---
title: "Lithium Toxicity"
url: https://mghmclean.org/residents/handbk/part2c/li.htm
description: "(dehydration, dietary restrictions, sodium wasting diuretics)"
published: 2026-08-10
updated: 2026-08-10
---

# Lithium Toxicity

Published 2026-08-10

PART 3 / CH 55

Amy Gagliardi and George Papakostas

A. Risk factors

1. sodium depletion

(dehydration, dietary restrictions, sodium wasting diuretics)

2. decreased renal blood flow

(CHF, cirrhosis, ACE-inhibitors, NSAIDs)

3. intrinsic renal disease

B. Management of suspected Li toxicity

1. Hold the next dose until a level can be checked

2. Send a lithium level immediately

3. *Toxicity correlates poorly with lithium level:*

- Any level above 2.0 requires treatment,

even if the patient appears well.

- Any patient with signs/symptoms of toxicity

requires treatment, regardless of level.

4. Consult renal service for possible hemodialysis

5. Consult medicine

5. Treat immediately

(damage caused by high level and *duration* of high level)

C. Lithium level and treatment

| lithium level | clinical picture | treatment |
|---|---|---|
| below 3.0 | with mild symptoms:lethargy, fatigue,weakness, coarsetremor,mild nausea | 1) NS at 150-200 cc/hr and IV lasix until level normalizes2) correct electrolyte abnormalities, especially K+3) avoid charcoal (does not bind Li)4) hold lithium, work up cause of toxicity - if unknown, check renal function (BUN/Cr, U/A, creatinine clearance): ?NSAID use, laxatives/diuretics, dehydration, … |
| 3.0 to 4.0 | with no symptoms,mild symptoms, ormoderate symptoms:nausea, vomiting,mild ataxia,dysarthria,incoordination,hyperreflexia,poor concentration,fasciculations | In patients with normal cardiac and renal function (able to tolerate volume load):1) call renal consult for possible hemodialysis and treat as above while awaiting consult.2) check Li levels q2hrs to be sure they are decreasing.3) consider ICU transfer. |
| 3.0 to 4.0 | with severe symptoms:delirium, ataxia,seizures,renal failure,hallucinations,coma | 1) dialysis required (hemodialysis best but peritoneal can be used)2) move patient to the ICU for hemodynamic monitoring3) re-equilibration occurs; retest levels several times after dialysis4) end-point is level of 1.0 or less 6 hours after dialysis5) work up cause of toxicity |
| above 4.0 | with no symptoms,mild symptoms, ormoderate symptoms | 1) IV NS at 250 cc/hr, recheck level every hour2) if level does not begin to decrease in 2-3 hours, institute dialysis regardless of patient's clinical appearance3) work up cause of toxicity |
| above 4.0 | with severe symptoms | as above |

Source: Hyman S and Tesar GE (1994) Manual of Psychiatric Emergencies.