QuestionSBA
QuestionChoice
Coarse tremor and polyuria are examples of symptoms and signs of toxicity. Patients should contact their doctors immediately if they experience any signs suggestive of lithium toxicity
34143
d
It is normal to experience frequent urination and coarse tremor during the course of treatment
QuestionChoice
It is recommended by the manufacturer to assess renal, cardiac and thyroid functions before the treatment. Lithium does not commonly affect the lungs or cause respiratory problems. Hence, chest x-ray is not required before the commencement of treatment
34141
b
He will need to take a chest x-ray before starting his medication
QuestionChoice
Patients should refrain from dietary changes which reduce or increase sodium intake so that the lithium levels will not go deranged
34144
e
He should go on a low salt diet to reduce the risk of lithium toxicity
QuestionChoice
Lithium has a narrow therapeutic/ toxic ratio, hence it is important to ensure that the level stays within the safe range. Routine serum-lithium monitoring is done weekly after initiation and then 3-monthly for the first year when the levels have become stable. The test needs to be performed every 6 months after that and not only when lithium toxicity is suspected
34142
c
Blood tests for lithium levels only need to be done if lithium toxicity is suspected
QuestionChoice
Lithium functions as a mood stabiliser. It is important to highlight to patients that lithium can leave a metallic taste in mouth so that they would not treat it as a symptom of toxicity and stop taking the drug
34140
a
Lithium can leave a metallic taste in mouth
QuestionComment
Is a fine tremor nota normal side effect? With course tremors being a sign of toxicity? The type was not listed
6504
QuestionComment
that's right!
8283
User
subscriber
Dominant Botox
User
subscriber
Kawasaki Pudendal
QuestionComment
great question! 
6918
User
subscriber
S 
Concept
Chapter
# Summary

Lithium, commonly used in psychiatric disorders, may produce a range of side effects, which can be categorised into those seen at a therapeutic dose and those indicating toxicity. Therapeutic dose side effects may include fine tremor, dry mouth, GI disturbances, increased thirst and urination, drowsiness, and thyroid dysfunction. Signs of toxicity encompass coarse tremor, CNS disturbance (including seizures, impaired coordination, dysarthria), arrhythmias, and visual disturbance. Diagnosis relies on identifying these clinical features and serum lithium levels. Management involves supportive measures, electrolyte balance maintenance, renal function monitoring, seizure control, IV fluid therapy, and, in severe cases, haemodialysis.

# Indications

Lithium is used primarily to treat bipolar disorder and mania, but can also be used in depression (especially if recurrent) and as mood stabiliser for aggressive/self-harming behaviour.

It is contraindicated in: Addison’s disease, cardiac disease associated with rhythm disorder, personal/family history of Brugada syndrome, low sodium diets and untreated hypothyroidism.

It should be avoided in severe renal impairment due to the risk of toxicity, as it has a very narrow therapeutic index.

# Side Effects

Can be remembered with the mneumonic LITHIuM:

* **L**eucocytosis
* **I**nsipidus
* **T**remor (fine)
* **H**ypothyroid
* **I**ncreased weight
* **U**
* **M**etallic taste 

Women of child bearing age should take contraception if commenced on lithium, which is generally avoided in pregnancy due to the high risk of development of cardiac malformations in the first trimester.

# Monitoring

- Before starting: renal (U+Es), cardiac (ECG), and thyroid function (TFTs). BMI and FBC should also be done beforehand.
- Monitor body-weight or BMI, serum electrolytes, eGFR, and thyroid function every 6 months during treatment, and more often if there is evidence of impaired renal or thyroid function, or raised calcium levels


# Lithium Toxicity

## Signs and Symptoms

### Clinical features at therapeutic dose 

- Fine tremor
- Dry mouth
- Gastrointestinal disturbance
- Increased thirst
- Increased urination
- Drowsiness
- Thyroid dysfunction

### Clinical features in lithium toxicity

- Coarse tremor
- Central nervous system disturbance, which may include seizures, impaired coordination, and dysarthria
- Cardiac arrhythmias
- Visual disturbance




## Differential Diagnosis

Lithium side effects and toxicity may be mistaken for several other conditions:

- **Neurological conditions**: Given the tremors, dysarthria, and impaired coordination, conditions like Parkinson's disease or cerebellar disorders may be considered.
- **Endocrine disorders**: Increased thirst and urination could point towards diabetes insipidus or diabetes mellitus.
- **Cardiac conditions**: Arrhythmias might suggest primary cardiac disease.
- **Substance intoxication or withdrawal**: Some symptoms overlap with those of alcohol or benzodiazepine withdrawal, or other substance intoxications.

## Investigations

- Serum lithium levels: This is the gold standard for diagnosing lithium toxicity.
- Electrolyte levels: To assess for any electrolyte imbalance.
- Thyroid function tests: Given the potential for thyroid dysfunction.
- Renal function tests: Given lithium's potential to cause renal impairment.
- ECG: To assess for arrhythmias.

## Management

Management of lithium toxicity is largely supportive and often requires specialist input. Key strategies include:

- Maintaining electrolyte balance
- Monitoring renal function
- Seizure control
- IV fluid therapy and urine alkalisation, which enhance the excretion of the drug
- Benzodiazepines may be used to treat agitation and seizures
- Haemodialysis might be required if renal function is poor

# References

[Click here to see the BNF guidance on Lithium](https://bnf.nice.org.uk/drug/lithium-carbonate.html)
911
3415
Lithium toxicity
Topic
90
Psychiatry
6839
Case presentation: A 32-year-old man attends the psychiatric clinic to discuss the long-term treatment of his bipolar disorder. He had an episode of mania two months ago but his condition is now under good control with combination of anti-psychotic and cognitive behavioural therapy.  

DH: Olanzapine 15mg PO OD
SH: Works as a baker, lives with family
The patient is advised to commence long-term treatment with lithium to prevent relapse.

Question: Select the most important information that should be provided for this patient.
a