eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Lithium: Treatment & Medication

Author: David C Lee, MD, Research Director, Department of Emergency Medicine, Associate Professor, North Shore University Hospital and New York University Medical School
Coauthor(s): Amit Gupta, MD, Fellow, Department of Toxicology, North Shore Hospital
Contributor Information and Disclosures

Updated: Mar 24, 2009

Treatment

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.1 However, hypokalemia has been reported and studies have still not shown definite evidence of benefit. 
 
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. 

Because postdialysis rebound elevations in lithium levels have been documented, continuous venovenous hemofiltration (CVVH) has been advocated.2,3  

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

Consultations

  • 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.

Medication

The goal of therapy is to remove or reduce the excess amounts of lithium resulting from an overdose.

GI decontaminants

Because adsorption to activated charcoal is minimal, whole-bowel irrigation is the GI decontamination method of choice.


Polyethylene glycol bowel prep (GoLYTELY, Colyte)

Laxative with strong electrolytic and osmotic effects that has cathartic actions in the GI tract.

Adult

1500-2000 mL/h PO or NG tube until rectal effluent is clear

Pediatric

Administer as in adults

Reduces effectiveness and absorption of oral medications

Documented hypersensitivity; colitis, megacolon, bowel perforation, gastric retention, or GI obstruction

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in ulcerative colitis and hot loop polypectomy

More on Toxicity, Lithium

Overview: Toxicity, Lithium
Differential Diagnoses & Workup: Toxicity, Lithium
Treatment & Medication: Toxicity, Lithium
Follow-up: Toxicity, Lithium
References
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References

  1. 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].

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

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

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

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

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

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

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

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

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

  12. Greller, H. Lithium. In: Goldfrank's Toxicologic Emergencies. Eighth. McGraw-Hill; 2006:1052-1058.

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  15. 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. May 2004;52(5):794-8. [Medline].

  16. 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].

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

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

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

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

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

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Further Reading

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Keywords

lithium toxicity, lithium exposure, lithium overdose, lithium intoxication, chronic lithium therapy, long-term lithium therapy, lithium in the treatment of depressive and bipolar disorders, lithium poisoning, lithium carbonate, Li2 CO3, lithium citrate, Li3 C6 H5 O7 ·4H2 O, treatment of depressive disorders, treatment of bipolar affective disorders, lithium ingestion

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Contributor Information and Disclosures

Author

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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Amit Gupta, MD, Fellow, Department of Toxicology, North Shore Hospital
Amit Gupta, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Medical Editor

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, and Ohio State Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

John G Benitez, MD, MPH, FACMT, FACPM, FAAEM, Associate Professor, Department of Medicine, Clinical Pharmacology Division, Vanderbilt University; Managing Director, Tennessee Poison Center
John G Benitez, MD, MPH, FACMT, FACPM, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, and Wilderness Medical Society
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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