Hypertensive bipolar: chronic lithium toxicity in patients taking ACE inhibitor

Area of Science:

• Neuroscience
• Nephrology
• Psychiatry

Background:

• Long-term treatment of bipolar I disorder with lithium and haloperidol is common.
• Concurrent use of ACE inhibitors for hypertension can affect renal function.
• Maintaining therapeutic lithium levels requires careful monitoring, especially with polypharmacy.

Observation:

• A patient on long-term lithium and haloperidol developed tremors and delirium despite regular monitoring.
• Hospital admission revealed significantly elevated serum lithium levels, indicating toxicity.
• Delirium persisted for two weeks after lithium discontinuation, followed by acute renal failure.

Findings:

• The patient experienced lithium toxicity, presenting with neurological and psychiatric symptoms.
• ACE inhibitor use may have contributed to impaired lithium excretion and subsequent toxicity.
• The case illustrates a complex interplay between medication, patient vulnerability, and adverse events.

Implications:

• Clinicians must be aware of potential drug interactions that increase lithium toxicity risk.
• Vigilant monitoring of lithium levels and renal function is crucial in patients with comorbidities or polypharmacy.
• Prompt recognition and management of lithium toxicity are essential to prevent severe complications like delirium and acute kidney injury.