1
|
Schneir A, Masom CP. Lithium Toxicity from the Addition of an ACE Inhibitor with an Unexpected Type I Brugada Pattern ECG: Case Files of the Medical Toxicology Fellowship at the University of California, San Diego. J Med Toxicol 2020; 16:321-328. [PMID: 32297151 PMCID: PMC7320113 DOI: 10.1007/s13181-020-00773-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/17/2020] [Accepted: 03/18/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- Aaron Schneir
- Division of Medical Toxicology, Department of Emergency Medicine, University of California, San Diego Health System, San Diego, CA, USA
| | - Clifford P Masom
- Medical Toxicology Fellowship, University of California, San Diego Health System, San Diego, CA, USA.
| |
Collapse
|
2
|
Fan M, Song C, Wang T, Li L, Dong Y, Jin W, LU P. Protective effects of lithium chloride treatment on repeated cerebral ischemia–reperfusion injury in mice. Neurol Sci 2014; 36:315-21. [DOI: 10.1007/s10072-014-1943-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 09/01/2014] [Indexed: 11/30/2022]
|
3
|
Albertson TE, Owen KP, Sutter ME, Chan AL. Gastrointestinal decontamination in the acutely poisoned patient. Int J Emerg Med 2011; 4:65. [PMID: 21992527 PMCID: PMC3207879 DOI: 10.1186/1865-1380-4-65] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/12/2011] [Indexed: 12/15/2022] Open
Abstract
Objective To define the role of gastrointestinal (GI) decontamination of the poisoned patient. Data Sources A computer-based PubMed/MEDLINE search of the literature on GI decontamination in the poisoned patient with cross referencing of sources. Study Selection and Data Extraction Clinical, animal and in vitro studies were reviewed for clinical relevance to GI decontamination of the poisoned patient. Data Synthesis The literature suggests that previously, widely used, aggressive approaches including the use of ipecac syrup, gastric lavage, and cathartics are now rarely recommended. Whole bowel irrigation is still often recommended for slow-release drugs, metals, and patients who "pack" or "stuff" foreign bodies filled with drugs of abuse, but with little quality data to support it. Activated charcoal (AC), single or multiple doses, was also a previous mainstay of GI decontamination, but the utility of AC is now recognized to be limited and more time dependent than previously practiced. These recommendations have resulted in several treatment guidelines that are mostly based on retrospective analysis, animal studies or small case series, and rarely based on randomized clinical trials. Conclusions The current literature supports limited use of GI decontamination of the poisoned patient.
Collapse
Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, School of Medicine, University of California, Davis, Sacramento, California, USA.
| | | | | | | |
Collapse
|
4
|
Ghannoum M, Lavergne V, Yue CS, Ayoub P, Perreault MM, Roy L. Successful treatment of lithium toxicity with sodium polystyrene sulfonate: a retrospective cohort study. Clin Toxicol (Phila) 2010; 48:34-41. [PMID: 19842945 DOI: 10.3109/15563650903344785] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Lithium (Li) is a first-line treatment for bipolar disorder but has a narrow therapeutic index. Treatment of Li toxicity includes supportive measures and hemodialysis in severe cases, but this modality is not always immediately available. Sodium polystyrene sulfonate (SPS, Kayexalate), a cation exchanger, has been promising in animal models and human reports to reduce absorption and enhance elimination of Li. MATERIAL AND METHODS A retrospective cohort study was conducted. All cases of chronic Li intoxication were reviewed in two adult-care hospitals from 2000 to 2009. A group comparison and a within-patient comparison were performed to compare the effect of SPS on the median Li half-life (T(1/2)). For this study, at least three serum Li levels were required for T(1/2) calculations. RESULTS Forty-eight patients met inclusion requirements, 12 of whom had taken SPS. Median Li T(1/2) in the treated and control groups was 20.5 and 43.2 hours, respectively (p = 0.0006). In the 12 treated patients, Li T(1/2) during SPS was on average 48.9% shorter than without SPS. Furthermore, in one subject in whom urinary Li data were available, Li clearance with SPS was superior to Li renal clearance. Prolonged constipation was noted in one patient whereas mild hypokalemia was noted in six patients treated with SPS. CONCLUSION This study shows that SPS reduced Li T(1/2) and suggests that SPS is capable of promoting Li elimination in chronic intoxications. These results warrant a prospective trial looking at the use of SPS in the treatment of Li overdose as an adjunct to supportive measures and hemodialysis.
