Guideline sources The following summarized guidelines for the evaluation and management of lithium toxicity are prepared by our editorial team based on guidelines from the Royal Australian and New Zealand College of Psychiatrists (RANZCP 2017), the British Association for Psychopharmacology (BAP 2016), the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP 2015), and the National Institute for Health and Care Excellence (NICE 2014). 1 2 3 4 Guidelines 1. Screening and diagnosis Clinical monitoring of patients taking lithium: monitor patients taking lithium at every appointment for symptoms of neurotoxicity, including paresthesia, ataxia, tremor and cognitive impairment. Recognize that these complications can occur at therapeutic levels of lithium. E Laboratory monitoring of patients taking lithium: As per BAP 2016 guidelines: Obtain serum lithium level monitoring in patients with bipolar disorder taking lithium to check whether it is within the therapeutic range (0.6-0.8 mEq/L; mmol/L), aiming for a higher serum levels within that range. Recognize that concentrations of 0.8-1.0 mEq/L (0.8-1.0 mmol/L) carry a greater risk of renal impairment, especially in female patients. A https://web.pathway.md/diseases/rece8PCXYPIHKD2ze 1/4 6/29/23, 5:53 AM Lithium toxicity Pathway Obtain serum lithium level monitoring every 3 months of the first year of treatment in otherwise healthy patients, and every 6 months thereafter. B As per NICE 2014 guidelines, obtain serum lithium levels 1 week after starting lithium and 1 week after every dose change, and weekly until the levels are stable. Aim to maintain serum lithium levels at 0.6-0.8 mEq/L (0.6-0.8 mmol/L) in patients with bipolar disorder taking lithium for the first time. E Show 5 more 2. Therapeutic procedures Extracorporeal treatment (indications for initiation): Initiate ECTR in patients with severe lithium poisoning, as defined by any of the following: impaired kidney function and serum lithium level of > 4.0 mEq/L decreased level of consciousness, seizures or life-threatening dysrhythmias, irrespective of the serum lithium level. B Consider initiating ECTR in patients with: serum lithium level of > 5.0 mEq/L significant confusion an expected time to reduce serum lithium level to < 1.0 mEq/L with optimal management of > 36 hours. C Extracorporeal treatment (choice of technique): perform intermittent hemodialysis as the preferred modality of ECTR in patients with lithium poisoning. B Show 2 more Extracorporeal treatment (indications for discontinuation): Discontinue ECTR in the following situations: serum lithium level of < 1.0 mEq/L (< 1.0 mmol/L) apparent clinical improvement after a minimum of 6 hours of ECTR if serum lithium level is not readily measurable. B 3. Patient education Counseling of patients taking lithium: educate patients taking lithium to report new developed diarrhea or vomiting or if they become acutely ill for any reason. E Show 2 more 4. Follow-up and surveillance Post-treatment lithium monitoring: obtain serial serum lithium measurements over 12 hours after interruption of ECTR to determine the need for subsequent ECTR sessions. B https://web.pathway.md/diseases/rece8PCXYPIHKD2ze 2/4 6/29/23, 5:53 AM Lithium toxicity Pathway Clinical findings Symptoms Past medical history Convulsion AKI Diarrhea CKD Drowsiness Vital signs Fatigue Muscle weakness Bradycardia Nausea Hypotension Polydipsia Abdominal exam Polyuria Vomiting Ileus Medication history ECG findings Lithium Brugada ECG pattern Prolonged QT interval Neurological exam Sinus bradycardia Altered mental status St-segment elevation Ataxia Coma Hyperreflexia Hypertonia Intention tremor Muscular rigidity Myoclonus Stupor Tremor Lab findings Metabolic acidosis serum PTH serum calcium serum sodium References 1. Gin S Malhi, Danielle Gessler, Tim Outhred. The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. J Affect Disord. 2017 Aug 1;217 266 280. Open 2. No authors listed. Bipolar disorder: assessment and management. NICE. 2014 Sep 24.;CG185. Open https://web.pathway.md/diseases/rece8PCXYPIHKD2ze 3/4 6/29/23, 5:53 AM Lithium toxicity Pathway 3. G M Goodwin, P M Haddad, I N Ferrier et al. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2016 Jun;30 6 495 553. Open 4. Brian S Decker, David S Goldfarb, Paul I Dargan et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol. 2015 May 7;10 5 875 87. Open https://web.pathway.md/diseases/rece8PCXYPIHKD2ze 4/4