Lithium is used for the treatment of bipolar depression and other psychiatric disorders and occasionally to raise the white blood cell count in patients with leukopenia. Serious toxicity is caused most commonly by chronic overmedication in patients with renal impairment. Acute overdose, in contrast, is generally less severe.
Mechanism of toxicity
Lithium is a cation that enters cells and substitutes for sodium or potassium. Lithium is thought to stabilize cell membranes. With excessive levels, it depresses neural excitation and synaptic transmission.
Pharmacokinetics. Lithium is completely absorbed within 6–8 hours of ingestion. The initial volume of distribution (Vd) is about 0.5 L/kg, with slow entry into tissues and a final Vd of 0.7–1.4 L/kg. Entry into the brain is slow; this explains the delay between peak blood levels and CNS effects after an acute overdose. Elimination is virtually entirely by the kidney, with a half-life of 14–30 hours. Thyroxine enhances tubular reabsorption, which may increase lithium levels in patients with hyperthyroidism.
Toxic dose. The usual daily dose of lithium ranges from 300–2400 mg (8–64 mEq/d), and the therapeutic serum lithium level is 0.6–1.2 mEq/L. The toxicity of lithium depends on whether the overdose is acute or chronic.
Acute ingestion of 1 mEq/kg (40 mg/kg) will produce a blood level after tissue equilibration of approximately 1.2 mEq/L. Acute ingestion of more than 20–30 tablets by an adult potentially can cause serious toxicity.
Chronic intoxication may occur in patients on stable therapeutic doses. Lithium is excreted by the kidneys, where it is handled like sodium; any state that causes dehydration, sodium depletion, or excessive sodium reabsorption may lead to increased lithium reabsorption, accumulation, and possibly intoxication. Common states causing lithium retention include acute gastroenteritis, diuretic use (particularly thiazides), use of nonsteroidal anti-inflammatory drugs or angiotensin-converting enzyme (ACE) inhibitors, and lithium-induced nephrogenic diabetes insipidus.
Clinical presentation. Mild to moderate intoxication results in lethargy, muscular weakness, slurred speech, ataxia, tremor, and myoclonic jerks. Rigidity and extrapyramidal effects may be seen. Severe intoxication may result in agitated delirium, coma, convulsions, and hyperthermia. Recovery is often very slow, and patients may remain confused or obtunded for several days to weeks. Rarely, cerebellar and cognitive dysfunction is persistent. Cases of rapidly progressive dementia, similar to Jakob-Creutzfeldt disease, have occurred and are usually reversible. The ECG commonly shows T-wave flattening or inversions and depressed ST segments in the lateral leads; less commonly, bradycardia, sinus node arrest, complete heart block, and unmasking of Brugada pattern may occur. The white cell count often is elevated (15–20,000/mm3).
Acute ingestion may cause initial mild nausea and vomiting, but systemic signs of intoxication are minimal and usually are delayed for several hours while lithium distributes into tissues. Initially high serum levels fall by 50–70% or more with tissue equilibration.
In contrast, patients with chronic intoxication usually already have systemic manifestations on admission, and toxicity may be severe with levels only slightly above therapeutic levels. Typically, patients with chronic intoxication have elevated BUN and creatinine levels and ...