The Patient Mr X 53 years old Presented to OPD
Loose Stool from last 2 Days
Loss of Energy
Known patient of Bipolar Disorder and under
treatment by Psychiatry.
On Lithium carbonate
Admit in ward
Stop the lithium
Lithium level repeated after 4 days is 0.68
Discharged via Psychiatry after one week.
• Lithium is used in the treatment of depressive
and bipolar affective disorders.
• The CNS is the major organ system
affected, although the
renal, GIT, endocrine, and CVS also may be
• Lithium is available only for oral
• Absorbed from the GI tract.
• Peak levels occur 2-4 hours postingestion,
• The half-life of a single dose of lithium is from
• The half-life increases to approximately 36
hours in elderly
• Additionally, half-life may be considerably
longer with chronic lithium use.
• An estimated 10,000 toxic exposures occur per
year. These data indicate a gradual increase
over the past 10 years*.
* From USA
• Lithium is similar to sodium
• In addition, lithium may inhibit the release of
monoamines from nerve endings and increase
• The exact mode of action of lithium in affective
disorders is unknown.
• Lithium has a narrow therapeutic ratio.
• Blood concentration must be carefully monitored
to avoid toxicity.
• Early signs of lithium toxicity are vomiting and
severe diarrhoea followed by tremor, ataxia, renal
impairment and convulsions
•Acute poisoning - Voluntary or accidental ingestion in a
previously untreated patient
•Acute-on-chronic - Voluntary or accidental ingestion in a
patient currently using lithium
•Chronic or therapeutic poisoning - Progressive lithium
toxicity, generally in a patient on lithium therapy
Drugs increase the lithium toxicity
• nonsteroidal anti-inflammatory drugs [NSAIDs],
• Nausea and vomiting
• Weakness and fatigue
• Lethargy and confusion
• Generalized weakness
• Fine resting tremor
• Mild confusion
• Severe tremor
• Muscle fasciculations
• Signs of cardiovascular collapse
GI (nausea, vomiting 42% 20%
CNS (seizures) delayed Common > 2.mmol/L
Renal Usualy non Universal
ECG normal QT prolongation usual
Thyroid none Hypothyroidism 20%
Recovery Usual, rapid Disability 10% delayed
Level correlation poor Good
Hypertox. 2007 14
• Lithium toxicity is dose related
• Lithium is minimally protein bound The
therapeutic dose is 300-2700 mg/d with desired
serum levels of 0.7-1.2 mEq/L.
• Lithium clear via kidneys.
• Most filtered lithium is reabsorbed in the PCT
• Diuretics acting distally to the proximal tubule,
such as thiazides and spironolactone
• Reabsorption of lithium is increased and toxicity is
more likely in patients who are hyponatremic or
volume depleted, both of which are possible
consequences of diuretic therapy.
Loop diuretics may increase serum lithium
levels and potentiate the risk of lithium
The exact mechanism is unknown but may be
related to the sodium loss induced by loop
diuresis, which produces a compensatory
increase in proximal tubular reabsorption of
sodium along with lithium.
Tubular lithium handling:
Effect of Furosemide
• Stabilize life-threatening conditions and initiate
• Obtain IV access with isotonic sodium chloride
• Monitor cardiac function to assess rhythm
• Obtain all pill bottles available to the patient.
• Supportive therapy should take precedence.
• Avoid onset of hypernatremia.
In general, consider dialysis in patients with chronic
toxicity and serum lithium concentrations higher than
4mEq/L; also consider dialysis in unstable chronic
patients with lithium levels higher than 2.5 mEq/L.
Guidelines for hemodialysis are more controversial in
patients with acute lithium intoxication but generally
refer to higher serum lithium levels despite relatively
Change in mental status assists in determining need for
• Admit patients with significant signs or
symptoms of toxicity.
• Admit symptomatic patients, regardless of
serum lithium levels; admit patients with
serum lithium levels higher than 2 mEq/L.
• Admit to an ICU patients with chronically
elevated lithium levels higher than 4 mEq/L.
• Perform serial serum lithium determinations
approximately 4 hours apart to confirm a
Asymptomatic patients and patients with serum
lithium concentrations in the therapeutic range
and minor toxicity may be discharged with
scheduled follow-up in 1-2 days.
Obtain psychiatric clearance before discharge
from the hospital
Truncal and gait ataxia
Short-term memory deficits
Most cases of lithium toxicity result in a
favourable outcome; however, up to 10% of
individuals with severe toxicity
Astruc B, Petit P, Abbar M. Overdose with sustained-release
lithium preparations. Eur Psychiatry. Jun 1999;14(3):172-4.
Bailey B, McGuigan M. Comparison of patients hemodialyzed for
lithium poisoning and those for whom dialysis was recommended
by PCC but not done: what lesson can we learn?. Clin Nephrol. Nov
Chen KP, Shen WW, Lu ML. Implication of serum concentration
monitoring in patients with lithium intoxication. Psychiatry Clin
Neurosci. Feb 2004;58(1):25-29.
Eyer F, Pfab R, Felgenhauer N. Lithium poisoning:
pharmacokinetics and clearance during different therapeutic
measures. J Clin Psychopharmacol. Jun 2006;26(3):325-30.
Groleau G. Lithium toxicity. Emerg Med Clin North Am. May
Hypertox 2007 Tables