- Jeanmarie Perrone, MD, FACMT
Jeanmarie Perrone, MD, FACMT
- Professor of Emergency Medicine
- University of Pennsylvania School of Medicine
- Pia Chatterjee, MD
Pia Chatterjee, MD
- Assistant Professor of Emergency Medicine
- New York University School of Medicine
- Section Editor
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
"Lithia" water was first used in the late 1800s to treat mania and gout. Over time, and likely due to low lithium content, "Lithia" water was ultimately replaced by lithium tablets. With the higher concentrations in the tablets, lithium's association with tremors and weakness became apparent and in 1898 the first descriptions of lithium toxicity appeared . About a half century later, the calming effects of lithium in 10 patients with mania were described ; the drug's more toxic effects were recognized when lithium chloride was used as a salt substitute in patients with heart failure in 1949 .
Lithium's toxic effects limited its clinical use until appropriate serum monitoring became more readily available. In the 1970s, Lithium carbonate was approved in the United States for the treatment of acute mania and bipolar disorder and it has been in use ever since. In 2014, there were 6850 cases of lithium intoxication reported to the American Association of Poison Control Centers [4-6].
This topic will review the diagnosis and management of acute and chronic lithium poisoning. The therapeutic use of lithium, major side effects of lithium therapy, and other aspects of the management of patients with acute poisoning are discussed separately. A summary table to facilitate emergent management of lithium poisoning is provided (table 1). (See "Bipolar disorder in adults: Pharmacotherapy for acute mania and hypomania" and "Bipolar disorder in adults: Choosing maintenance treatment" and "Renal toxicity of lithium" and "Lithium and the thyroid" and "General approach to drug poisoning in adults".)
PHARMACOLOGY AND CELLULAR TOXICOLOGY
Lithium's exact mechanism of action is not clearly understood. It affects two intracellular signaling pathways, inositol monophosphate and glycogen synthase kinase-3 . Lithium decreases intracellular inositol, which may be a mechanism for mood stabilization. Lithium also inhibits glycogen synthase kinase-3, a component of diverse signaling pathways involved in energy metabolism, neuroprotection, and neuroplasticity.
Lithium has a narrow therapeutic index; a large proportion of patients on chronic lithium therapy experience at least one episode of toxicity during treatment . The highest intracellular lithium levels are found in the brain and the kidneys.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- PHARMACOLOGY AND CELLULAR TOXICOLOGY
- CLINICAL PRESENTATION
- Types of poisoning and risk factors
- Acute and acute-on-chronic poisoning
- - History
- - Clinical findings
- - Long-term neurologic sequelae
- Chronic toxicity
- - History and common presentations
- - Clinical findings
- LABORATORY TESTING
- General testing
- Serum lithium concentration
- - When to obtain measurements
- - Correlation with clinical toxicity
- Renal function
- Serum sodium
- Thyroid function
- Acute and acute-on-chronic poisoning
- Chronic toxicity
- DIFFERENTIAL DIAGNOSIS
- ABCs and supportive care
- Gastrointestinal decontamination
- Extracorporeal removal
- - Hemodialysis
- - Alternative methods
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS