Management of chronic lithium toxicity

This is chronic lithium poisoning: maintenance lithium plus a drug–drug interaction and volume depletion. Baird-Gunning: chronic is the most common pattern, usually unintentional, from intake exceeding elimination. The CNS is the primary target — tremor, ataxia, dysarthria, confusion and drowsiness fit EXTRIP’s mild-to-severe spectrum.^[1][2]

Precipitants. Ibuprofen: NSAIDs raise serum lithium and diminish renal lithium clearance (Ragheb; ibuprofen and naproxen named). Diarrhoea and poor intake: EXTRIP names volume depletion (and thiazides) as conditions that increase proximal lithium reabsorption and raise [Li+]. Do not add ACE-inhibitor or loop-diuretic mechanisms as sourced EXTRIP facts — they are not in the papers fetched for this pass.^[1][3]

Immediate management. Stop lithium and the NSAID. Give intravenous isotonic saline. Do not give activated charcoal — it does not bind lithium. Whole-bowel irrigation is not required in this chronic-accumulation presentation; EXTRIP notes there are no outcome data for any decontamination procedure, and no millilitre-per-hour irrigation recipe is sourced. Unsourced 1 L boluses, urine-output targets, QTc-surveillance recipes and benzodiazepine milligram lists are not taught here.^[1]

EXTRIP indication already met. GCS 13 drowsiness is a decreased level of consciousness — extracorporeal treatment is recommended (1D) irrespective of the lithium concentration. Do not justify dialysis with a circulating “chronic above 2.5 mmol/L with neurotoxicity” ladder; those 2.5 figures appear in other sources EXTRIP tabulated, not as EXTRIP’s own 1D vote. The 4.0 mEq/L 1D rule is paired with impaired kidney function as EXTRIP defines it (CKD 3B–5 / eGFR below 45, KDIGO AKI stage 2 or 3, or no-baseline creatinine 176 micromol/L in adults) — creatinine 168 from 95 is not automatically that definition. Intermittent haemodialysis is preferred (1D); CRRT if intermittent HD is unavailable.^[1]

After extracorporeal treatment. Stop when [Li+] is below 1.0 mEq/L or clinical improvement is apparent (1D); continue at least 6 hours if the level is not measurable. Then obtain serial [Li+] over 12 hours to decide further sessions. Redistribution rebound after high-efficiency dialysis is maximal at 6–12 hours (about 0.5–1.0 mEq/L) and is not typically associated with recurrent symptoms. The circulating “recheck at six hours and re-dialyse if above 1.0 with symptoms” rule is not EXTRIP.^[1]