Do you or someone you know use lithium, a medication prescribed by doctors for certain mental health conditions, especially bipolar disorder? While this medication can be very helpful when used properly, taking too much can lead to a dangerous condition called lithium toxicity. Let's talk about this today. Simply put, lithium toxicity is when your body has too much lithium. This can cause stomach upset (such as vomiting, diarrhea) and nervous system symptoms (such as confusion, tremors). If not treated properly, this can be life-threatening. Lithium is a naturally occurring salt. It reduces mania. That's why doctors often prescribe this medication for bipolar disorder. However, the margin between a safe and dangerous dose of this medication is very small. This means that even a little too much can be unbearable for the body.

How can lithium toxicity occur?

There are several ways this can happen. Let's see what they are.

Acute Toxicity

This happens if you suddenly take a lot of lithium pills, or if your body suddenly becomes very dehydrated. Think about it, sometimes you make mistakes when taking your medication. That can happen.

Taking more than you need daily (Acute-on-chronic Toxicity)

This can happen if you normally take lithium every day, but one day you take an extra dose, or if your body becomes dehydrated one day. For example, if you don't drink enough water for two or three days, or if you vomit a lot and lose water from your body.

Chronic toxicity

This happens because when you take lithium every day, the amount of lithium in your body gradually increases and builds up over time. This can easily happen. Many things, such as dehydration, kidney health, and other medications you take, can affect how your body handles lithium.

What are the levels of lithium toxicity?

Doctors check your lithium levels with a blood test. Your doctor will determine what level is right for you. In general, lithium toxicity levels are divided as follows:

Mild toxicity : 1.5 to 2.5 mmol/L.
Moderate toxicity: 2.5 to 3.5 mmol/L.
Severe toxicity: Higher than 3.5 mmol/L.

You don't need to think too much about this unit called millimoles (mmol/L), it's something that's important to doctors. What's important for you is to be aware of the symptoms.

What are the symptoms of lithium toxicity?

These symptoms can vary depending on the type of poisoning and how severe it is.

Symptoms of acute and acute-on-chronic poisoning

At times like these, the first thing that comes to mind is stomach problems (Gastrointestinal - GI problems). That means:

Nausea and vomiting .
Diarrhea (vomiting).
Stomach ache .
Feeling like your stomach is full.

These symptoms usually begin to appear within an hour of taking too much lithium.

Important: If you experience these symptoms, it is very important to seek medical advice immediately.

If the poisoning is moderate to severe, symptoms related to the nervous system may follow the stomach upset. These include:

Changes in mental status: Can range from mild confusion to severe delirium.
Uncontrollable shaking (Tremors).
Loss of balance and coordination while walking or standing (Ataxia).
Muscle twitching (Myoclonus).
Slurring of speech (Dysarthria).
Hyperreflexia (overreaction).
Uncontrolled movement of the eyes (Nystagmus).
In severe cases, fever increases (Hyperthermia).
In severe cases, seizures .
In severe cases, loss of consciousness (Coma).

If you are taking lithium and experience any of these symptoms, you should see a doctor immediately.

Symptoms of Chronic Lithium Toxicity

When lithium is ingested over a long period of time, it can often damage the kidneys. This can lead to a variety of kidney diseases, each with its own set of symptoms. Here are some of the conditions that can occur:

Nephrogenic Diabetes Insipidus

This is when your kidneys are unable to properly balance the fluids in your body. They are unable to respond properly to the antidiuretic hormone (ADH). Symptoms include:

Dehydration: Dry mouth, tiredness, and dizziness.
Feeling excessively thirsty ( Polydipsia ).
Passing a lot of urine (Polyuria).

Sodium-losing Nephritis

In this, damage to the kidneys causes electrolyte imbalances in the body. Symptoms include:

The flesh is turning over and becoming weak.
Changes in mental state.
Tired.
Excessive thirst.
Excessive urination (Polyuria).

Nephrotic Syndrome

In this condition, your kidneys excrete too much protein in your urine (Proteinuria). Symptoms:

Increased cholesterol (Hyperlipidemia).
Swelling of the legs and ankles (Edema).
The food is tasteless.
Stomach ache.
The urine is foaming.

Endocrine system problems can also occur due to lithium poisoning over a long period of time. Examples:

Decreased thyroid function (Hypothyroidism).
Increased activity of the thyroid gland (Hyperthyroidism).
Increased activity of the parathyroid glands (Hyperparathyroidism).

If you experience any of these symptoms while taking lithium, talk to a doctor as soon as possible.

The relationship between lithium and serotonin syndrome

Lithium can cause a condition called serotonin syndrome. This risk is especially high if you are taking other medications that affect serotonin levels. This can also be life-threatening. Symptoms of serotonin syndrome (ranging from mild to severe):

Restlessness.
Nausea and vomiting.
Diarrhea.
The pupils of the eyes become larger.
Tremor.
Anxiety, restlessness.
Grinding and pressing meatballs.
Sweating and shivering.
Confusion, loss of consciousness (Delirium).
Heart palpitations.
High blood pressure.

If you have these symptoms, seek medical advice immediately!

What are the causes of lithium toxicity?

