The clinical characteristics and correlates of lithium toxicity in a tertiary referral centre

  • Niamh M. GanterEmail author
  • Kezanne Tong
  • Colm McDonald
  • Anne M. Doherty
Original Article



Lithium is a medication indicated for the treatment of bipolar disorder and treatment-resistant depression, with a narrow therapeutic index. Overdose, either acute or chronic can result in neurological symptoms, requiring dialysis and admission to intensive care in some cases. Lithium toxicity is avoidable with careful monitoring. However, we have noted several recent cases of lithium toxicity in our local service and thus sought to investigate this issue in a more systematic manner.


We aimed to quantify the incidence of lithium toxicity in our local population over a single year and identify the patients most at risk. We also aimed to generate clinical recommendations on the prevention of lithium toxicity to improve patient safety.


We identified the incidence of lithium toxicity in our local population, by searching the hospital pathology database for patients with serum lithium levels greater than 1.0 mmol/L. We examined the available clinical notes for these patients.


We identified 74 serum lithium readings above 1.0 mmol/L measured in 44 individual patients. The highest recorded level was 3.2 mmol/L. Of these, 11 patients were aged 65 years or older. Hospital admission was required in 14 cases. There were missing data of note: 29.5% had no renal function/eGFR measurement at time of toxicity and 52.3% without a baseline eGFR.


Lithium toxicity is common in our population. Given the narrow therapeutic index, this demonstrates the need for careful monitoring and prescribing, especially patients aged 65 and over.


Clinical Galway Lithium Monitoring Overdose Tertiary Toxicity Toxicology 


Funding information

Grant supplied by Undergraduate Research Committee, School of Medicine, National University of Ireland, Galway.

Compliance with ethical standards

Ethical disclosure statement

For this project, we sought quality and integrity. We were in contact with no patients for the duration of the study. No identifiable patient data was used. Data was obtained via an electronic hospital laboratory system and was anonymised to ensure patient confidentiality. Data was stored on a fire-walled computer with coded access. Funding was obtained from the undergraduate research program at NUI Galway.

Conflict of interest

No conflicts of interest existed in relation to this.


  1. 1.
    Cade J (1999) Lithium salts in the treatment of psychotic excitement. Aust N Z J Psychiatry 33:349–352. CrossRefGoogle Scholar
  2. 2.
    NICE: National Institute for Health and Clinical Excellence (2008) Early identification and management of chronic kidney disease in adults in primary and secondary care. (Clinical guideline 73)Google Scholar
  3. 3.
    Fouser P, Abbasi Y, Mathilakath A (2017) Nilforooshan R. Case report: Do not treat the numbers: lithium toxicity. BMJ Case Rep.
  4. 4.
    Birch N, Greenfield A, Hullin R (1980) Pharmacodynamic aspects of long-term prophylactic lithium. Int Pharmacopsychiatry 15:91–98. CrossRefGoogle Scholar
  5. 5.
    Freeman M, Freeman S (2006) Lithium: clinical considerations in internal medicine. Am J Med 119:478–481. CrossRefGoogle Scholar
  6. 6.
    Oruch R, Elderbi M, Khattab H et al (2014) Lithium: a review of pharmacology, clinical uses, and toxicity. Eur J Pharmacol 740:464–473. CrossRefGoogle Scholar
  7. 7.
    (2018) Bipolar disorder: assessment and management | Guidance and guidelines | NICE. In: Accessed 13 May 2018
  8. 8.
    Taylor DM, Barnes TRE, Young AH (2018) The Maudsley prescribing guidelines in psychiatry, 13th edn. Wiley-Blackwell, LondonGoogle Scholar
  9. 9.
    Markowitz GS, Radhakrishnan J, Kambham N, Valeri AM, Hines WH, D'Agati VD (2000) Lithium nephrotoxicity: a progressive combined glomerular and tubulointerstitial nephropathy. J Am Soc Nephrol 11:1439Google Scholar
  10. 10.
    Aubry R, Scott L, Cassidy E (2017) Lithium monitoring patterns in the United Kingdom and Ireland: can shared care agreements play a role in improving monitoring quality? A systematic review. Ir J Psychol Med 34:127–140. CrossRefGoogle Scholar
  11. 11.
    Dennison U, Clarkson M, O’Mullane J, Cassidy EM (2011) The incidence and clinical correlates of lithium toxicity: a retrospective review. Ir J Med Sci 180:661–665. CrossRefGoogle Scholar
  12. 12.
    Offerman S, Alsop J, Lee J et al (2010) Hospitalized lithium overdose cases reported to the California poison control system. Clin Toxicol 48:443–448. CrossRefGoogle Scholar
  13. 13.
    (2009) Safer lithium therapy. In: Accessed 13 May 2018
  14. 14.
    Davis A (2012) Best practice guidelines for prescribing and monitoring if lithium therapy. 1–10. Accessed 3 Jan 2019
  15. 15.
    Ott M, Stegmayr B, Salander Renberg E, Werneke U (2016) Lithium intoxication: incidence, clinical course and renal function – a population-based retrospective cohort study. J Psychopharmacol 30:1008–1019. CrossRefGoogle Scholar
  16. 16.
    Mercer D, Douglass A, Links P (2009) Meta-analyses of mood stabilizers, antidepressants and antipsychotics in the treatment of borderline personality disorder: effectiveness for depression and anger symptoms. J Personal Disord 23:156–174. CrossRefGoogle Scholar
  17. 17.
    Finley P, Warner M, Peabody C (1995) Clinical relevance of drug interactions with lithium. Clin Pharmacokinet 29:172–191. CrossRefGoogle Scholar
  18. 18.
    Juurlink D, Mamdani M, Kopp A et al (2004) Drug-induced lithium toxicity in the elderly: a population-based study. J Am Geriatr Soc 52:794–798. CrossRefGoogle Scholar
  19. 19.
    Cipriani A, Hawton K, Stockton S, Geddes JR (2013) Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ 346:f3646–f3646. CrossRefGoogle Scholar
  20. 20.
    Dyson E, Simpson D, Prescott L et al (1987) Self-poisoning and therapeutic intoxication with lithium. Hum Toxicol 6:325–329. CrossRefGoogle Scholar
  21. 21.
    Shine B, McKnight R, Leaver L et al (2015) Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data. Lancet 386:461–468. CrossRefGoogle Scholar
  22. 22.
    Webb A, Solomon D, Ryan C (2001) Lithium levels and toxicity among hospitalized patients. Psychiatr Serv 52:229–231. CrossRefGoogle Scholar
  23. 23.
    Smith R, Helms P (1982) Adverse effects of lithium therapy in the acutely ill elderly patient. J Clin PsychiatryGoogle Scholar
  24. 24.
    HSE & NSRF. Saving lives and reducing harmful outcomes: care systems for self harm and suicidal behaviour. National guidelines for the assessment and management of patients presenting to Irish emergency departments following self-harm. 2016Google Scholar

Copyright information

© Royal Academy of Medicine in Ireland 2019

Authors and Affiliations

  • Niamh M. Ganter
    • 1
  • Kezanne Tong
    • 2
  • Colm McDonald
    • 1
    • 2
  • Anne M. Doherty
    • 2
  1. 1.School of MedicineNational University of IrelandGalwayIreland
  2. 2.Department of PsychiatryUniversity Hospital GalwayGalwayIreland

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