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# Lithium toxicity

Build-up of lithium, a mood stabiliser, to harmful levels. It causes vomiting, tremor, confusion and unsteadiness and can damage the brain and kidneys.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Cerebellum](https://durgical.com/en/anatomy/anterior-quadrangular-lobule/)
- [Kidneys](https://durgical.com/en/anatomy/kidney/)
- [Vermis](https://durgical.com/en/anatomy/central-lobule/)
- [Thyroid gland](https://durgical.com/en/anatomy/thyroid-gland/)
- [Parathyroid glands](https://durgical.com/en/anatomy/parathyroid-glands/)
- [Vessels inside the kidney](https://durgical.com/en/anatomy/intrarenal-arteries-and-veins/)

## Why it happens

- [Injury by therapeutic drugs: the classic examples](https://durgical.com/en/general-pathology/injury-by-therapeutic-drugs-the-classic-examples/)
- [Proximal tubule transport](https://durgical.com/en/physiology/proximal-tubule-transport/)
- [Where and how diuretics act](https://durgical.com/en/physiology/where-and-how-diuretics-act/)
- [ADH, thirst and water balance](https://durgical.com/en/physiology/adh-thirst-and-water-balance/)

## What it is

Poisoning from excess lithium, a mood stabiliser with a narrow margin between effective and toxic blood levels. It can be acute (overdose), chronic (gradual build-up during treatment, often from dehydration, kidney impairment or drug interactions) or acute-on-chronic, and the [nervous system](https://durgical.com/en/anatomy/system/nervous-system/) and kidneys are mainly affected.

## Who gets it

Lithium remains a key treatment for bipolar disorder in Colombia and worldwide, so toxicity is a recurring emergency, mostly as chronic toxicity in older patients or during intercurrent illness. Monitoring of levels, kidney and thyroid function is part of standard care.

## Causes

- Intentional or accidental overdose
- Dehydration from vomiting, diarrhoea, fever, heat or low fluid intake
- Reduced kidney function (acute kidney injury, chronic kidney disease, older age)
- Drug interactions: thiazide diuretics, ACE inhibitors, angiotensin receptor blockers and NSAIDs
- Low-sodium diet or sudden changes in salt intake

## Risk factors

- Older age
- Chronic kidney disease
- Heart failure and cirrhosis
- Starting or increasing an interacting medicine
- Intercurrent illness with vomiting or diarrhoea

## Pathophysiology

Lithium is not protein-bound and is cleared almost entirely by the kidneys, where it is reabsorbed together with sodium in the proximal tubule. When sodium or volume is low, or when interacting drugs reduce clearance, reabsorption rises and levels climb. Lithium enters the brain slowly, so in chronic toxicity tissue levels are high and neurological signs can be severe even with modest blood levels. Long-term it blocks the kidney's response to antidiuretic hormone, causing nephrogenic diabetes insipidus, and it affects thyroid and parathyroid function.

## Classification

- Acute toxicity: overdose in a person not taking lithium; gastrointestinal symptoms dominate early
- Chronic toxicity: gradual build-up during treatment; neurological signs dominate
- Acute-on-chronic toxicity: overdose in a person already taking lithium

## Symptoms and signs

- Nausea, vomiting and diarrhoea
- Coarse tremor, muscle twitching and myoclonus
- Unsteadiness (ataxia) and slurred speech
- Drowsiness, confusion and agitation
- Increased reflexes and seizures
- Polyuria and thirst (nephrogenic diabetes insipidus)

## Red flags

- Decreased consciousness, seizures or coma
- Arrhythmias, bradycardia or a prolonged QT interval
- Very high lithium levels, especially with impaired kidney function
- Worsening neurological signs despite falling blood levels

## Diagnosis

**Clinical**
History of lithium use, recent illness, new medicines or overdose, with gastrointestinal and neurological signs. Chronic toxicity can be mistaken for worsening of the psychiatric illness.

**Tests**
Serum lithium level (repeated, because it can keep rising after sustained-release tablets), [kidney](https://durgical.com/en/anatomy/kidney/) function, electrolytes and sodium, calcium, glucose, thyroid function and ECG (T-wave flattening, sinus node dysfunction, QT prolongation). Paracetamol and salicylate levels in intentional overdose.