Collapse
Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, Verdun, QC, Canada.
| | | | | | | | | | | |
Collapse
|
5
|
Evaluation of available treatment guidelines for the management of lithium intoxication. Ther Drug Monit 2009; 31:247-60. [PMID: 19057466 DOI: 10.1097/ftd.0b013e318190cc26] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intoxications with lithium carry considerable risk for long-term morbidity and even mortality. Consequently, any patient suspected of lithium intoxication requires immediate and appropriate care. The objectives of this study were to assess the completeness and the applicability of generally available treatment guidelines for the management of patients with a lithium intoxication and, hence, to provide general recommendations for improvement of existing treatment guidelines. Nineteen treatment guidelines originating from 7 different countries were gathered by searching the Internet, online databases, and textbooks and by contacting different poison information centers and university medical centers. A list of items was composed from the retrieved treatment guidelines and a further literature search. Most relevant items were present in the various guidelines. However, in some guidelines, essential information was missing or potentially hazardous information was provided. Clarity, presentation, and applicability of the guidelines, as assessed using parts of the Appraisal of Guidelines Research and Evaluation instrument, were relatively poor. Regular updates of treatment guidelines should be performed to incorporate new essential information. To improve applicability of guidelines, unambiguous key recommendations, alternative treatments, and special care requirements should be provided and authors are recommended to test treatment guidelines using a panel of less experienced caregivers in a hypothetical case scenario.
Collapse
|
6
|
Abstract
Drug- and toxin-associated seizures (DTS) may result from exposure to a wide variety of agents. Most DTS can be managed with supportive care. First-line anticonvulsant therapy should include benzodiazepines, unless agents require a specific antidote. Phenytoin is generally not expected to be useful for DTS and in some instances may be harmful. In this article the authors discuss the pathophysiology of DTS, the potential differential diagnosis, and the clinical presentation. They also review selected agents that cause DTS and provide an overview of how the clinician should approach the management of patients who have DTS.
Collapse
|
7
|
Abstract
Lithium salts have been used in the prophylaxis and treatment of depression and bipolar disorder for >50 years. Lithium has a narrow therapeutic range, and several well characterised adverse effects limit the potential usefulness of higher doses. Acute ingestion in lithium-naive patients is generally associated with only short-lived exposure to high concentrations, due to extensive distribution of lithium throughout the total body water compartment. Conversely, chronic toxicity and acute-on-therapeutic ingestion are associated with prolonged exposure to higher tissue concentrations and, therefore, greater toxicity. Lithium toxicity may be life threatening, or result in persistent cognitive and neurological impairment. Therefore, enhanced lithium clearance has been explored as a means of minimising exposure to high tissue concentrations. Although haemodialysis is highly effective in removing circulating lithium, serum concentrations often rebound so repeated or prolonged treatment may be required. Continuous arteriovenous haemodiafiltration and continuous venovenous haemodiafiltration increase lithium clearance, albeit to a lesser extent than haemodialysis, and are more widely accessible. Haemodiafiltration sustained for >16 hours allows effective removal of total body lithium, thereby avoiding rebound effects. Enhanced elimination should be considered in patients at greatest risk of severe poisoning: namely those with chronic or acute-on-therapeutic toxicity, those with clinically significant features, and those with chronic toxicity whose serum lithium concentration is >2.5 mmol/L. The choice between haemodialysis and continuous haemodiafiltration techniques will depend on local accessibility and urgency of enhancing lithium elimination. Further research is required to establish the potential benefits of assisted elimination on clinical outcome in patients with lithium poisoning.
