What is the management for lithium toxicity?

Management of Lithium Toxicity

Hemodialysis is the treatment of choice for severe lithium toxicity, particularly when serum levels are ≥3.5 mEq/L with significant symptoms, or when patients present with severe neurological or cardiovascular compromise regardless of level. 1

Initial Assessment and Stabilization

Immediately discontinue lithium and assess the severity of toxicity based on clinical presentation and serum lithium levels. 2

Key Clinical Distinctions

The type of toxicity significantly impacts management:

• Acute toxicity (overdose) typically presents with milder symptoms despite potentially lethal serum levels (>3.5 mEq/L), and patients may not require hemodialysis even at levels of 4.7-5.7 mEq/L if symptoms are mild. 3
• Chronic toxicity (during maintenance therapy) presents with more severe symptoms at lower serum levels and requires more aggressive intervention. 3, 4

Identify Precipitating Factors

Evaluate for conditions that precipitated toxicity: 1

• Dehydration (the most common predisposing factor) 4
• Medication interactions, particularly NSAIDs which increase lithium levels 1
• Renal impairment (creatinine clearance <50 mL/min is a significant predictor) 5
• Intercurrent illness 1

Treatment Algorithm by Severity

Mild Toxicity (Early Symptoms)

For tremor, nausea, diarrhea, or polyuria-polydipsia: 1

• Discontinue lithium 2
• Correct fluid and electrolyte imbalances 2
• Resume treatment at lower dose after 24-48 hours if appropriate 2

Moderate to Severe Toxicity

Implement supportive care: 2

• Gastric lavage (if recent ingestion) 2
• Correction of fluid and electrolyte imbalance, particularly potassium and magnesium 1
• Regulation of kidney function 2
• Infection prophylaxis and regular chest X-rays 2

Consider agents that increase lithium excretion: urea, mannitol, and aminophylline all produce significant increases in lithium excretion. 2

Avoid sodium chloride infusion as it has no specific effect on lithium excretion and can lead to hypernatremia. 4

Hemodialysis Indications

Hemodialysis is urgently indicated for: 1

• Serum lithium ≥3.5 mEq/L with significant neurological or cardiovascular symptoms
• Any lithium level with severe cardiovascular compromise (symptomatic bradycardia, advanced AV block, refractory hypotension)
• Refractory toxicity despite conservative management
• Severe symptoms in chronic toxicity patients even with therapeutic-range levels 3

Hemodialysis Protocol

• Continue dialysis until serum lithium <1.0 mEq/L after redistribution (generally 6-8 hours of dialysis) 1, 4
• Measure lithium level 4-6 hours post-dialysis to evaluate for rebound, as lithium redistributes from intracellular to extracellular fluid 1, 6
• Prolonged or repeated dialysis may be necessary due to the rebound effect 6
• Peritoneal dialysis is appropriate only if hemodialysis is unavailable, though it is less effective 4, 7

Management of Specific Complications

Cardiovascular Complications

For arrhythmias: 1

• Correct electrolytes (especially potassium and magnesium)
• Proceed with hemodialysis as primary treatment
• Avoid antiarrhythmic drugs that prolong QT interval (amiodarone, sotalol) if QT prolongation is present

For hypotension: 1

• Administer intravenous fluids
• Use vasopressors (norepinephrine) if needed
• Initiate urgent hemodialysis if hypotension persists despite support

Renal Complications

Monitor closely for acute renal failure, which can occur with severe toxicity and may be reversible with appropriate treatment including hemodialysis. 6

Critical Pitfalls to Avoid

• Do not rely solely on serum lithium levels in chronic toxicity—severity of symptoms does not always correlate with levels, especially in chronic versus acute intoxication. 1, 3
• Do not use sodium loading as a treatment strategy—it is ineffective and potentially harmful. 4
• Do not underestimate chronic toxicity—patients on maintenance therapy with toxicity are at higher risk for severe symptoms and permanent sequelae. 3, 4
• Do not stop dialysis prematurely—ensure adequate time for redistribution and check post-dialysis rebound levels. 1, 6

Ongoing Monitoring

After acute management: 1

• Regular monitoring of lithium levels, electrolytes, and renal function
• Assess renal concentrating ability regularly during future therapy 4
• Educate patients and caregivers about early signs of toxicity for rapid intervention 1