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

Urgent hemodialysis is indicated for: 1

• Serum lithium ≥3.5 mEq/L with significant neurological or cardiovascular symptoms 1
• Any lithium level with severe cardiovascular compromise (symptomatic bradycardia, advanced AV block, refractory hypotension) 1
• Severe symptoms with serum levels above therapeutic range in chronic toxicity 3
• Refractory toxicity despite conservative management 1

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
• Multiple dialysis sessions may be required due to this rebound effect 6
• Peritoneal dialysis is less effective but appropriate if hemodialysis is unavailable 4, 7

Management of Specific Complications

Cardiovascular Complications

For arrhythmias: 1

• Correct electrolytes (especially potassium and magnesium) 1
• Proceed with hemodialysis as primary treatment 1
• Avoid antiarrhythmic drugs that prolong QT interval (amiodarone, sotalol) if QT prolongation is present 1

For hypotension: 1

• Administer intravenous fluids 1
• Use vasopressors (norepinephrine) if needed 1
• Initiate urgent hemodialysis if hypotension persists despite support 1

Renal Complications

Monitor closely as renal insufficiency is common (found in 17 of 23 patients in one series), and some patients may not regain normal renal function. 4 Acute renal failure from lithium toxicity is typically reversible with hemodialysis but may require prolonged treatment. 6

Prevention of Future Toxicity

Implement regular monitoring: 1

• Serum lithium concentrations twice weekly during acute phase until stabilized 1
• Regular monitoring of lithium levels, electrolytes, and renal function 1
• Assess creatinine clearance, as values <50 mL/min significantly increase toxicity risk 5

Temporarily suspend lithium during: 1

• Intercurrent illness 1
• Planned IV radiocontrast administration 1
• Bowel preparation 1
• Prior to major surgery 1

Maintain adequate hydration especially during illness, as water loss from impaired renal concentrating ability is a major predisposing factor. 1, 4

Avoid concomitant NSAIDs which increase lithium levels. 1

Critical Pitfalls to Avoid

• Do not rely solely on serum lithium levels in chronic toxicity—severity of symptoms does not always correlate with levels, and patients with chronic toxicity have more severe symptoms at lower levels than acute overdose patients. 1, 3
• Do not use sodium chloride infusion as specific treatment—it is ineffective and risks hypernatremia. 4
• Do not stop hemodialysis prematurely—continue until post-redistribution level is <1.0 mEq/L to prevent rebound toxicity. 1, 4
• Educate patients and caregivers about early signs of toxicity to allow rapid intervention. 1