Medscape is available in 5 Language Editions – Choose your Edition here.


Lithium Toxicity Treatment & Management

  • Author: David C Lee, MD; Chief Editor: Asim Tarabar, MD  more...
Updated: Feb 02, 2015

Prehospital Care

Stabilize life-threatening conditions and initiate supportive therapy according to local EMS protocols.

Obtain intravenous access with isotonic sodium chloride solution.

Monitor cardiac function to assess rhythm disturbances.

Obtain all pill bottles available to the patient.


Emergency Department Care

Supportive therapy is the mainstay of treatment of lithium toxicity. Airway protection is crucial due to emesis and risk of aspiration. Seizures can be controlled with benzodiazepines, phenobarbital, or propofol.

GI decontamination

Gastric lavage may be attempted if the patient presents within one hour of ingestion.

Lithium is a monovalent cation that does not bind to charcoal; therefore, activated charcoal has no role. However, activated charcoal might be considered in the case of exposure to co-ingestants. The clinician also has to be aware that acute lithium toxicity can produce vomiting and precipitate aspiration of activated charcoal.

Whole-bowel irrigation with polyethylene glycol lavage can be effective in preventing absorption from extended-release lithium.

Because of its similarity to potassium, the use of sodium polystyrene sulfonate has been proposed as a method of eliminating lithium.[3] However, hypokalemia has been reported and studies have still not shown definite evidence of benefit. One retrospective review showed a possible decrease in lithium half-life with administration of sodium polystyrene sulfonate in patients presenting with chronic lithium toxicity.[4] However, it is unknown if this was clinically relevant or if patient outcome was improved.

The benefit of early decontamination of the digestive tract with sodium polystyrene sulfonate, whole bowel irrigation, or both was demonstrated in a retrospective study of 59 cases of acute lithium poisoning in patients on long-term therapy. Compared with the 44 patients in whom decontamination was delayed more than 12 hours or not performed, the 15 patients who underwent early decontamination had a significantly lower risk of severe poisoning (odds ratio, 0.21; P = 0.049), regardless of the lithium dose ingested or the serum lithium level.[5]

Enhanced elimination

The mainstay of treatment is fluid therapy. The goal of saline administration is to restore glomerular filtration rate (GFR), normalize urine output, and enhance lithium clearance.

Lithium is readily dialyzed because of water solubility, low volume of distribution, and lack of protein binding.

Hemodialysis is indicated for patients who have renal failure and are unable to eliminate lithium. It is also indicated in patients who cannot tolerate hydration such patients with congestive heart failure (CHF) or liver disease. Hemodialysis should be considered in patients who develop severe signs of neurotoxicity such as profound altered mental status and seizures. An absolute level of 4 mEq/L in acute toxicity and a level of 2.5 mEq/L in chronic toxicity in patients with symptoms should also be considered for hemodialysis (GF), although guidelines for hemodialysis based on levels alone are controversial.

The Extracorporeal Treatments in Poisoning Workgroup recommends extracorporeal treatment in severe lithium poisoning. The group recommends performing extracorporeal treatment in patients with the following[6] :

  • Impaired kidney function and lithium levels >4.0 mEq/L
  • Decreased consciousness, seizures, or life-threatening dysrhythmias, regardless of lithium levels
  • Levels are >5.0 mEq/L, significant confusion is noted, or the expected time to reduce levels to < 1.0 mEq/L is more than 36 hours

Extracorporeal treatment should be continued until clinical improvement is seen or levels fall to < 1.0 mEq/L. If levels are not readily measurable, extracorporeal treatments should be continued for a minimum of 6 hours.

Because postdialysis rebound elevations in lithium levels have been documented, continuous venovenous hemofiltration (CVVH) has been advocated.[7, 8]

Patients who are already on peritoneal dialysis should continue with it while awaiting hemodialysis or CVVH.



Consult renal service personnel for hemodialysis in severe intoxications.

Consult psychiatric service personnel for patients with intentional overdose.

Consult the poison control center and a medical toxicologist regarding appropriate treatment.

Contributor Information and Disclosures

David C Lee, MD Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School

David C Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


Amit Gupta, MD Department of Emergency Medicine, Staten Island University Hospital

Amit Gupta, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center

John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Mark S Slabinski, MD, FACEP, FAAEM Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Ohio State Medical Association

Disclosure: Nothing to disclose.


The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, James G Linakis, PhD, MD, to the development and writing of this article.

  1. Mowry JB, Spyker DA, Cantilena LR Jr, McMillan N, Ford M. 2013 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 31st Annual Report. Clin Toxicol (Phila). 2014 Dec. 52(10):1032-283. [Medline]. [Full Text].

  2. National Poison Data System Annual Reports. American Association of Poison Control Centers. Available at Accessed: February 2, 2015.