**Imaging**
Not routinely needed; head CT when there is reduced consciousness, trauma or another suspected cause.

## Differential diagnosis

- Serotonin syndrome and neuroleptic malignant syndrome
- Other poisonings (anticonvulsants, sedatives)
- Encephalitis, stroke or metabolic encephalopathy
- Acute gastroenteritis with dehydration

## Goal of treatment

Stop absorption and further intake, restore volume and kidney clearance, remove lithium by dialysis when severe, and prevent permanent neurological damage.

## Treatment

**Acute**
Stop lithium and interacting drugs, secure the airway, breathing and circulation, and restore volume with intravenous isotonic saline while watching sodium and fluid balance.

**Acute**
Activated charcoal does not bind lithium; whole bowel irrigation may be used after a large overdose of sustained-release tablets.

**Procedure**
Haemodialysis for severe toxicity: reduced consciousness, seizures, dangerous arrhythmias, very high levels or impaired kidney function.

**Follow-up**
Monitoring: serial lithium levels, kidney function, electrolytes, cardiac monitoring and neurological checks; nursing measures include fall and seizure precautions and strict fluid balance.

**Medical**
After recovery, review of the need for lithium, its dose and interacting medicines, with education on hydration and regular level, kidney and thyroid monitoring.

## Complications

- Seizures and coma
- Persistent cerebellar damage (SILENT syndrome)
- Acute kidney injury and nephrogenic diabetes insipidus
- Cardiac arrhythmias
- Hypothyroidism and hyperparathyroidism with hypercalcaemia (long-term use)

## Prognosis

Most patients recover fully with early treatment. Chronic toxicity in older adults and delayed treatment carry a higher risk of permanent cerebellar and cognitive damage, and severe cases can be fatal.

## Prevention

- Regular lithium levels, kidney and thyroid function tests
- Avoiding thiazides, NSAIDs and ACE inhibitors or adjusting with close monitoring
- Education on hydration and stopping lithium during vomiting or diarrhoea according to the treating team's plan

## Test yourself

Think of the answer, then tap the question to see it.

## Which drug classes raise lithium levels by reducing its renal clearance?

Thiazide diuretics, ACE inhibitors, angiotensin receptor blockers and NSAIDs.

## Why is activated charcoal not useful in lithium overdose?

It does not bind lithium; whole bowel irrigation may be used for sustained-release tablets.

## What is the definitive treatment for severe lithium toxicity with seizures or reduced consciousness?

Haemodialysis.

## Which kidney complication of long-term lithium causes polyuria and thirst?

Nephrogenic diabetes insipidus.

## Which neurological signs dominate chronic lithium toxicity?

Coarse tremor, ataxia, confusion, hyperreflexia and, in severe cases, seizures and coma.

[Add to my cards (5)](https://durgical.app/estudiar/?add=/en/conditions/lithium-toxicity/)

## Related conditions

- [Bipolar disorder](https://durgical.com/en/conditions/bipolar-disorder/)
- [Diabetes insipidus (central and nephrogenic)](https://durgical.com/en/conditions/diabetes-insipidus/)
- [Acute kidney injury](https://durgical.com/en/conditions/acute-kidney-injury/)
- [Chronic kidney disease](https://durgical.com/en/conditions/chronic-kidney-disease/)
- [Dehydration (fluid volume deficit)](https://durgical.com/en/conditions/dehydration/)
- [Acute (viral) gastroenteritis](https://durgical.com/en/conditions/acute-gastroenteritis/)
- [Hypothyroidism](https://durgical.com/en/conditions/hypothyroidism/)
- [Primary hyperparathyroidism](https://durgical.com/en/conditions/primary-hyperparathyroidism/)
- [Serotonin syndrome](https://durgical.com/en/conditions/serotonin-syndrome/)
- [Neuroleptic malignant syndrome](https://durgical.com/en/conditions/neuroleptic-malignant-syndrome/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Lithium Toxicity](https://my.clevelandclinic.org/health/diseases/25207-lithium-toxicity) (Cleveland Clinic, 2025); [Lithium](https://medlineplus.gov/druginfo/meds/a681039.html) (MedlinePlus (U.S. National Library of Medicine), 2025).

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Source: https://durgical.com/en/conditions/lithium-toxicity/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/lithium-toxicity/