Acute clozapine overdose: plasma concentration and outcome

Clozapine is a tricyclic dibenzodiazepine derivative that is classified as an "atypical neuroleptic" drug for treatment of psychotic diseases. A 19-year-old schizophrenic female, treated with 400 mg clozapine per day, was admitted to the emergency department after ingestion of 5000 mg (50 x 100 mg tablets) of clozapine. Clozapine plasma level 2.5 hours after ingestion was 3.8 microg/ml (normal range 0.2-0.7 microg/ml) and very high in gastric lavage. Contrary to reported cases with such high plasma concentrations the patient suffered only from somnolence with intermittent periods of agitation and a mild anticholinergic syndrome with sinus tachycardia and slight hypotension. After detoxication with gastric lavage and short-term administration of pyridostigmine she remained stable, and 24 hours after ingestion she was transferred to the psychiatric unit without further sequelae. To prevent late-onset complications she was carefully monitored for five days. The clozapine plasma level 24 hours after the first measurement was normal. This case and others reported in the literature confirm that signs and symptoms after clozapine intoxication are variable and that high plasma levels are not lethal in every case.

Suicide with moclobemide and perazine

A 51-year-old woman who was diagnosed as suffering from depression was found dead in her flat. The autopsy revealed no morphological changes sufficient to explain death. Toxicological analysis was performed and the drugs moclobemide (49.9 mg/l), perazine (1.27 mg/l) and some metabolites were identified in the blood. A combined drug intoxication resulting in synergistic effects to cardiovascular disorders was proposed as the cause of death.

Suicide with the veterinary drug acepromazine

A suicide case involving the veterinary drug acepromazine is described. After a single-step liquid alkaline extraction, acepromazine was identified in a chest-cavity blood sample using gas chromatography (GC) with nitrogen-phosphorus (NPD) and mass selective detectors. Acepromazine was then quantitated in the blood and other postmortem tissues by GC with NPD using chlorpromazine as the internal standard. Acepromazine concentrations in the chest-cavity blood, liver, brain, and bile were 0.6, 3.0, 0.4, and 6.5 micrograms/mL, respectively. The stomach contents contained a total of 2.5 mg acepromazine.

Fatal overdose of olanzepine

An ingestion of an unknown quantity of Zyprexa (olanzapine) tablets in a suicide is described. Biological fluid samples obtained at autopsy were analyzed for the presence of olanzapine by gas chromatography equipped with nitrogen-phosphorous detector and gas chromatography/mass spectroscopy. The blood concentration of olanzapine was 490 micrograms/dl and the concentration in gastric contents was 4100 micrograms/dl.

[Fatal poisoning with clozapine and perazine. A case report]

An intoxication following an apparent overdose of clozapine (Leponex) and perazine (Taxilan) is reported. There was a wide range of variation in postmortem blood and tissue concentrations of clozapine, desmethyclozapine and perazine. Clozapine/norclozapine blood and tissue ratios and perazine-pill-fragments in the gastric content could be used as a sign of suspected acute clozapine and perazine overdose.

Life-threatening dysrhythmias in severe thioridazine poisoning treated with physostigmine and transient atrial pacing

OBJECTIVES

To describe clinical, electrocardiographic, and blood chemistry findings in a case of high-dosage thioridazine self-poisoning, focusing on the cellular mechanisms of the cardiovascular toxicity.

DESIGN

Case report and literature review.

SETTING

Intensive care unit (ICU) of a district hospital in Germany.

PATIENT

A 68-yr-old male patient admitted to the ICU for treatment of a severe thioridazine intoxication.

INTERVENTIONS

Prevention of absorption (gastric lavage), mechanical ventilation, fluids, alkalinization, catecholamines, drugs (physostigmine, neostigmine), direct current cardioversion/defibrillation, and transient pacemaker (atrial stimulation).

MEASUREMENTS AND MAIN RESULTS

Central nervous, cardiovascular, and gastrointestinal systems indicated the adverse side effects of thioridazine intoxication over a period of 9 days. During high toxic thioridazine plasma concentrations (6061 to 6480 ng/mL), a life-threatening crisis occurred due to malignant ventricular arrhythmias followed by bradycardia (e.g., sinus node arrest). The electrocardiogram showed delays in all parts of the conduction system of the heart, including prolonged repolarization for several days, which disappeared completely when thioridazine plasma concentrations were within the therapeutic range.

CONCLUSIONS

An individual therapeutic approach is needed in cases of thioridazine overdose. The primary aim is to stabilize the cardiac rhythm and the circulation.

Haloperidol overdose during pregnancy

BACKGROUND

Suicide attempts during pregnancy are rare. Over-the-counter and psychotropic medications are most commonly used. Although intentional overdose of haloperidol has been reported in nonpregnant adults, it has not, to our knowledge, been reported previously during pregnancy. In this case of suicide attempt by haloperidol overdose, maternal and fetal responses were studied extensively.

CASE

Intentional ingestion of 300 mg haloperidol by a pregnant woman at 34 weeks' gestation caused maternal unresponsiveness, an extrapyramidal reaction, temporary fetal akinesia, and a nonreactive nonstress test. The mother recovered in 48 hours. The fetus did not reach a biophysical profile score of ten until 5 days after presentation.

CONCLUSION

Haloperidol overdose during pregnancy causes a maternal extrapyramidal reaction, temporary fetal akinesia, and prolonged fetal neuromuscular depression.

