Blood level monitoring is recommended to decrease the risk of potential toxicity. Lithium is used in the treatment of depressive and bipolar affective disorders. Management of lithium toxicity initial bloods should include a lithium level and ues along with a clinical assessment of fluid status and signs of established neurotoxicity confusion, increased tone, tremor, hyperreflexia, clonus. Occurs in patients not previously receiving lithium i. Lithium toxicity should also be suspected at therapeutic levels in compromised patients with relevant symptoms. After lithium toxicity is confirmed, management depends on the lithium level as well as the clinical presentation. Thyroid function tests and calcium should be checked in patients on chronic lithium therapy. Mental status is often altered and can progress to coma and seizures if the diagnosis is unrecognized. While lithium is a boon in the management of bipolar disorders, it has unfortunately undesirable side effects and lithium therapy could be likened to a doubleedged swordit cuts. Symptoms may include a tremor, increased reflexes, trouble walking, kidney problems, and a altered level of consciousness. Severe toxicity is an indication for haemodialysis. Lithium potentiates the action of neuromuscular blocking agents. For this reason, lithium toxicity depends on the exposure pattern which needs to be considered regarding treatment strategy waring et al.
Blood monitoring, prescribing, supply and administration 5. Common sideeffects these can usually be reduced or eliminated by lowering the lithium dose or changing the dosage schedule. Some symptoms may last for a year after levels return to normal. More detailed information about the symptoms, causes, and treatments of lithium toxicity is available below. When prescribing lithium agents in elderly we should consider agerelated changes in pharmacokinetics. The objective is to adjust the lithium carbonate dose so as to maintain the serum lithium level permanently within the diurnal range of 0.
In practice, the blood sample should be taken between 12 and 24 hours after the previous dose of lithium carbonate. If levels become too high, diarrhea, vomiting, poor coordination, sleepiness, and ringing in the ears may occur. This article focuses on lithium overdose, or toxicity. Neurotoxicity could be suspected at serum lithium levels which are considered therapeutic in younger adults. Her home medications included lithium, trazadone, paliperidone. This condition causes volume depletion, which in turn results in increased lithium reabsorption and subsequent toxicity. A narrow therapeutic window and long halflife make toxicity a risk. Jan 24, 2018 lithium toxicity can happen when this level reaches 1. The toxic reaction of the body to the substance, possibly via allergic reaction or overdose. Know the symptoms, management and prevention of lithium toxicity. Lithium is associated with increased risk of reduced urinary concentrating ability, hypothyroidism, hyperparathyroidism, and weight gain. More detailed information about the symptoms, causes, and treatments of lithium toxicity is available below symptoms of lithium toxicity. What constitutes lithium toxicity, know its symptoms. This guideline for the management of lithium toxicity should be used as an adjunct to the advice of the clinical toxicologist on call as well as the toxicology handbook.
Syndrome of irreversible lithiumeffectuated neurotoxicity. Nov 01, 2003 lithium is the most common cause of drug induced nephrogenic diabetes insipidus which is characterized by polyuria, polydipsia, hypernatremia, and low urine osmolality. Even if an individual takes in the prescribed amount of lithium, conditions such as decreased renal function and dehydration may lead to the accumulation of lithium in the body. Although risk factors for lithium intoxication seem. Acute ingestion in lithium naive patients is generally associated with only shortlived exposure to high concentrations, due to extensive. Apr 28, 2016 this guideline for the management of lithium toxicity should be used as an adjunct to the advice of the clinical toxicologist on call as well as the toxicology handbook. Since lithiums primary medical use is as a mood stabilizer, most cases occur among people who have bipolar disorder. Choosing pharmacotherapy and bipolar disorder in adults. Do not use lithium without telling your doctor if you are pregnant. Choosing maintenance treatment and renal toxicity of lithium and lithium and the thyroid and general approach to drug poisoning in adults.
