis until serum lithium <1.0 mEq/L after redistribution 1
• Duration typically 6-8 hours 1
• Measure lithium level 4-6 hours post-dialysis to evaluate for rebound, as lithium redistributes from intracellular compartments 1, 7
• Be prepared for secondary elevation requiring repeat dialysis, particularly after massive ingestion or with anticholinergic co-ingestion 7

Management of Specific Complications

Cardiovascular Complications

• Correct electrolytes (potassium and magnesium) as primary treatment for arrhythmias 1
• Avoid antiarrhythmic drugs that prolong QT interval (amiodarone, sotalol) if QT prolongation already present 1
• For hypotension: IV fluids and vasopressors (norepinephrine) 1
• Urgent hemodialysis if hypotension persists despite support 1

Adjunctive Measures to Enhance Elimination

• Urea, mannitol, and aminophylline produce significant increases in lithium excretion 2
• Sodium administration and maintenance of high-normal sodium levels may reduce intracellular lithium in excitable cells 3
• Peritoneal dialysis is less effective than hemodialysis but may be alternative if hemodialysis unavailable 3, 6

Critical Monitoring Considerations

• Serial lithium levels are more informative than single measurements for guiding dialysis decisions 5
• Clinical features of toxicity are more important than spot lithium levels, particularly in acute versus chronic intoxication 5
• In chronic toxicity, serum levels better reflect intracellular concentration and clinical toxicity 5
• Regular chest X-rays, infection prophylaxis, and preservation of adequate respiration are essential 2
• Monitor for persistent neurological deficits, particularly cerebellar dysfunction, though this appears uncommon in uncomplicated acute poisoning 4

Common Pitfalls

• Do not delay hemodialysis in severe cases waiting for conservative management to work—mortality and morbidity increase with delayed intervention 1, 4
• Do not rely solely on serum lithium level to determine severity; clinical presentation is paramount 5
• Do not forget to check for rebound 4-6 hours post-dialysis, as redistribution from tissues can cause re-elevation 1, 7
• Avoid NSAIDs during recovery as they increase lithium levels 1