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 severe cardiovascular/neurological compromise), hemodialysis is the definitive treatment and should be initiated urgently. 1

Immediate Management Steps

Discontinue Lithium and Assess Severity

• Stop lithium immediately in all cases of suspected toxicity 2
• Measure serum lithium level, electrolytes (especially potassium, magnesium, sodium), and renal function (creatinine, BUN) 1
• Identify precipitating factors: dehydration, NSAID use, renal impairment, or medication interactions 1
• Obtain ECG to assess for arrhythmias, QT prolongation, or conduction abnormalities 1

Severity-Based Treatment Algorithm

Mild Toxicity (levels 1.5-2.5 mEq/L with minimal symptoms):

• Discontinue lithium for 24-48 hours 2
• Provide supportive care with IV fluids to maintain hydration and support renal clearance 2
• Correct electrolyte imbalances, particularly sodium depletion 2
• Monitor serum lithium levels every 4-6 hours until declining 1
• Resume lithium at lower dose once levels normalize and symptoms resolve 2

Moderate to Severe Toxicity (levels >2.5 mEq/L or significant symptoms):

• Consider hemodialysis, particularly if neurological symptoms (confusion, seizures, dysarthria, tremor) or cardiovascular symptoms (arrhythmias, hypotension) are present 1, 3
• Chronic toxicity patients require more aggressive treatment than acute overdose patients, even at similar serum levels, because symptoms are typically more severe 4, 3

Hemodialysis Indications

Hemodialysis should be initiated urgently 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
• Significant renal impairment preventing adequate lithium clearance 3

Hemodialysis Protocol

• Continue dialysis until serum lithium <1.0 mEq/L is achieved after redistribution 1
• Typical duration is 6-8 hours 1
• Measure lithium level 4-6 hours post-dialysis to assess for rebound, as lithium redistributes from intracellular to extracellular compartments 1, 5
• Multiple dialysis sessions may be required if rebound occurs 5, 6
• Hemodialysis is far more effective than peritoneal dialysis, which should only be used if hemodialysis is unavailable 3, 6

Management of Specific Complications

Cardiovascular Complications

• Correct electrolyte abnormalities (potassium and magnesium) as primary treatment for arrhythmias 1
• Avoid antiarrhythmic drugs that prolong QT interval (amiodarone, sotalol) if QT prolongation is present 1
• For hypotension: administer IV fluids and vasopressors (norepinephrine) as needed 1
• Initiate urgent hemodialysis if hypotension persists despite supportive measures 1

Renal Complications

• Acute renal failure can occur with severe lithium toxicity and may require prolonged hemodialysis 5
• Monitor for nephrogenic diabetes insipidus and maintain adequate hydration 3
• Some patients may not regain normal renal function, particularly with chronic toxicity 3

Critical Pitfalls to Avoid

Do NOT use sodium chloride infusion as specific treatment - it has no specific effect on lithium excretion and can cause dangerous hypernatremia 3, 6

Do NOT rely solely on serum lithium levels - chronic toxicity patients often have severe symptoms at lower levels than acute overdose patients 4, 3. A patient with chronic toxicity at 2.0 mEq/L may be more severely affected than an acute overdose patient at 5.0 mEq/L 4

Do NOT use forced diuresis - it is minimally more effective than supportive care alone and requires intact renal function 6

Do NOT delay hemodialysis in severe cases - the duration and severity of toxicity, not just the peak level, determine outcomes 3. Waiting for oliguria, semi-coma, or convulsions significantly worsens prognosis 6

Supportive Care Measures

• Gastric lavage may be considered in acute overdose if presenting within 1-2 hours 2
• Maintain adequate respiration and consider infection prophylaxis with regular chest X-rays 2
• Monitor for neurological sequelae including persistent tremor, dysarthria, and cognitive impairment 3, 7

Post-Recovery Monitoring

• Evaluate and address all precipitating factors before restarting lithium 1
• Avoid NSAIDs permanently, as they increase lithium levels 1, 8
• Ensure regular monitoring of lithium levels, renal function, and electrolytes 1, 9
• Educate patients and caregivers about early toxicity signs (tremor, nausea, diarrhea, polyuria) for rapid intervention 1, 9