This paper summarizes the knowledge base on side effects and toxicity and suggests optimal management of these problems. Lithium affects the flow of sodium through nerve and muscle cells in the body. Aug 21, 2018 chronic lithium toxicity is usually precipitated by introduction of a new medication that may impair renal functionexcretion or cause a hypovolemic state. Management and treatment of lithium induced nephrogenic. Common side effects include increased urination, shakiness of the hands, and increased thirst. This guidance does not cover treatment for under 18s, as this is a sub specialist area requiring tertiary referral and monitoring. Lithium a mood stabilizer that is a used to treat or control the manic episodes of bipolar disorder manic depression.
Lithium is an effective medication for the treatment of bipolar disorder, and national institute for health and care excellence nice guidelines recommend it as the firstline pharmacological treatment for longterm management. Two cases of lithium intoxication are presented that demonstrate that predisposing factors and. Lithium toxicity symptoms, levels, signs, treatment. Acute toxicity occurs when you swallow too much of a lithium prescription at one time. Capitals indicate lifethreatening, underlines indicate most frequent. Management of lithium toxicity should be dictated primarily by patient presentation and not serum concentrations. Lithium toxicity, also known as lithium overdose, is the condition of having too much lithium. Mrg 26 lithium good practice standards 3 initial monitoring a lithium level should be taken no earlier than 57 days after starting treatment. Lithium toxicity symptoms, diagnosis, treatments and. Toxicity can also be caused by taking a slightly higher dose of lithium over time. Acute lithium toxicity occurs as a result of taking in an increased amount of lithium. Dry mucous membranes, disorientation to place and time with gcs of 15.
Assess patient for signs and symptoms of lithium toxicity vomiting, diarrhea, slurredspeech,decreasedcoordination,drowsiness. Acute ingestion in lithiumnaive patients is generally associated with only shortlived exposure to high. Dry mucous membranes, disorientation to place and time with. Three recognized patterns of lithium toxicity acute, acuteonchronic, and chronic. Chronic lithium toxicity is usually precipitated by introduction of a new medication that may impair renal functionexcretion or cause a hypovolemic state. Jan 02, 2008 lithium toxicity can present with several faces. Treatment of lithium toxicity depends on severity and should consist of supportive care with monitoring of vital signs, cardiac, pulmonary and neurologic status, electrolytes, and.
Complications may include serotonin syndrome lithium toxicity can occur due to excessive. Chronic toxicity, on the other hand, is the result of longterm lithium therapy. Target serum lithium concentrations at 12 and 24 hours are shown. Although risk factors for lithium intoxication seem to be welldescribed, lacking patient education and inexperience of treatment are assumed to contribute to the probability of lithium. Although this observation is multifactorial, one obvious potential contributor is the side effect and toxicity burden associated with lithium. Lithium has been used as the gold standard in the treatment of major depressive and bipolar disorders for decades. Lithium is a prescription medicine used to treat bipolar disorder. Hemodialysis is the treatment of choice for severe lithium intoxication but does not guarantee a halt in the progression of lithium toxicity.
It is approved for the treatment of bipolar disorder also known as manic depression. The riskof development of neurotoxicity is directly related to the pattern of exposure that led to the poisoning, which in turn reflects the pharmacokinetic properties of lithium. Admit in ward iv fluids stop the lithium supportive care lithium level repeated after 4 days is 0. Clinicians have been well aware of lithium toxicity for many years. Chronic toxicity occurs when you slowly take a little too much lithium prescription every day for a while. Due to its narrow therapeutic index, lithium toxicity is a common clinical problem. Lithium toxicity california poison control system cpcs. Lithium toxicity is a potentially serious condition caused by having too much lithium in your system. Even if an individual takes in the prescribed amount of lithium, conditions such as decreased renal function and dehydration may lead to the accumulation of lithium in the body and cause the toxicity 1, 2, 3, 4. Although lithium can eventually lead to multisystem toxicity, lithiumsmost importantsiteof toxicityisthecns.