There are three main reasons for this:

Excessive intake of lithium: Taking too many lithium pills, either intentionally or accidentally, can cause acute or acute-on-chronic toxicity. This can also happen if a doctor increases your dose too much, but this is very rare.
Dehydration or fluid changes: This is the most common cause. When the body loses sodium (salt) and water, the kidneys reabsorb lithium. This increases the concentration of lithium in the blood. Possible causes include:
When vomiting.
When diarrhea occurs.
When you get a fever.
Kidney failure.
When taking medications that cause urination, such as diuretics.
When exercising excessively.
Excessive sweating (Hyperhidrosis).
Just like when you don't drink water.
When eating a low-salt diet.
Heart conditions (Congestive heart failure).
During pregnancy or childbirth.
Thyroid gland changes (Hyperthyroidism).
Issues with excretion of lithium: Sometimes the body cannot properly excrete lithium. This can also be due to the reasons mentioned above.

Who is at higher risk for lithium toxicity?

The following people are at higher risk for chronic lithium toxicity:

People over 50 years old.
People with thyroid disease.
People with poor kidney function.
People with diabetes insipidus.

Even if you use lithium for a long time, you are at increased risk of developing nephrogenic diabetes insipidus, which is caused by lithium. This can lead to lithium toxicity. If you develop any of these conditions while taking lithium, talk to your doctor.

How do doctors diagnose lithium toxicity?

To know exactly how severe this is, this information is very important for doctors:

How much lithium did you take?
What time did you take it?
But did you take any other medications or other things at the same time?
Was this intentional or a mistake?

To confirm lithium toxicity, doctors perform several tests. Some of them include:

Blood tests to check the level of lithium in your blood.
Blood tests that check the levels of electrolytes (such as sodium and calcium) in your blood.
Blood tests that check thyroid-stimulating hormone (TSH) levels.
Urinalysis.
Kidney function tests (such as blood urea and creatinine levels).
Brain imaging tests (this is done very rarely).

Doctors will also monitor your health for things like:

Your heart with an EKG (electrocardiogram).
How much you urinate (urine output).
Your oxygen level - often measured with a pulse oximeter (pulse ox).

How is lithium toxicity treated?

Treatment for acute and acute-on-chronic lithium poisoning varies depending on how severe it is and how quickly you get to the emergency room. The main goals are to remove the lithium from your body and control your symptoms. Treatment may include:

Gastric lavage.
Whole-bowel irrigation: This involves giving a special liquid either by mouth or through a tube inserted through the nose into the stomach. This removes all the lithium from the gastrointestinal tract.
Activated charcoal: This is given if you have taken other medications or things.
Hemodialysis: This is the main way to remove lithium from the kidneys.
Giving saline (IV fluids).
Various medications treat symptoms.

Most of the time, you will be treated in an emergency room. If the poisoning is severe, you may need to be treated in an intensive care unit (ICU).

Treatment for Chronic Lithium Toxicity

Long-term lithium poisoning often causes kidney damage. Treatment depends on the type of kidney problem. Hemodialysis may be necessary.

What are the chances of recovery in this situation? (Prognosis)

Recovery from lithium toxicity depends on the type of poisoning, how severe it is, and how quickly you seek medical attention. People who do not develop neurological symptoms from acute lithium toxicity usually do not have long-term complications. However, if you develop severe neurological symptoms, they can be permanent. That's why prompt treatment is so important. In severe cases, lithium toxicity can lead to coma, brain damage, or even death. Chronic lithium toxicity can be difficult to detect because symptoms can develop over time. This delay can lead to long-term kidney and nervous system problems.

How to prevent lithium toxicity?

Following these steps can help prevent acute lithium toxicity:

Take your medications exactly as prescribed: Take only the amount of lithium (and other medications) your doctor prescribes. Keep a label on your medicine bottles, or write down the times you take them. This can help you avoid accidentally taking a double dose.
Keep your lithium medicine safe: Keep it out of reach of children and others.
Stay hydrated:Drink plenty of water. Dehydration can cause lithium toxicity. Tell your doctor if you experience vomiting, diarrhea, or fever.
Always tell your doctor a list of all the medications you take: Before starting a new medication, tell your doctor that you are taking lithium (and any other medication). Some medications can affect the way your body handles lithium.
Tell your doctor if you have any new or sudden changes in your health: for example, pregnancy and hormonal (endocrine) changes.

If you are having suicidal thoughts, or if you are thinking of taking too much lithium on purpose, please go to the nearest hospital emergency department, or talk to someone you trust. In Sri Lanka, you can also get help from organizations like Sumithrayo (phone number 0112692909 or 0112682535).

If you are taking lithium for a long time, your doctor will likely recommend regular blood and urine tests to monitor your health. These tests can help detect chronic lithium toxicity early. These are the tests and guidelines:

Lithium levels in the blood are checked within three to five days after starting lithium or changing the dosage.
For those taking medication for a long time , lithium levels in the blood are checked every three to six months.
Electrolyte, urea, and creatinine levels are checked every three to six months.
Calcium and thyroid stimulating hormone (TSH) levels are checked every six to twelve months.

Finally, things to remember

Lithium is a very powerful and effective medication, but it requires extra care when using it. Lithium toxicity is a potentially life-threatening complication that can occur from taking too much of the medication or from losing too much water while taking the medication. Talk to your doctor about ways to prevent lithium toxicity and the symptoms to watch out for. Doctors are there to help you and keep you healthy. So, don't be afraid to ask if you have any questions or concerns. Remember, the most important thing is to take your medication exactly as your doctor prescribes, at the right times. Also, don't forget to drink plenty of fluids.