What is the treatment for lithium toxicity?

Treatment 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 treatment of choice and should be initiated urgently. 1

Immediate Management Based on Severity

Mild Toxicity (Early Symptoms)

• Discontinue lithium immediately and reduce or cease dosage 2
• Early symptoms include tremor, nausea, diarrhea, and polyuria-polydipsia 1
• Treatment can typically be managed by stopping the drug for 24-48 hours, then resuming at a lower dose 2
• Evaluate and correct precipitating factors: dehydration, medication interactions (especially NSAIDs), or renal impairment 1

Severe Toxicity Requiring Hemodialysis

Absolute indications for urgent hemodialysis include: 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

Important caveat: Patients with chronic toxicity (developing during maintenance therapy) have more severe symptoms than acute overdose patients, even at similar serum levels, and are more likely to require hemodialysis 3. In contrast, acute overdose patients may have levels >3.5 mEq/L with mild symptoms and may not require dialysis 3.

Hemodialysis Protocol

• Continue dialysis until serum lithium <1.0 mEq/L after redistribution (generally 6-8 hours of treatment) 1
• Measure lithium level 4-6 hours post-dialysis to evaluate for rebound, as lithium redistributes from tissues back into serum 1
• Hemodialysis is more effective than peritoneal dialysis; use peritoneal dialysis only if hemodialysis is unavailable 4

Supportive Care Measures

Cardiovascular Management

• Correct electrolytes, especially potassium and magnesium, as primary treatment for arrhythmias 1
• Avoid antiarrhythmic drugs that prolong QT interval (amiodarone, sotalol) if QT prolongation is already present 1
• For hypotension: administer intravenous fluids and vasopressors (norepinephrine); proceed urgently to hemodialysis if hypotension persists 1
• Monitor for ECG changes including T-wave inversion, sinoatrial block, PR prolongation, QT prolongation, and bradycardia 5

General Supportive Measures

• Gastric lavage in acute ingestion 2
• Correction of fluid and electrolyte imbalance 2
• Regulation of kidney function 2
• Infection prophylaxis, regular chest X-rays, and preservation of adequate respiration 2

Agents That Enhance Lithium Excretion

• Urea, mannitol, and aminophylline 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

Monitoring During Treatment

• Regular monitoring of lithium levels, electrolytes, and renal function throughout treatment 1
• Assess for neurological sequelae, as persistent cerebellar deficits can occur, though they appear uncommon in uncomplicated acute poisoning 6
• Monitor renal function closely, as renal insufficiency may persist; chronic lithium nephropathy may be a predisposing factor for toxicity 4

Prevention of Future Toxicity

• 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, as water loss from impaired renal concentrating ability is a major predisposing factor 4
• Resume regular monitoring of serum lithium concentrations twice weekly until stabilized 1