Lithium is an alkali metal used in the management of bipolar disorder. Lithium is for use in adults and children at least 7 years old. Lithium salts have been used in the prophylaxis and treatment of depression and bipolar disorder for 50 years. The effects of lithium toxicity are diverse and varied. Lithium toxicity symptoms, diagnosis, treatments and causes. A 60 yo african american female with history of manicdepressive disorder was brought to emergency room for altered mental status of three day duration. Lithium is a mood stabilizer medication that works in the brain.
Most frequently, acute ingestions result in gi symptoms such as nausea, vomiting, and diarrhea, at times with significant volume loss. Lithium toxicity can happen when this level reaches 1. Acute is considered in any patient who is lithium naive and consumes a large amount of lithium at once, acute on chronic is seen in patients who have been on chronic lithium and overdose, while chronic toxicity is a slow accumulation of lithium in patients who have a decreased ability to excrete the drug due to the its side effects. Toxicity can occur if you take a large dose of lithium at one time. Mar 20, 2020 lithium will clear your system more slowly in chronic toxicity than in the acute type. After the diagnosis is made, management depends on the clinical presentation and serum lithium level. Hemodialysis is the treatment of choice for severe lithium intoxication. This route provides another option to decrease urine output during lithium induced ndi.
Although risk factors for lithium intoxication seem to be welldescribed, lacking patient education and inexperience of treatment are assumed to contribute to the. Use an effective form of birth control, and tell your doctor if you become pregnant during treatment. In the cases of acute lithium toxicity, lithium concentrations tend to fall rapidly due to distribution in several tissues, meanwhile chronic toxicity faces lithiumsaturated tissues. Request pdf management of lithium toxicity lithium salts have been used in the prophylaxis and treatment of depression and bipolar disorder for 50 years. Serious side effects include hypothyroidism, diabetes insipidus, and lithium toxicity. If your symptoms are detected early, reducing your lithium dosage or stopping it altogether may be sufficient treatment, resuming a lower dosage when appropriate. Chronic lithium intoxication before treating lithium intoxication, it is important to distinguish whether it is an acute exposure or a chronic exposure. Use of a thiazide diuretic also might warrant decreasing the lithium dose by as much as 50% to prevent toxicity. Otherwise, a series of dialysis treatments may be necessary to clear the excess lithium from. The dosage of lithium that can be used without risking any symptom development within the patient is 0. Hydrochlorothiazide use requires careful monitoring of potassium and lithium levels. Lithium toxicity happens when the amount of lithium in your blood is too high.
Despite these therapeutic advantages the use of lithium in the treatment of bipolar disorder has been. Clinical presentations and management lithium may be responsible for a large spectrum of central nervous system toxicity, ranging from mental confusion to life. While lithium toxicity can affect almost every system, the scope of this paper will focus mainly on the neurological side effects. A summary table to facilitate emergent management of lithium poisoning is provided. In fact, many people who take lithium regularly experience this drug toxicity at least once, so its very important for people who take. In the cases of acute lithium toxicity, lithium concentrations tend to fall rapidly due to distribution in several tissues, meanwhile chronic toxicity faces lithium saturated tissues. Oct 22, 2015 lithium has been used as the gold standard in the treatment of major depressive and bipolar disorders for decades. Three presentations of lithium poisoning should be clearly distinguishedacute, acuteonchronic and chronic poisoningsas presentation has a significant influence on the relationship between severity and toxicitytoserum lithium concentration.
There is little evidence for a clinically significant reduction in renal function in most patients, and the risk of endstage renal failure is low. Additionally, side effect concerns assuredly play some role in lithium nonadherence. Assess patient for signs and symptoms of lithium toxicity vomiting, diarrhea, slurredspeech,decreasedcoordination,drowsiness,muscleweakness,ortwitching. Poisoning management is mainly supportive based on saline diuresis but should also include. Although lithium can eventually lead to multisystem toxicity, lithium smost importantsiteof toxicityisthecns. Acute lithium toxicity patients with acute lithium toxicity typically present with a history of deliberate ingestion and do not have the already elevated body stores associated with chronic toxicity.
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