  3. Linakis JG, Savitt DL, Wu TY, Lockhart GR, Lacouture PG. Use of sodium polystyrene sulfonate for reduction of plasma lithium concentrations after chronic lithium dosing in mice. J Toxicol Clin Toxicol. 1998. 36(4):309-13. [Medline].

  4. Ghannoum M, Lavergne V, Yue CS, Ayoub P, Perreault MM, Roy L. Successful treatment of lithium toxicity with sodium polystyrene sulfonate: a retrospective cohort study. Clin Toxicol (Phila). 2010 Jan. 48(1):34-41. [Medline].

  5. Bretaudeau Deguigne M, Hamel JF, Boels D, Harry P. Lithium poisoning: the value of early digestive tract decontamination. Clin Toxicol (Phila). 2013 May. 51(4):243-8. [Medline].

  6. Decker BS, Goldfarb DS, Dargan PI, Friesen M, Gosselin S, Hoffman RS, et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol. 2015 Jan 12. [Medline].

  7. Menghini VV, Albright RC Jr. Treatment of lithium intoxication with continuous venovenous hemodiafiltration. Am J Kidney Dis. 2000 Sep. 36(3):E21. [Medline].

  8. van Bommel EF, Kalmeijer MD, Ponssen HH. Treatment of life-threatening lithium toxicity with high-volume continuous venovenous hemofiltration. Am J Nephrol. 2000 Sep-Oct. 20(5):408-11. [Medline].

  9. Alexander MP, Farag YM, Mittal BV, Rennke HG, Singh AK. Lithium toxicity: a double-edged sword. Kidney Int. 2008 Jan. 73(2):233-7. [Medline].

  10. Aral H, Vecchio-Sadus A. Toxicity of lithium to humans and the environment--a literature review. Ecotoxicol Environ Saf. 2008 Jul. 70(3):349-56. [Medline].

  11. Burkhart, K. Lithium. Rosen's Emergency Medicine: Concepts and Clinical Practice. Sixth Edition. Mosby Elsevier; 2006. 2442-2444.

  12. Chen KP, Shen WW, Lu ML. Implication of serum concentration monitoring in patients with lithium intoxication. Psychiatry Clin Neurosci. 2004 Feb. 58(1):25-9. [Medline].

  13. Eyer F, Pfab R, Felgenhauer N, et al. Lithium poisoning: pharmacokinetics and clearance during different therapeutic measures. J Clin Psychopharmacol. 2006 Jun. 26(3):325-30. [Medline].

  14. Freeman MP, Freeman SA. Lithium: clinical considerations in internal medicine. Am J Med. 2006 Jun. 119(6):478-81. [Medline].

  15. Giles JJ, Bannigan JG. Tetatogenic and developmental effects of lithium. Curr Pharm Des. 2006. 12(12):1531-41.

  16. Gitlin M. Lithium and the kidney: an updated review. Drug Saf. 1999 Mar. 20(3):231-43. [Medline].

  17. Greller H. Lithium. Goldfrank's Toxicologic Emergencies. Eighth. McGraw-Hill; 2006. 1052-1058.

  18. Groleau G. Lithium toxicity. Emerg Med Clin North Am. 1994 May. 12(2):511-31. [Medline].

  19. Hsu CH, Liu PY, Chen JH, Yeh TL, Tsai HY, Lin LJ. Electrocardiographic abnormalities as predictors for over-range lithium levels. Cardiology. 2005. 103(2):101-6. [Medline].

  20. Juurlink DN, Mamdani MM, Kopp A, Rochon PA, Shulman KI, Redelmeier DA. Drug-induced lithium toxicity in the elderly: a population-based study. J Am Geriatr Soc. 2004 May. 52(5):794-8. [Medline].

  21. Lee DC, Klachko MN. Falsely elevated lithium levels in plasma samples obtained in lithium containing tubes. J Toxicol Clin Toxicol. 1996. 34(4):467-9. [Medline].

  22. Ng YW, Tiu SC, Choi KL, Chan FK, Choi CH, Kong PS. Use of lithium in the treatment of thyrotoxicosis. Hong Kong Med J. 2006 Aug. 12(4):254-9. [Medline].

  23. Rosenqvist M, Bergfeldt L, Aili H, Mathe AA. Sinus node dysfunction during long-term lithium treatment. Br Heart J. 1993 Oct. 70(4):371-5. [Medline].

  24. Scharman EJ. Methods used to decrease lithium absorption or enhance elimination. J Toxicol Clin Toxicol. 1997. 35(6):601-8. [Medline].

  25. Timmer RT, Sands JM. Lithium intoxication. J Am Soc Nephrol. 1999 Mar. 10(3):666-74. [Medline].

  26. Zimmerman JL. Poisonings and overdoses in the intensive care unit: general and specific management issues. Crit Care Med. 2003 Dec. 31(12):2794-801. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.