When should dialysis be performed in lithium poisoning? A kinetic study in 14 cases of lithium poisoning.

Service de Réanimation, Hopital Civil, Strasbourg, France.
Journal of toxicology. Clinical toxicology 02/1993; 31(3):429-47. DOI: 10.3109/15563659309000411
Source: PubMed

ABSTRACT Lithium kinetics were studied in 14 patients with lithium poisoning. Three patients were treated by hemodialysis. Serum lithium peak concentrations ranged between 1.4 and 9.6 mmol/L. The apparent mean serum half-life was 23.16 +/- 9 h, the mean total clearance was 26.5 +/- 13.3 mL/min and the mean renal clearance was 17.2 +/- 5.4 mL/min. The kinetic parameters were dependent on the duration of the study and on the type of the poisoning: acute, acute upon chronic or chronic. During the first 12 h after admission ten patients were in a distribution phase, three were in an elimination phase and one was in an absorption phase. The serum half-life during hemodialysis ranged from 3.6 to 5.7 h and hemodialysis clearance was 63.2 to 114.4 mL/min. The mean volume of distribution calculated in six cases was 0.63 +/- 0.09 L/kg. The evolution of the lithium pools showed a different kinetic pattern between the extra- and the intracellular pool which decreased more slowly. During hemodialysis the decrease of the extracellular pool was about twice that of the cellular pool. Among the factors which may modify lithium toxicity and kinetics, are the type of the poisoning, the presence of an underlying disease and renal impairment. No general and rigid indication for hemodialysis can be set, but the need for hemodialysis should be based on clinical and kinetic data determined during the 12 h following admission.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Bipolar affective disorder is a recurrent, long term mood disorder characterised by the presence of both depressive and manic phases. It involves substantial morbidity with a high suicide risk, and frequently causes a variety of psychological and social problems. The primary goals in the management of patients with bipolar disorder are the treatment of acute depressive and manic episodes and the prevention of future affecti ve episodes. Other equally important goals are interepisodic mood stabilisation and the reduction of excess mortality, mostly caused by suicide. Long term treatment of bipolar disorder requires the development of an overall psychiatric management strategy, that addresses many issues such as pharmacotherapy. informing the patient about the course and treatment of the illness. and supportive psychotherapy. Specific drug treatments are the most important tool in the treatment of bipolar disorder. Lithium is regarded as the drug of first choice for prophylaxis against bipolar disorder. In a number of controlled investigations, lithium has been shown to be preventive and mood stabilising by substantially reducing the frequency, duration and severity of future episodes. Carbamazepine is being used increasingly as an alternative to lithium in patients who fail to respond to lithium prophylaxis. Novel pharmacological alternatives for the prophylactic management of bipolar disorder include valproic acid (sodium valproate), highdose thyroxine and specific drug combinations (such as lithium and carbamazepine or valproic acid). Lithium is the drug of choice for the immediate treatment of acute mania. either on its own or in combination with anti psychotics. Alternatives are primarily valproic acid and carbamazepine. The treatment of the depressive phase is often complicated by the potential risk of an antidepressant-induced rapid change to a manic phase. However, the treatment of depression in patients with bipolar disorder does not generally differ from the treatment of unipolar depression.
    CNS Drugs 07/1996; 6(1). DOI:10.2165/00023210-199606010-00004 · 4.38 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: with bipolar disorder was admitted with altered behavior and mental status. He was maintained on lithium for 20 years. Nine months ago, lithium dose was increased and risperidone was added. Telmisartan was prescribed around 25 days ago and he had mild tremor since then. Two days ago, fluvoxamine was initiated and he developed restlessness, agitation, insomnia and confusion after one dose. On admission, fluvoxamine, lithium, telmisartan and risperidone were discontinued. Abnormal findings were temporary ST depression, hyponatremia and high creatine kinase. He had fever since day 2 and was covered for meningoencephalitis and neuroleptic malignant syndrome. On the next day, he was comatose and treated for septic shock. On day 7, result of serum lithium taken on day 3 revealed severe toxicity (3.2 mEq/L). The lithium level was normalized after hemodialysis. He subsequently regained full Glasgow Coma Scale score and his toxicity completely resolved on day 16. Interactions of risperidone and telmisartan with lithium possibly precipitated the lithium toxicity. However, the onset of the toxicity suggested fluvoxamine as the major cause of poisoning. Clinicians should be aware of these potential drug interactions.
    Journal of Applied Pharmaceutical Science 09/2013; 3(8 Suppl 1):S79-S82. DOI:10.7324/JAPS.2013.38.S13
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Metformin toxicity, a challenging clinical entity, is associated with a mortality of 30%. The role of extracorporeal treatments such as hemodialysis is poorly defined at present. Here, the Extracorporeal Treatments In Poisoning workgroup, comprising international experts representing diverse professions, presents its systematic review and clinical recommendations for extracorporeal treatment in metformin poisoning. A systematic literature search was performed, data extracted, findings summarized, and structured voting statements developed. A two-round modified Delphi method was used to achieve consensus on voting statements and RAND/UCLA Appropriateness Method to quantify disagreement. Anonymized votes and opinions were compiled and discussed. A second vote determined the final recommendations. One hundred seventy-five articles were identified, including 63 deaths: one observational study, 160 case reports or series, 11 studies of descriptive cohorts, and three pharmacokinetic studies in end-stage renal disease, yielding a very low quality of evidence for all recommendations. The workgroup concluded that metformin is moderately dialyzable (level of evidence C) and made the following recommendations: extracorporeal treatment is recommended in severe metformin poisoning (1D). Indications for extracorporeal treatment include lactate concentration greater than 20 mmol/L (1D), pH less than or equal to 7.0 (1D), shock (1D), failure of standard supportive measures (1D), and decreased level of consciousness (2D). Extracorporeal treatment should be continued until the lactate concentration is less than 3 mmol/L (1D) and pH greater than 7.35 (1D), at which time close monitoring is warranted to determine the need for additional courses of extracorporeal treatment. Intermittent hemodialysis is preferred initially (1D), but continuous renal replacement therapies may be considered if hemodialysis is unavailable (2D). Repeat extracorporeal treatment sessions may use hemodialysis (1D) or continuous renal replacement therapy (1D). Metformin poisoning with lactic acidosis appears to be amenable to extracorporeal treatments. Despite clinical evidence comprised mostly of case reports and suboptimal toxicokinetic data, the workgroup recommended extracorporeal removal in the case of severe metformin poisoning.
    Clinical Journal of the American Society of Nephrology 04/2015; DOI:10.2215/CJN.10021014 · 5.25 Impact Factor