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Lithium toxicity⚠️
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⚠️ Always seek cardiology input before stopping antiplatelets after coronary stenting.
⚠️ Haemodialysis is the mainstay of treatment for acute severe lithium toxicity. 💡 Lithium usually causes a fine tremor at therapeutic doses - a coarse tremor suggests toxicity.
📖 About
- Lithium Toxicity ⚡: An alkali metal prescribed for bipolar disorder as a mood stabiliser. Narrow therapeutic window makes toxicity common in both acute overdose and chronic accumulation.
💊 Pharmacology
- Therapeutic range: 0.6–1.2 mmol/L (some guidelines 0.4–1.0).
- Toxicity: Usually >1.5 mmol/L. Severe neurotoxicity at >2.0, coma at >3.0.
- Rapid GI absorption, minimal protein binding → dialysable.
- 🚰 Risk factors: dehydration, renal impairment, diuretics.
🧠 Clinical Presentation
- Acute toxicity: coarse tremor 🤲, dysarthria, confusion, delirium, seizures, coma.
- Polyuria & polydipsia: due to nephrogenic diabetes insipidus.
- Chronic toxicity: insidious encephalopathy, ataxia, neuropathy, cerebellar dysfunction.
⚠️ Exacerbating Interactions
- 💊 Thiazide diuretics
- 💊 NSAIDs
- 💊 ACE inhibitors
- 💊 Loop diuretics (less marked)
- Risk ↑ with age, dehydration, renal disease.
🔬 Investigations
- 📈 Lithium levels: repeat every 4–6h until falling; symptoms often lag behind levels.
- 🫀 ECG: may show T-wave flattening, QT prolongation.
- 🧪 Renal function, U&E, thyroid function, calcium (chronic lithium → hyperparathyroidism).
💊 Management
- 🛑 Stop lithium immediately; withhold interacting drugs.
- 💧 IV normal saline: aggressive rehydration to enhance renal clearance.
- 🚫 GI decontamination: charcoal ineffective. Whole-bowel irrigation if sustained-release prep or very large ingestion.
- 💉 Haemodialysis: gold standard if level >4.0 mmol/L acutely, >2.5 mmol/L with symptoms, or in renal failure. May need repeated sessions due to tissue redistribution.
- Consult TOXBASE / NPIS for specialist advice.
⚠️ Complications
- Persistent cerebellar signs: truncal/gait ataxia, nystagmus, memory loss.
- SILENT syndrome: Syndrome of Irreversible Lithium-Effectuated NeuroToxicity → chronic neurocognitive impairment despite stopping lithium.
- Renal impairment, hypothyroidism, hyperparathyroidism with long-term therapy.
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