Symptoms of lithium toxicity

Repeat dialysis may be required every 6-10 hours, until the lithium level is within nontoxic range and the patient has no signs or symptoms of lithium toxicity. 

Lithium Carbonate Common symptoms of lithium toxicity are nausea, vomiting, and diarrhea followed by tremor, increased muscle tone, and rigidity. Acute kidney problems and nephrogenic diabetes insipidus may be possible hazards. In serious cases, coma and convulsions can be observed along with toxicity. 

A 51-year-old woman developed symptoms of lithium toxicity (serum concentration 1.4 mmol/1) while taking valsartan, which resolved when the valsartan was replaced by diltiazem (serum lithium concentration 0.8 mmol/1) (580). 

Mefenamic acid may have interacted with lithium in a patient with reduced renal function, causing acute symptoms of lithium toxicity (SEDA-13, 83). 

Symptoms of lithium toxicity can be expected when serum lithium level increases above 1.5 mEq/L. Most... 

Symptoms of lithium toxicity can be expected when serum hthium level increases above 1.5 mEq/L. Most patients receiving lithium have side effects, reflecting the drug s narrow therapeutic index [1]. Many symp-... 

If any ACE inhibitor is added to established lithium treatment, monitor well for symptoms of lithium toxicity (see Lithium , (p. 1111)) and consider measuring lithium levels more frequently. Be alert for the need to reduce the lithium dosage (possibly by between one-third to one-half) The development of the interaction may be delayed, so monitoring lithium levels every week or every two weeks" for several weeks has been advised. 

This appears to be the first and only report of this interaction, but it would now be prudent to monitor for symptoms of lithium toxicity (see Lithium , (p.llll)) and consider monitoring lithium levels if high-dose intravenous aciclovir is given to any patient. The report recommends measuring lithium levels every second or third day. Oral aciclovir is predicted not to interact because of its low bioavailability, and no interaction would be expected with topical aciclovir as the plasma levels achieved by this route are minimal. 

A report describes a 74-year-old woman with increased lithium levels of 2.3 mmol/L and symptoms of lithium toxicity, which were associated with several drugs including irbesartan, lisinopril, escitalopram, levomepro-mazine, furosemide and spironolactone. It was suggested that these drugs could have delayed lithium excretion or worsened neurotoxic effects. An increase in the lisinopril dose and the addition of irbesartan several weeks before admission may have contributed to the lithium toxicity. ... 

Patients on lithium should be aware of the symptoms of lithium toxicity and told to report them immediately should they occur. This should be reinforced when they are given angiotensin II receptor antagonists. As with ACE inhibitors , (p.lll2), the risk of lithium toxicity would be expected to increase when risk factors such as advanced age, renal insufficiency, heart failure and volume depletion are also present. 

A man on long-term treatment with lithium earbonate became confused within a day of starting to take doxycycline 100 mg twice daily. By the end of a week he had developed symptoms of lithium toxicity (ataxia, dysarthria, worsened tremor, fatigue, etc.). His serum-lithium levels had risen from a range of 0.8 to 1.1 mmol/L up to 1.8 mmol/L his renal function remained normal. He recovered when the doxycycline was withdrawn. ... 

An isolated report describes a woman, who had been taking lithium for 3 years, with serum levels within the range of 0.5 to 0.84 mmol/L. Within 2 days of starting to take a sustained-release form of tetracycline (Tetrabidj her serum-lithium levels had risen to 1.7 mmol/L, and 2 days later they had further risen to 2.74 mmol/L. By then she showed clear symptoms of lithium toxicity (slight drowsiness, slurring of the speech, fine tremor and thirst). ... 

Symptoms of lithium toxicity (sometimes with unchanged lithium levels) have been seen in a few patients concurrently treated with phen doin, although the interaction has not been clearly demonstrated. 

In a further case a man taking phenytoin became ataxic within 3 days of starting to take lithium. He had no other toxic symptoms and his serum-lithium level was 2 mmol/L. However, as he only ever took lithium in the presence of phenytoin, it is not possible to say whether the effects were as a result of an interaction, or whether toxic levels would have occurred with the lithium alone. Another similar case has also been reported. Information seems to be limited to these reports and none of them presents a clear picture of the role of phenytoin in the reactions described. The interaction is not well established. Patients taking lithium should be aware of the symptoms of lithium toxicity and told to report them immediately should they occur. This should be reinforced when they are given phenytoin. Increased serum lithium monitoring does not appear to be of value in this situation as the interaction occurred in patients with lithium levels within the normally accepted range. 

Symptoms of lithium toxicity, not always associated with raised lithium levels, have been described in four patients and four healthy subjects when they were also given methyidopa. 

There are 3 other cases of patients who took methyidopa with lithium, and developed symptoms of lithium toxicity. In one of these cases the patient had lithium levels within the normal therapeutic range, but in the other two the lithium levels increased to 1.5 and 1.87 mmol/l. A small study in 3 healthy subjects also found that the combination of lithium and methyidopa resulted in increased confusion, sedation and dysphoria. ... 

Three other case reports describe patients with symptoms of lithium toxicity that occurred within 1 to 7 days of them starting to take ibuprofen 1.2 g daily.In another case, episodes of unsteadiness and tremor associated with raised lithium levels were attributed to varying use of prescribed ibuprofen 400 mg three times daily. ... 

A case report describes lithium toxicity in a man given indometacin 50 mg every 6 hours. Three days after he started the indometacin his serum creatinine was raised, and 9 days later he had symptoms of lithium toxicity and was found to have a lithium levels of 3.5 mmol/L. It was suggested that the indometacin caused renal impairment, which led to lithium retention and toxicity. ... 

A 42-year old woman taking lithium was given nimesulide 100 mg and ciprofloxacin 250 mg, both twice daily, for flank pain and dysuria. After 72 hours, she developed symptoms of lithium toxicity and the dose of lithium was reduced. After 98 hours she had vomiting, ataxia, and oliguria, and lithium levels were found to be 3.23 mmol/L (previous level 1.08 mmol/L) and her serum creatinine was raised. ... 

A 73-year-old man, with lithium levels of between 0.6 and 0.9 mmol/L for the past 13 years, developed symptoms of lithium toxicity (serum-lithium level 1.5 mmol/L) within 9 days of starting to take rofecoxib 12.5 mg daily. An interaction was strongly suspected. However, it should be noted that the patient had required his lithium dose to be successively decreased over the 13 years to maintain his lithium levels within the desired range. Captopril 6.25 mg daily had also been started during this time, although it is unclear whether it had a part to play either in the lithium dose reduction or the development of an interaction. 

Lithium levels increased. Two patients developed increased serum-lithium levels apparently due to the use of sulindac. In one case the lithium levels rose from 1 to 2 mmol/L after 19 days of treatment with sulindac 150 mg twice daily, and symptoms of toxicity were seen. The levels fell to 0.8 mmol/L within 5 days of stopping the sulindac. The other patient had a rise from 0.9 to 1.7 mmol/L within a week of adding sulindac 150 mg twice daily. The sulindac was continued and the lithium dosage was reduced from 1.8 to 1.5 g daily. The serum-lithium levels fell and were 1.2 mmol/L at 37 days and 1 mmol/L at 70 days. No symptoms of lithium toxicity occurred. ... 

Patients on lithium should be aware of the symptoms of lithium toxicity and told to report them immediately should they occur. This should be reinforced when they are given an NSAID. 

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