Psych · Emergency psychiatry
Lithium toxicity
Also known as Lithium poisoning · Lithium intoxication · Chronic lithium toxicity · Acute-on-chronic lithium toxicity · Lithium overdose · SILENT lithium
Exam-exhaustive fellowship topic on lithium toxicity — acute vs chronic vs acute-on-chronic patterns, serum levels and timing, neurotoxicity and SILENT, renal/NDI mechanisms, interactions (NSAIDs, ACEI/ARB, thiazides, dehydration), supportive care, EXTRIP extracorporeal criteria, rebound, prevention and monitoring, special populations. FRANZCP-primary, globally tagged.
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Red flags
- Coarse tremor, ataxia, dysarthria, vomiting, or confusion on lithium — stop lithium, urgent level and renal panel, do not wait for a trough
- Decreased consciousness, seizures, or life-threatening dysrhythmia at any lithium level — EXTRIP-recommended extracorporeal treatment pathway
- New NSAID, ACE inhibitor/ARB, or thiazide with rising lithium symptoms — classic iatrogenic precipitant cluster
- Chronic toxicity can be severe at levels that look only modestly elevated — treat the patient, not the number alone
- Post-haemodialysis rebound from tissue stores — recheck serial levels after extracorporeal treatment
- Persistent cerebellar or extrapyramidal deficits after levels normalise — consider SILENT and early rehab neurology input
- Assuming activated charcoal binds lithium — it does not
Meet the patient
A 68-year-old woman, twelve years stable on lithium for bipolar I, is brought in drowsy and dysarthric after four days of vomiting and diarrhoea. She has self-medicated with ibuprofen, and her GP started ramipril last month for blood pressure. She has a coarse tremor, a wide-based ataxia, and keeps drifting mid-sentence. The lithium level returns 2.1 mmol/L.[5][11]
The registrar asks the question that owns the next hour: is this a dosing error or a clearance failure — and do we dialyse? This whole topic is the disciplined answer. The pattern is chronic toxicity from reduced clearance, not a slipped dose. The precipitants are the gastroenteritis, the NSAID, the ACE inhibitor and the dehydration. And the EXTRIP triggers — never the absolute number alone — decide the dialysis.[1][7]
References20ShowHide
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- [2]Baird-Gunning J, Lea-Henry T, Hoegberg LCG, et al. Lithium Poisoning J Intensive Care Med, 2017.PMID 27516079
- [3]Gitlin M Lithium side effects and toxicity: prevalence and management strategies Int J Bipolar Disord, 2016.PMID 27900734
- [4]Waring WS Management of lithium toxicity Toxicol Rev, 2006.PMID 17288494
- [5]Waring WS, Laing WJ, Good AM, et al. Pattern of lithium exposure predicts poisoning severity: evaluation of referrals to a regional poisons unit QJM, 2007.PMID 17412747
- [6]Timmer RT, Sands JM Lithium intoxication J Am Soc Nephrol, 1999.PMID 10073618
- [7]Finley PR Drug Interactions with Lithium: An Update Clin Pharmacokinet, 2016.PMID 26936045
- [8]Finley PR, O'Brien JG, Coleman RW Lithium and angiotensin-converting enzyme inhibitors: evaluation of a potential interaction J Clin Psychopharmacol, 1996.PMID 8834421
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- [11]Hansen HE, Amdisen A Lithium intoxication. (Report of 23 cases and review of 100 cases from the literature) Q J Med, 1978.PMID 356084
- [12]Nolen WA, Licht RW, Young AH, et al. What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium Bipolar Disord, 2019.PMID 31112628
- [13]Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
- [14]Offerman SR, Alsop JA, Lee J, et al. Hospitalized lithium overdose cases reported to the California Poison Control System Clin Toxicol (Phila), 2010.PMID 20515402
- [15]Eyer F, Pfab R, Felgenhauer N, et al. Lithium poisoning: pharmacokinetics and clearance during different therapeutic measures J Clin Psychopharmacol, 2006.PMID 16702900
- [16]McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699
- [17]Shine B, McKnight RF, Leaver L, et al. Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data Lancet, 2015.PMID 26003379
- [18]Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: whole bowel irrigation for gastrointestinal decontamination of overdose patients Clin Toxicol (Phila), 2015.PMID 25511637
- [19]Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder Bipolar Disord, 2018.PMID 29536616
- [20]Malhi GS, Gessler D, Outhred T The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines J Affect Disord, 2017.PMID 28437764