Lithium poisoning

Three cases among 26 cases of chronic lithium poisoning (668). 

There seems no reason, therefore, to eschew the description of lithium therapy as the treatment of manic patients by lithium poisoning, in the words of an early critic (Wikler 1957). Anticonvulsants do not share the toxicity profile of lithium, but by virtue of their use to prevent epileptic fits, they all exert depressant effects on the activity of the central nervous system. With this profile of drug-induced effects in mind, let us examine the research on whether lithium or other drugs currently used in manic depression act in a disease-centred way and consider whether they have any real benefits. 

There is a particular irony in the date of the first publication on the use of lithium in mental patients Cade s article appeared in 1949, the same year that Corcoran et al. published Lithium Poisoning From the Use of Salt Substitutes in the Journal of the American Medical Association. 

In 1987, Adityanjee discussed so-called lithium poisoning and made an observation that remains true today There is a general lack of awareness about irreversible and unbeatable complications of lithium treatment despite evidence to the contrary. ... 

Corcoran, A. C., Taylor, R. D., Page, L. H. (1949). Lithium poisoning from the use of salt substitutes. Journal of the American Medical Association, 139, 685-688. 

A literature review of permanent neurological complications of acute lithium toxicity noted that a cerebellar syndrome is quite common and that neuroleptic drugs can worsen toxicity, as might rapid reduction of raised serum lithium concentrations (182). However, the latter point is speculative at best hemodialysis remains the treatment of choice for severe lithium poisoning. 

Hypernatremia can occur secondary to dehydration in patients taking lithium and is not uncommon in association with lithium poisoning. Lithium-induced diabetes insipidus is often a contributing factor. 

Thus, the term overdose (109,530,531) can be misleading, because poisoning can develop not only as a result of overdosage but also by a fall in lithium clearance. Of 205 cases of lithium poisoning reported to the Ontario Canada Regional Poison Information Centre in 1996,12 were acute overdoses (someone else s tablets), 19 were chronic poisonings, and 174 were acute-on-chronic poisonings. Over 80% had no or... 

The 2001 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System included six fatal exposures to lithium, three of which were intentional suicides. A total of 4607 exposures to lithium were reported, and death was the outcome in eight (543). A retrospective review of eight cases of lithium poisoning included one death (151). 

The authors warned that button battery ingestion can be a source of lithium poisoning in youngsters. 

Hemodialysis (383,552,553), sometimes with additional continuous venovenous hemofiltration dialysis (554,555), continues to be described as a successful intervention for lithium poisoning. Peritoneal dialysis is a far less efficient way to clear lithium from the body. One patient treated in this way had permanent neurological abnormalities and another died a third toxic patient who also had diabetic ketoacidosis died after treatment with hydration and insulin (556). On the other hand, a 51-year-old woman who took 50 slow-release lithium carbonate tablets (450 mg) had a serum lithium concentration of 10.6 mmol/1 13 hours later, but no evidence of neurotoxicity or nephrotoxicity. She was treated conservatively with intravenous fluids and recovered fully (557). Acute lithium overdose is often better tolerated than chronic intoxication. 

However, the more problematic cases of lithium poisoning are those in which the lithium concentration increases slowly. 

Roy M, Fond L, Ratrema M, Convers P, Lutz MF, Cathebras P. Intoxication au lithium complications neuro-logiques severes. [Lithium poisoning severe neurologic complications.] Presse Med 2001 30(18) 900-1. 

Roy M, Stip E, Black DN, Lew V, Langlois R. Sequelles neurologiques secondaires a une intoxication aigue au lithium. [Neurologic sequelae secondary to acute lithium poisoning.] Can J Psychiatry 1999 44(7) 671-9. 

Bailey B, McGuigan M. Lithium poisoning from a poison control center perspective. Ther Drug Monit... 

Montagnon F, Said S, Lepine JP. Lithium poisonings and suicide prevention. Eur Psychiatry 2002 17(2) 92-5. 

Ochoa ER, Farrar HC, Shirm SW. Lithium poisoning in a toddler with fever and altered consciousness. Case presentation and discussion. J Invest Med 2000 48 612. 

Bocchia M, Bertola G, Morganti D, Toscano M, Colombo E. Intossicazione da litio e uso di nimesulide. [Lithium poisoning and the use of nimesulide.] Recenti Prog Med 2001 92(7-8) 462. 

Nordt SP, Cantrell FL. Elevated lithium level a case and brief overview of lithium poisoning. Psychosom Med 1999 61(4) 564-5. 

Bailey B, McGuigan M. Comparison of patients hemodia-lyzed for lithium poisoning and those for whom dialysis was recommended by PCC but not done what lesson can we learn Chn Nephrol 2000 54(5) 388-92. 

Pond SM. Extracorporeal techniques in the treatment of poisoned patients. Med Ausf. 1991 154 617-622 Jaeger A, Sauder P, Kopferschmitt J. When should dialysis be performed in lithium poisoning A kinetic study in 14 cases of lithium poisoning. Toxicol Clin Toxicol. 1993 31 429-447... 

Table 2. Clinical symptomatology associated with lithium poisoning.

Leblanc M, Raymond M, Bonnardeaux A, Isenring P, PichetteV,Geadah D,Quimet D, Ethier J, Cardinal J. Lithium poisoning treated by high-performance continuous arteriovenous and venovenous hemodiafiltration. Am J Kidney Dis 1996 27 365-372. 

Therapeutically, bentonite has been investigated as an adsorbent for lithium poisoning. ... 

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