Abstract
Lithium has been used as the gold standard in the treatment of major depressive and bipolar disorders for decades. Due to its narrow therapeutic index, lithium toxicity is a common clinical problem. Although risk factors for lithium intoxication seem to be well-described, lacking patient education and inexperience of treatment are assumed to contribute to the probability of lithium intoxication. A review of literature shows that the treatment of lithium intoxication has not been adequately studied or standardized. The aim of this literature review is to compile and present current evidence on the treatment of lithium intoxication and contribute to a standardization regarding general treatment recommendations as well as evidence on indication for extracorporeal methods. Against the background of this common and potentially life-threatening condition, the standardization of the treatment of lithium intoxication is definitely a task for the future.
Highlights
Since 1970, lithium has been approved and widely used as the gold standard for the treatment of acute episodes and maintenance treatment of bipolar disorder (Nolen 2015; Severus et al 2014) and frequently used in the treatment of recurrent major depressive disorders since the 1950s (Bschor 2014)
Since clinical trials dealing with treatment of lithium intoxication are lacking, current treatment guidelines of lithium intoxication are predicated on animal studies, pharmacokinetic studies and small observational studies (Wiltling et al 2009)
A review of case series of intoxications treated in a hemodialysis unit showed that lithium intoxication is largely a therapeutic oversight—it is mostly preventable because the vast majority of cases were due to treatment based on inexperience or because patients lacked sufficient education about the principles of lithium maintenance
Summary
Since 1970, lithium has been approved and widely used as the gold standard for the treatment of acute episodes and maintenance treatment of bipolar disorder (Nolen 2015; Severus et al 2014) and frequently used in the treatment of recurrent major depressive disorders since the 1950s (Bschor 2014). Acute lithium intoxication is most often associated with gastrointestinal symptoms, cardiotoxic effects and late developing neurological signs whereas chronic forms manifest primarily as neurological symptoms, including confusion, myoclonus and seizures (Timmer and Sands 1999; Ward et al 1994; Haussmann 2015) (Fig. 1). In the cases of acute lithium toxicity, lithium concentrations tend to fall rapidly due to distribution in several tissues, chronic toxicity faces lithium-saturated tissues. For this reason, lithium toxicity depends on the exposure pattern which needs to be considered regarding treatment strategy (Waring et al 2007)
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