Lithium Toxicity: Your GoodRx Guide

Lithium (Lithobid) is a mood stabilizer and first-choice medication for bipolar disorder. Studies have shown it helps both manic and depressive symptoms of this disease.

Some healthcare providers feel that lithium is underused. One of the reasons for this may be a fear of lithium toxicity. But what is lithium toxicity, and how can you help prevent it if you’re taking lithium? 

What is lithium?

Lithium is a mood stabilizer medication. It was FDA approved in 1970, and healthcare providers have been prescribing it for over 50 years.

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Lithium is a medication with a narrow therapeutic index. That means there’s only a small difference between a safe, effective dose and a dose that’s either too low or too high. Due to this, healthcare providers use blood tests to help them find the right lithium dosage for your symptoms. The goal lithium blood level typically ranges between 0.6 mEq/L and 1.5 mEq/L, depending on what you’re taking it for. 

What is lithium toxicity?

Lithium toxicity occurs when you have too much lithium in your body. A lithium blood level over 1.5 mEq/L increases your risk for lithium toxicity. But not everyone who experiences lithium toxicity has a high blood level. It can also happen when your blood levels are normal. This is more common in older people or those with kidney disease, but it can happen to anyone. Your healthcare provider will look at both your blood levels and your symptoms to see if lithium toxicity is an issue for you.

Lithium toxicity has three main categories:

• Acute toxicity: Acute, or sudden, toxicity typically happens if you take too much lithium in one dose, or over a short period of time. 

• Chronic toxicity: Chronic, long-term toxicity can happen when lithium slowly builds up in your body over time. 

• Acute-on-chronic toxicity: This happens when you’re taking lithium as prescribed, but then have a dose increase or drug interaction that pushes levels too high.

Chronic and acute-on-chronic toxicity are considered the most dangerous of the three. That’s because with chronic use, lithium has more time to be absorbed into your brain. This can cause more serious side effects at toxic levels.

How common is lithium toxicity?

Lithium toxicity doesn’t seem to be as common as healthcare providers once thought. One study followed 1,340 people taking lithium for 16 years. Based on the data collected, it found that lithium toxicity happens in about 1 out of every 100 people taking lithium each year.

Frequent monitoring has also made a difference in managing lithium toxicity before it becomes deadly. A 1978 study reported death in 9% to 25% of people who experienced lithium toxicity. But in 2012, the U.S. the death rate from lithium toxicity was only 0.16%.

Signs and symptoms of lithium toxicity

The symptoms of lithium toxicity depend on how severe it is. 

• Mild lithium toxicity (1.5 mEq/L to 2.5 mEq/L): Symptoms include nausea or vomiting, fatigue, and diarrhea. You may also notice a small tremor in your hands and feel light-headed. These symptoms are also common lithium side effects. So if you experience them, it’s best to contact your healthcare provider to get your blood level checked. They can help determine if your symptoms are a sign your lithium levels are too high.

• Moderate lithium toxicity (2.5 mEq/L to 3.5 mEq/L): Symptoms include confusion, agitation, and a rapid heart beat. You may also notice slurred speech, blurry vision, and a worsening tremor. 

• Severe lithium toxicity (>3.5 mEq/L): Symptoms include uncontrolled muscle movements, seizures, and trouble breathing. You can also have abnormal heart rhythms and other toxic effects on the heart. If untreated, this could lead to coma and even death.

Acute lithium toxicity usually causes more gastrointestinal side effects. Chronic lithium toxicity is more associated with the effects on the brain and nervous system. This is why chronic lithium toxicity can be more dangerous. If you think you might be experiencing lithium toxicity, contact your healthcare provider. But if your symptoms are severe, call 911 or seek emergency care right away.

What causes lithium toxicity?

There are two main ways lithium toxicity happens. Either too much lithium is entering the body or not enough lithium is leaving the body. 

Too much lithium entering the body can happen if your dose is too high. It can also happen if you intentionally or accidentally take too much lithium.

Lithium is removed from your body by the kidneys. So anything that affects your kidney function, or that makes you pee less, can raise your lithium levels higher than they should be. This includes: 

• Dehydration caused by vomiting, diarrhea, a fever, or not drinking enough water

• Heart failure

• Intense exercise or heat exposure (especially without proper hydration)

• Suddenly lowering your salt intake

• Kidney disease 

Other medications can also raise lithium levels if they’re taken together. This can increase your risk of lithium toxicity. Some common interacting medications include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin) and naproxen (Aleve)

• ACE inhibitors, such as lisinopril (Zestril) or enalapril (Vasotec)

• Thiazide diuretics, such as hydrochlorothiazide (Microzide)

• Loop diuretics, such as furosemide (Lasix) 

• Calcium channel blockers, such as diltiazem (Cardizem)

How to prevent lithium toxicity

There are several things you can do to help prevent lithium toxicity. 

1. Share your medications with your provider

Be sure your healthcare provider knows all the medications you’re taking. Don’t add or change any medications without talking to your provider first. This includes over-the-counter (OTC) medications and supplements, especially NSAIDs. Keep in mind that NSAIDs are often included in other OTC products, such as cough and cold medications.

2. Talk to your provider before changing your diet

You should avoid making large changes to your diet without your healthcare provider’s OK. Salt and caffeine can affect your lithium levels. It’s OK to have both, but consistency matters. So be sure to tell your provider if you’re looking to make a change in your diet so they can monitor you properly. This also applies if you’re starting or changing your exercise routine, as this can also affect your salt and electrolyte levels in your blood.

3. Don’t drink alcohol while taking lithium

It’s best to avoid alcohol while you’re taking lithium. It can make lithium side effects worse. And alcohol can also make you dehydrated, which raises your risk for lithium toxicity. There’s no amount of alcohol that’s considered safe while taking lithium. Talk with your healthcare provider if you have questions or concerns about alcohol use.

4. Take your lithium as directed

Be sure to follow your provider’s instructions when taking lithium. Also try to be consistent with how and when you take it. If you have trouble, try a medication reminder app. Or talk to your provider about extended-release dosage forms that you don’t have to take as often.

5. Keep track of your healthcare appointments

Be sure to stay on top of your healthcare appointments while taking lithium. You’ll likely need frequent lithium blood level tests, especially when you first start taking it. This helps your provider make sure your lithium levels are safe. Missing appointments can make it harder for your provider to know if you’re at risk for lithium toxicity.

When to seek medical care for lithium toxicity

Lithium toxicity requires prompt medical treatment. And the sooner you treat it, the better your chances are for a full recovery. If you’re experiencing mild symptoms of lithium toxicity, contact your healthcare provider. But moderate to severe symptoms require immediate medical care. If you or someone you know is experiencing these symptoms — especially any confusion or changes in their mental status — call 911 or go to the nearest emergency room.

If you or a loved one takes too much lithium, call the Poison Control Center at 1-800-222-1212 or contact your provider right away. This includes accidentally taking one extra dose as well as an intentional overdose. Both can cause lithium toxicity.

Keep in mind that it may take up to 24 hours for toxicity symptoms to appear after taking too much. So don’t wait for symptoms before you take action. If symptoms are already happening, seek medical care right away.

Why trust our experts?

Written by:

Alex Evans, PharmD, MBA

Alex Evans, PharmD, MBA, has been a pharmacist for 12 years. His first job was floating in a community chain pharmacy.

Edited by:

Stacia Woodcock, PharmD

Stacia Woodcock, PharmD, is a pharmacy editor for GoodRx. She earned her Doctor of Pharmacy degree from the University of Kentucky and is licensed in New York and Massachusetts.

Reviewed by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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