Lithium, Sodium & Dehydration
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Q:  Lithium, Sodium & Dehydration

Dr Phelps,

I am from Chile and I was diagnosed 4 years ago. Since that I have been right but, 1month ago I relapsed. I went to my Doctor and he told me my lythium level was 50% lower than normal. I asked why and he said he don't know. I researched through the internet and founded that lithium competes with sodium in dehydration situations. I am a sportsman, I practice mountain biking, adventure races and I am a ski instructor too. All this activities produce heavy perspiration and in conclusion low levels of lithyum due to the competition with sodium.

If that's right maybe my doctor needs more info? I take valproic acid too and tiroid hormone. It would be so very helpful if you can give me a response, thanks a lot.

Hola Senor Q' -- 
I too was a ski instructor and a sportsman. I still whitewater kayak and ski, at areas and in the backcountry. So I understand the importance of these activities. I also understand how much fluid loss you can have, doing those kinds of things out there.  

You are right that lithium and sodium "compete", in a way.  The same body mechanisms for handling sodium appear to also handle lithium. As a result, when the body is trying to hang on to sodium, it will also hang on to lithium. But here is one more bit of physiology for you that may shift your understanding:  when the body is dehydrated, it hangs on to sodium.  This creates an "osmotic" force to draw fluid in from the gut and to hang on to any fluid the body has to spare. One of the results is a very concentrated urine, as that osmotic force pulls back all the extra water, leaving only a minimum to be lost (you have surely used this information on the mountain -- when you urinate and the snow is very yellow, you know you need more fluid, right?)

So, when the body is dehydrated, it hangs on to sodium, and thus, it will hang on to lithium as well. That's one of the ways some people end up with "lithium toxicity": their usual lithium dose is okay as long as they have enough water coming in. But if their water loss goes up, through sweating during heavy physical exertion, their lithium level can go up quite a bit. If it gets too high (e.g. 1.2 to 1.5 mEq/L or more) this can lead to vomiting, which leads to more fluid loss and inability to keep new fluids in, leading to even higher lithium levels; the person can get very, very sick at that point. 

According to online seemingly trustworthy site, "Approximately 95% of lithium is excreted in urine, 4% in sweat...".  So, if you tripled your sweat loss, you would still overwhelmingly be determining your lithium level with your kidneys, not your sweat. However, if you were very careful, as an athlete like you might well be, to replace all the fluid you lost, so that your kidneys did not perceive you as being dehydrated, then you would not collect back so much lithium and indeed, you could lower your blood level by losing it in sweat and not increasing kidney reabsorbtion. How much you could lower it is not clear; seems to me you'd have to really sweat a lot to lower it much, all the while very diligently replacing that lost fluid (as with a Camelbak-style water supply, which many competitors like you use routinely nowadays).  

So I would not be certain you have the complete explanation as to why your lithium level went down in your exercise and loss of lithium through perspiration.  This could also be due to different timing of when the test was taken, or numerous other minor variables, and generally I'd want to look at a repeat level before drawing any major conclusions such as considering changing your dosing if otherwise things were going well.  I hope that's the case. Ski on. 

Dr. Phelps

Published June, 2006


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