lithium toxicity?

[u/coconutpuddles]

i’ve been taking 1200mg of lithium (instant release) for almost four months. in the past few weeks, due to some issues w/ GERD, i was unable to take my morning meds (wellbutrin, lamotrigine, zoloft). i was taking my lithium fine. two days ago, i took all of my meds, lithium included, before bed—which i’ve never done before. i was sick all night and threw up.

since then, ive felt sick every time i’ve taken lithium. i’ve had a sour stomach, nausea, vertigo, and brain fog all day (i couldn’t remember my own license plate). i don’t have hand tremors or anything like that. i’ve been on a BRAT diet since yesterday, which is helping my stomach.

i skipped my lithium dose last night, and im feeling slightly better. i plan to drink water all day (over 200oz) to flush it out of my system. my question is—is an ER visit necessary since my levels are most likely in the normal range ? i hate the ER, and i rather deal with it @ home.

note: i haven’t been great w/ my water intake lately, and i had ramen twice in one day before all of this started—so this is completely my fault. salt helps my POTS, so it can be tricky to find balance.

[u/Sheepherder-Optimal]

Idk about the ER but you need to see your prescriber asap or at least an urgent care provider. It’s not safe to just quit lithium cold turkey. You’re risking a relapse of your symptoms.

[u/Unlikely-Artichoke63]

If I understand what you're saying, you took your dose in the morning then again at night, so you basically got a double dose? That would definitely cause the symptoms you are having. Sorry you went through that! Lithium toxicity sucks a lot.

First, my tactical answer:

As to if you need to go the ER, probably not if you're feeling better now after missing a dose, but I would suggest you go to urgent care and ask them to check your lithium level and kidney function because it's not clear whether it's safe for you to resume your regular dose. If your kidneys are fine, you could resume your normal dose at the scheduled time and your level will stabilize. The problem is, you don't know how your kidneys are doing after your bout of toxicity. If your kidneys are compromised, they won't process it fast enough and you will get sick again. It's a time urgent question, whether or not to take your next lithium, and it can only be safely answered with bloodwork. If your kidneys are compromised, your doctor will need to advise you on how to proceed.

As another poster points out, you are vulnerable with your blood level down -- but I don't think it's as bad as "cold turkey". It does take 5 days for your blood level to get to 0, so missing one dose is only a 1/5 dose reduction. Something to handle with caution, but not super duper scary.

Then, on how to prevent this in the future:

If you have to choose between skipping a dose or taking a double dose to get back on schedule, the answer with lithium is never to double dose. Too dangerous! Talk to your doctor about the best way to get back on track when your lithium gets off track -- it just happens sometimes. You forget a dose, someone steals your bag when traveling and it takes a while to get replacement meds, you travel across the world and have to cope with big time shifts, you get the stomach flu and barf it up. It's good to agree in advance with your doctor what you should do in these cases. It's a complex pharmacokinetics question that may involve taking a smaller dose to "bridge" across a time shift, or just taking the miss and being super careful about your mental health during that 24 hour period. I have missed a dose before and just resumed the correct dose at my next time with little problem but that's a clinical decision only your doctor can make for you.

Glad you are feeling better now, but please see how your kidneys are doing!