Collapse
Affiliation(s)
- W Stephen Waring
- Scottish Poisons Information Bureau, Royal Infirmary of Edinburgh, Edinburgh, UK.
| |
Collapse
|
8
|
Abstract
Drug- and toxin-associated seizures may result from exposure to a wide variety of agents. Obtaining a comprehensive history behind the exposure is generally more helpful than diagnostic testing. Most DTS may be managed with supportive care, including benzodiazepines, except in the case of agents that require a specific intervention or antidote.
Collapse
Affiliation(s)
- Brandon Wills
- Department of Emergency Medicine, University of Illinois, Chicago, Chicago, IL 60612, USA.
| | | |
Collapse
|
9
|
Linakis JG, Savitt DL, Wu TY, Lockhart GR, Lacouture PG. Use of sodium polystyrene sulfonate for reduction of plasma lithium concentrations after chronic lithium dosing in mice. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1998; 36:309-13. [PMID: 9711196 DOI: 10.3109/15563659809028026] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Previous studies have shown that oral sodium polystyrene sulfonate lowers plasma lithium concentrations after acutely administered oral doses of lithium chloride. However, a significant proportion of lithium overdose cases resulting in morbidity and mortality are those in which exposure to lithium is chronic. This study was designed to determine whether multiple oral doses of sodium polystyrene sulfonate are effective in reducing plasma lithium concentrations after chronic dosing. DESIGN Placebo-controlled animal study. INTERVENTIONS One hundred thirty mice were given 75 mM lithium chloride in their drinking water for a period of 14 days. At the end of that period, half of the animals were given orogastric sodium polystyrene sulfonate at 5 g/kg/dose 0, 60, 120, 180, and 360 minutes after the cessation of lithium chloride; the remaining half received orogastric water at equivalent times. Subgroups of each group were sacrificed at 90, 150, 330, 480, 1440, and 2880 minutes after lithium chloride cessation and plasma analyzed for lithium content. Lithium concentrations were compared by analysis of variance and single degree of freedom contrasts. Significance was set at an alpha level of 0.05. RESULTS Lithium concentration was lower overall in the animals treated with sodium polystyrene sulfonate (p < .0001) and specifically at 150, 330, and 480 minutes after lithium chloride cessation (p < .05). CONCLUSIONS Repetitive oral doses of sodium polystyrene sulfonate effectively lowered plasma lithium concentrations. Further study may ultimately define a role for the use of sodium polystyrene sulfonate in the treatment of patients with chronic lithium toxicity.
Collapse
Affiliation(s)
- J G Linakis
- Rhode Island Hospital, Providence 02903, USA.
| | | | | | | | | |
Collapse
|
10
|
Scharman EJ. Methods used to decrease lithium absorption or enhance elimination. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1997; 35:601-8. [PMID: 9365427 DOI: 10.3109/15563659709001240] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To review current methods, well documented and investigational, being used to decrease lithium absorption or enhance lithium elimination. METHODS The basic science and clinical literature on lithium were reviewed by a comprehensive Medline search from 1984 to 1996. Additional references were identified by reviewing the reference citations from the results of the Medline search. RESULTS Prevention of Absorption: Whole bowel irrigation has been demonstrated to be an effective means of enhancing lithium removal from the gastrointestinal tract. Sodium polystyrene sulfonate resin administration has been shown to be effective in binding lithium elimination in animal and human models. However, the lower limits of effective sodium polystyrene sulfonate dosing and the extent of potassium lowering in humans are questions that need to be answered before sodium polystyrene sulfonate resin can be recommended for routine, use. Enhancement of Elimination: Saline or forced diuresis is not effective in enhancing lithium elimination unless the patient is volume or sodium depleted. The use of continuous arteriovenous hemodiafiltration or low dose dopamine to enhance lithium elimination has only been documented in case reports. Intravenous aminophylline (theophylline) is not consistently effective and its risks outweigh possible benefits. The literature supports hemodialysis as a well documented and effective means of enhancing lithium elimination. Controversy exists over the appropriate indications for its initiation. DISCUSSION Given the wide interpatient variability in lithium pharmacokinetics, single case reports do not provide sufficient evidence of the effectiveness of a given method to enhance
Collapse
Affiliation(s)
- E J Scharman
- West Virginia Poison Center, Charleston 25304, USA.
