Is it safe to stop lithium therapy in an adult patient with a history of bipolar disorder presenting to the Emergency Department (ED) with acute respiratory distress and potential impaired renal function?

Is Stopping Lithium Dangerous in Acute Respiratory Distress?

Do not abruptly stop lithium in a patient presenting to the ED with acute respiratory distress unless there is evidence of severe lithium toxicity or life-threatening contraindications requiring immediate discontinuation. The decision hinges on distinguishing between respiratory distress caused by lithium toxicity versus other etiologies, and assessing renal function.

Critical Initial Assessment

Immediately obtain a serum lithium level and basic metabolic panel to determine if the respiratory distress is related to lithium toxicity or represents a separate acute illness 1. This distinction is essential because:

• Lithium-induced ARDS is rare but documented at toxic levels (3.3-4.9 mmol/L), presenting with bilateral pulmonary edema and hypoxic respiratory failure requiring intubation 2
• Most acute respiratory distress in lithium patients is unrelated to the medication itself and represents concurrent illness 3

When to Continue Lithium (Most Common Scenario)

Continue lithium therapy if:

• Serum lithium level is therapeutic (0.6-1.2 mEq/L) 4, 5
• Creatinine is stable or only mildly elevated 1
• The patient is not severely dehydrated 1
• Respiratory distress has an identifiable non-lithium cause (pneumonia, heart failure, COPD exacerbation) 3

Rationale: Abrupt lithium discontinuation carries a >90% relapse risk in bipolar disorder, with rebound mania occurring within 6 months in the majority of patients 4, 6. The psychiatric consequences of sudden discontinuation typically outweigh the risks of continuing therapeutic-level lithium during acute medical illness 4, 5.

When to Temporarily Hold Lithium

Hold lithium doses temporarily if:

• Significant renal impairment (creatinine >2.5 mg/dL or acute kidney injury) 1
• Severe dehydration requiring aggressive IV fluid resuscitation 1, 7
• Hemodynamic instability (systolic BP <85 mmHg) requiring vasopressors 3
• Patient is NPO or undergoing bowel preparation 8
• Concurrent diuretic therapy is being initiated or escalated 7

Resume lithium once renal function stabilizes and the patient can maintain adequate oral hydration 8, 1.

When to Discontinue Lithium Emergently

Discontinue lithium immediately and initiate hemodialysis if:

• Serum lithium level ≥3.5 mEq/L with significant symptoms 8, 2
• Clinical signs of severe lithium toxicity: coarse tremor, confusion, ataxia, seizures, or altered mental status 6, 8
• Cardiovascular compromise: symptomatic bradycardia, advanced AV block, or refractory hypotension 8
• Suspected lithium-induced ARDS: new bilateral pulmonary edema without cardiogenic cause at toxic lithium levels 2

Practical Management Algorithm

Step 1: Obtain Labs Immediately

• Serum lithium level (stat)
• Basic metabolic panel with creatinine
• Arterial blood gas if hypoxic
• BNP if heart failure suspected 3

Step 2: Risk Stratify Based on Lithium Level

Therapeutic range (0.6-1.2 mEq/L):

• Continue lithium at current dose
• Treat respiratory distress per standard protocols 3
• Monitor lithium level in 24-48 hours if renal function changes 1

Mildly elevated (1.3-2.0 mEq/L):

• Hold next 1-2 doses
• Aggressive IV hydration with normal saline 8, 7
• Recheck lithium level in 6-12 hours
• Resume at reduced dose once level <1.2 mEq/L 1

Moderately elevated (2.1-3.4 mEq/L):

• Hold all lithium doses
• IV hydration and supportive care 8
• Consider hemodialysis if symptomatic or renal impairment present 8
• Psychiatry consultation for alternative mood stabilization 4

Severely elevated (≥3.5 mEq/L):

• Emergent hemodialysis 8, 2
• ICU admission
• Continue dialysis until level <1.0 mEq/L after redistribution 8

Step 3: Address Precipitating Factors

Common triggers for lithium toxicity in acute illness:

• Dehydration from decreased oral intake 1, 7
• NSAID use (increases lithium levels 25-40%) 7
• ACE inhibitors or diuretics (especially thiazides) 7
• Acute kidney injury from any cause 1, 7

Avoid initiating these medications during acute illness if lithium is being continued 7.

Critical Pitfalls to Avoid

Do not reflexively stop lithium in every acutely ill patient – this creates unnecessary psychiatric destabilization in the vast majority of cases where lithium is not contributing to the acute illness 4, 5.

Do not assume respiratory distress is lithium-related without checking a level – lithium-induced ARDS is exceedingly rare and only occurs at frankly toxic levels (>3.3 mmol/L) 2.

Do not restart lithium at full dose after holding – if lithium was held for >5 days, restart with gradual titration to minimize toxicity risk 4, 6.

Do not discharge patients on lithium without ensuring adequate hydration and follow-up – dehydration is the most common precipitant of lithium toxicity in outpatients 8, 1.

Monitoring During Hospitalization

• Daily lithium levels if initially elevated or if renal function is changing 6, 8
• Twice-weekly lithium levels if therapeutic and stable 6
• Daily creatinine to detect acute kidney injury 1
• Fluid balance – ensure adequate hydration (typically 2-3 L/day) 8, 1
• Neurological exam for early signs of toxicity (tremor, confusion, ataxia) 6, 8

Psychiatric Consultation

Obtain psychiatry consultation if:

• Lithium must be held for >48-72 hours 4
• Patient has history of severe mania or rapid cycling 4
• Alternative mood stabilization is needed during acute illness 4
• Patient has history of medication nonadherence 4

Psychiatry can recommend bridging strategies (such as adding an atypical antipsychotic temporarily) to minimize relapse risk during lithium interruption 4.