HPLC-DAD and HPLC-MS findings in fatality involving (Z)-cis-clopenthixol (zuclopenthixol)

A fatality that was due to massive ingestion of the thioxanthene neuroleptic (Z)-cis-clopenthixol (zuclopenthixol, Z-CPT) is described. The total toxicological screening and the quantitation of both the ingested drugs and its inactive isomer (E)-trans-clopenthixol (E-CPT, produced by in vivo isomerization) in postmortem fluids and viscerae were produced by high-performance liquid chromatography (HPLC)-diode array detection. Drug confirmation was carried out by HPLC-mass spectrometry with an ionspray interface. Although death occurred 40 h after the drug intake, postmortem blood concentrations were 391 and 275 mg/mL for Z-CPT and E-CPT, respectively (50 to 100 times the usual therapeutic values). The cause of death was suicide, and the manner was acute neuroleptic overdosage.

[Acute encephalomyopathy and persistent cerebellar syndrome after lithium salt and haloperidol poisoning]

A 44-year-old maniacodepressive woman developed acute encephalopathy due to the association of lithium carbonate and haloperidol. She was treated with lithium salts for many years and the serum level of lithium was within the therapeutic range. The encephalopathy was worsened by hyperthermia, dehydration, and reintroduction of haloperidol, 5 days after the first discontinuation of the neuroleptic. The clinical features were characterized by a persistent cerebellar syndrome, more than one year after the interruption of these medications.

Fatal overdose of clozapine

An ingestion of an unknown quantity of Leponex (clozapine) tablets in a suicide is described. Although clozapine is known for over 30 years now, relatively few cases of intoxications due to clozapine overdose have been reported. The authors report a new and quick method to analyze and determine the clozapine and N-desmethylclozapine concentration in body fluids. The analytes and an internal standard (zolpidem) were extracted from alkalinized samples into ethyl acetate before GC/NPD analysis. The proposed method resulted in a rapid procedure most useful in cases of deliberate poisoning with the neuroleptic drug Leponex.

Acute risperidone overdose

Risperidone (Risperdal) is a recently released novel antipsychotic medication. It is different from the conventional neuroleptics, such as haloperidol, as it has both serotinergic and dopaminergic activity. It has a more tolerable side-effect profile compared with other antipsychotic medications. We review the literature regarding the side effects of risperidone use, describe a case of overdose with risperidone, and discuss the clinical sequelae and management of such an overdose.

A complication of self-poisoning

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Abnormal ventricular repolarization mimicking myocardial infarction after heterocyclic antidepressant overdose

In 2 young adult women who experienced acute heterocyclic antidepressant intoxication, we found a quite unusual electrocardiographic pattern characterized by abnormal ST-tract elevation in the right precordial leads associated with a marked QRS widening (right bundle branch block and left anterior fascicular block type). Because serum electrolyte imbalance and acute myocardial ischemic events were excluded, the mechanism by which antidepressant overdose may produce such elevation of the ST tract remains unclear.

Upper airway compromise in acute chlorpromazine ingestion

A 16-year-old boy developed symptoms of acute upper airway compromise after chlorpromazine ingestion. The patient took six 100-mg Thorazine tablets "to help him sleep". Laryngeal-pharyngeal dystonia is a life-threatening form of dystonic reaction that is dose-dependent. In children, acute upper airway compromise should raise the suspicion of exposure to phenothiazines.

Pediatric clozapine intoxication

Clozapine is a tricyclic dibenzodiazepine derivative used as an antipsychotic in adults. Clozapine's safety in children has not been established. This report describes three unintentional clozapine ingestions in pediatric patients. These are the first reported cases of clozapine intoxication in children. All three patients demonstrated dramatic alterations in mental status and tone, and two demonstrated extrapyramidal effects. Serum clozapine levels obtained in two patients were within the average range of steady state plasma concentrations for adults. These cases show the dramatic presentations of pediatric ingestion of clozapine and the differences between adult and pediatric intoxications.

[Acute poisoning with thioridazine]

OBJECTIVE

As previous single case reports have indicated that acute poisoning with thioridazine can be potentially dangerous, an investigation was undertaken to find out whether the risk of severe poisoning in adults and children can be judged from the amount of the drug that has been taken.

PATIENTS AND METHODS

In a case-control study 202 medical notes of 202 patients were analysed (141 adults, aged 16-82 years; 61 children, aged 0.3-15 years) in which thioridazine was the only potentially harmful substance taken, the precise amount swallowed was known and the drug was the certain or probable cause of the signs. 30 children were excluded from the study, because their body weight was not known.

RESULTS

Mild thioridazine poisoning was characterized by somnolence, tremor, ataxia and dysarthria. The severity of the poisoning and the degree of disorder of consciousness correlated significantly with the amount of thioridazine taken. Severe intoxication with coma and ventricular arrhythmias was observed at a dose of 2 g and more. While the disorder of consciousness completely regressed in the first 24 hours, in a few of the patients the cardiac arrhythmias persisted for up to 28 hours after the drug intake. Charcoal administration seemed to influence the course favourably.

CONCLUSION

Prolonged, intensive care supervision and treatment are essential if more than 2 g thioridazine have been swallowed. In addition to standard treatment with gastric lavage charcoal should be given as early as possible to limit absorption.