Which electrolyte imbalance contributes to lithium toxicity

Reported cases of minimally symptomatic patients with serum levels of There is relatively poor correlation between initial serum levels and systemic toxicity, particularly after an acute or acute-on-chronic overdose. Currently, most authors agree that clinical symptoms are more reliable than serum lithium levels. Initial treatment measures include appropriate airway management, assessment of vital signs, and continuous cardiac monitoring. In patients with altered mental status, check the fingerstick glucose and use dextrose and naloxone as appropriate.

Treat hypothermia or hyperthermia appropriately. If seizures develop, treat initially with benzodiazepines, followed by barbiturates if needed. Since activated charcoal binds very poorly to lithium, its use should be reserved for patients who are suspected of ingesting other substances.

Consider gastric lavage for very recent ingestion less than 1 hour , and whole bowel irrigation if very large amounts have been ingested or if a sustained release product was used. Although a few studies suggest that sodium polysterene sulfonate Kayexelate can bind ingested lithium, the magnitude of benefit was small and evidence of clinical efficacy is lacking.

Intravenous fluid therapy is very important. Replace volume losses with isotonic saline boluses, followed by an infusion to maintain good urine output. Fluid replacement will help prevent the continued reabsorption of lithium by the kidney. However, there is no evidence that forced diuresis with very large volumes is any more effective, and it may lead to fluid and electrolyte disturbances.

Hemodialysis is an effective method for enhanced removal of lithium. Lithium has a small volume of distribution and minimal protein binding, and modern dialysis machines can achieve fairly high clearance rates for the ion. However, there is poor agreement about the selection of patients for dialysis, particularly the precise serum lithium levels at which to dialyze. As mentioned earlier, patients with very high levels after an acute overdose may remain asymptomatic, while patients with chronic intoxication may be seriously ill with only modest levels.

In general, toxicologists agree that patients who have symptoms of severe toxicity, renal failure, or clinical deterioration should be dialyzed. During hemodialysis, serum lithium levels drop rapidly but symptoms often persist for hours or days, and serum levels often rebound as the drug re-equilibrates slowly from the intracellular space to the extracellular space.

For this reason, repeated hemodialysis sessions are usually required. While hemodialysis may enhance the elimination of lithium there remains controversy in the available literature as to whether hemodialysis confers any short or long term benefits to the lithium poisoned patient. Reports of successful lithium removal with use of continuous renal replacement therapy CRRT, also known as continuous veno-venous hemofiltration or CVVH do exist. Although CRRT does not achieve clearance rates as high as those with hemodialysis, it has the advantage of being easier to implement and requiring less specialized staff and facilities, and can be performed continuously 24 hours a day.

To date, there are no controlled studies demonstrating an advantage of CRRT over hemodialysis. All patients with symptoms of lithium intoxication not attributable to another cause should be admitted to a monitored setting.

If symptoms are moderate or severe, they should be admitted to an intensive care unit. After an acute ingestion in asymptomatic patients, serial serum lithium levels should be obtained every 6 hours until there is a downward trend, serum levels are less than 1.

However, moderate to severe lithium toxicity is a medical emergency and might require additional treatment, such as stomach pumping. If you take lithium, make sure you know the signs of an overdose and keep the number for poison control handy in your phone. Contact your doctor if you have any concerns about medication or food interactions that might occur while you take lithium. You may not even realize that you're buying into these damaging falsehoods that are spreading the stigma of bipolar disorder.

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Health Conditions Discover Plan Connect. The Facts About Lithium Toxicity. Medically reviewed by Dena Westphalen, Pharm. Lithium is one of the first-line mood stabilizers in the treatment of bipolar disorder BPD , and it has been shown to reduce the risk of suicide in patients with BPD [ 1 , 2 ].

It also has other indications in psychiatry including augmentation of antidepressant therapy in depression [ 3 ]. Its use is sometimes limited by its narrow therapeutic index, thus requiring regular monitoring. Lithium levels can be affected by pharmacokinetic interactions with other drugs including angiotensin receptor blockers ARBs like Valsartan, diuretics, and there is also the potential for neurotoxicity including delirium, serotonin syndrome SS , and neuroleptic malignant syndrome NMS.

We present a case of lithium toxicity with a therapeutic lithium level that we believe was the result of a pharmacokinetic interaction with Valsartan and probable NMS resulting from the ensuing lithium toxicity. B is a year-old African American male with a long history of bipolar disorder, maintained on fluphenazine decanoate, and lithium carbonate for over 30 years without any incidence of toxicity. His past medical history is significant for hypertension, Type II diabetes, and morbid obesity.

He presented with a 1-week history of increasing confusion and lethargy, slurred speech, urinary incontinence, worsening tremor, and gait difficulties. He was found lying on the floor beside his bed on the day of presentation. The family was unaware of how long the patient had been lying there but found him awake and alert, unable to lift himself off the floor.

His last recorded lithium level was 0. Collateral history from his outpatient psychiatrists revealed that patient had been stable on the above regimen of lithium and fluphenazine decanoate with no medication changes made within the past 6 months.

On examination in the ER, the patient was in moderate distress, dehydrated asking for water to drink. His vital signs were fluctuating with temperature ranging from Cardiovascular and respiratory exams were unremarkable. Neurological exam revealed slurred speech, hand tremors, and rigidity in the extremities with decreased motor strength in the upper extremities and lower extremities.

Patient was oriented to place and person but not to time. Admission labs showed a leukocytosis of WBC Blood, urine and sputum cultures yielded no growth. CSF from spinal tap was unremarkable. Patient was commenced on IV fluid hydration and broad-spectrum antibiotics. Lithium was discontinued and fluphenazine decanoate was not administered.

Repeated blood cultures yielded no growth, and thus antibiotics were discontinued. Patient showed gradual improvement in his mental status, he had no problems with articulation, and he was fully orientated within a week of admission. His lithium levels had decreased to 0. Lithium is an effective agent both in acute and prophylactic management of BPAD.

Dehydration and drug overdoses are other causes of lithium toxicity. Our patient had features consistent with lithium toxicity; confusion and lethargy, slurred speech, urinary incontinence, worsening tremor, and gait difficulties. Typically signs of Li toxicity are evident with high lithium level greater than 1. We believe this was as a result of pharmacokinetic interaction between lithium and ARB, and this is consistent with previous case reports of similar interactions [ 8 , 9 ].

The other consideration in our patient was NMS. This is a rare but potentially life-threatening condition associated with the use of psychotropic medications. To diagnose toxicity in a person who normally takes lithium, doctors should take their serum levels 6 to 12 hours after their last dose.

To confirm the diagnosis or better understand the extent of the toxicity, a doctor may also order tests to assess or monitor:. Most people who recognize the signs and symptoms of lithium toxicity early and seek treatment recover fully. In chronic cases, it may take weeks to months for the symptoms to resolve. Ignoring or missing signs of toxicity, especially over time, can result in serious complications, including coma or death.

Untreated cases of lithium toxicity can also lead to permanent complications, such as brain damage, kidney damage, and serotonin syndrome. Lithium toxicity is fairly common in people who usually take medications containing lithium. In most cases, when a person receives early diagnosis and treatment, the symptoms are temporary and do not cause lasting damage. Untreated, severe, or chronic cases of lithium toxicity can be fatal, so it is important for people taking lithium to learn the signs and symptoms of toxicity.

If they notice any of these, they should seek medical care as soon as possible. Mood stabilizers, such as lithium, can help treat a range of conditions, including bipolar disorder.

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