| |
Collapse
|
11
|
Linakis JG, Hull KM, Lacouture PG, Lockhart GR, Lewander WJ, Maher TJ. Enhancement of lithium elimination by multiple-dose sodium polystyrene sulfonate. Acad Emerg Med 1997; 4:175-8. [PMID: 9063542 DOI: 10.1111/j.1553-2712.1997.tb03736.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether multiple doses of sodium polystyrene sulfonate (SPS) enhance the elimination of IV-administered lithium (Li). METHODS The study was a placebo-controlled, investigator-unblinded, murine trial of multiple doses of SPS on serum Li concentrations. Seventy-five male CD-1 mice were given IV pretreatment with LiCl (125 mg/ kg) followed by gavage treatments with SPS (5 g/kg/dose) 20, 40, 90, 150, and 210 minutes after LiCl (experimental group) or deionized water at equivalent times (control group). Subgroups of each treatment group were sacrificed at 1, 2, 4, and 6 hours after LiCl administration and blood was collected for Li analysis. RESULTS Statistical analyses indicated that the SPS group had lower serum Li concentrations overall than did the control animals. This difference was apparent at the 2-, 4-, and 6-hour time points. CONCLUSION In this murine model, repetitive doses of orogastric SPS enhanced the elimination of parenterally administered Li.
Collapse
Affiliation(s)
- J G Linakis
- Department of Pediatrics, Rhode Island Hospital, Providence 02903, USA.
| | | | | | | | | | | |
Collapse
|
12
|
Linakis JG, Savitt DL, Lockhart GR, Trainor B, Lacouture PG, Lewander WJ. In vitro binding of lithium using the cation exchange resin sodium polystyrene sulfonate. Am J Emerg Med 1995; 13:669-70. [PMID: 7575808 DOI: 10.1016/0735-6757(95)90061-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
|
13
|
Linakis JG, Hull KM, Lee CM, Maher TJ, Lewander WJ, Lacouture PG. Effect of delayed treatment with sodium polystyrene sulfonate on serum lithium concentrations in mice. Acad Emerg Med 1995; 2:681-5. [PMID: 7584745 DOI: 10.1111/j.1553-2712.1995.tb03618.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine the efficacy of sodium polystyrene sulfonate (SPS) in lowering serum lithium (Li) concentrations. Specifically, to determine the effects of both different doses of SPS and different times to treatment with SPS on serum Li levels. METHODS The study was a controlled, single-dose murine trial of SPS on serum Li levels. Male CD-1 mice (n = 525) were given orogastric LiCl and then divided into three main treatment groups: group SPS received a single orogastric administration of SPS in a dose of 5 gm/kg body weight at either 0, 15, 30, 45, or 90 minutes after LiCl; group half-SPS received a single orogastric administration of SPS in a dose of 2.5 gm/kg body weight at times equivalent to those of group SPS; and the control group received orogastric deionized water in a volume equivalent to that of group SPS at 0, 15, 30, 45, or 90 minutes after LiCl. Subgroups of seven to ten mice in each of the four treatment groups were sacrificed at one, two, four, and eight hours after administration of LiCl, and their blood was analyzed for Li concentration. RESULTS 1) Single doses of SPS significantly lowered serum Li concentrations; 2) this effect was dose-related; 3) the delays in administration of SPS used in this study did not significantly reduce its ability to lower serum Li concentrations; and 4) even when administered after peak serum Li concentrations had been achieved, a single dose of SPS was effective in lowering serum Li levels. CONCLUSIONS SPS may be efficacious in the treatment for Li toxicity under certain circumstances, even when there is delay to treatment. Additional study is warranted to further characterize the ability of SPS to alter Li kinetics.
Collapse
Affiliation(s)
- J G Linakis
- Department of Pediatrics, Rhode Island Hospital, Providence, USA
| | | | | | | | | | | |
Collapse
|
14
|
Scranton AB, Rangarajan B, Klier J. Biomedical applications of polyelectrolytes. BIOPOLYMERS II 1995. [DOI: 10.1007/3540587888_13] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
15
|
|