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Goldfine CE, Troger A, Erickson TB, Chai PR. Beta-blocker and calcium-channel blocker toxicity: current evidence on evaluation and management. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:247-253. [PMID: 37976176 DOI: 10.1093/ehjacc/zuad138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
Beta-blocker and calcium-channel blocker overdoses are associated with severe morbidity and mortality; therefore, it is important to recognize and appropriately treat individuals with toxicity. The most common clinical findings in toxicity are bradycardia and hypotension. In addition to supportive care and cardiac monitoring, specific treatment includes administration of calcium salts, vasopressors, and high-dose insulin euglycaemia treatment. Other advanced treatments (e.g. ECMO) may be indicated depending on the severity of toxicity and specific agents involved.
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Affiliation(s)
- Charlotte E Goldfine
- Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham Boston, 75 Francis St, Boson, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
| | - Andrew Troger
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Timothy B Erickson
- Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham Boston, 75 Francis St, Boson, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
- Department of Global Health and Population, Harvard Humanitarian Institute, Harvard T.H. Chan School of Public Health, Cambridge, USA
| | - Peter R Chai
- Division of Medical Toxicology, Department of Emergency Medicine, Mass General Brigham Boston, 75 Francis St, Boson, MA 02115, USA
- Harvard Medical School, 25 Shattuck St, Boson, MA 02115, USA
- Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, USA
- The Koch Institute for Integrated Cancer Research, Massachusetts Institute of Technology, Cambridge, USA
- The Fenway Institute, Boston, USA
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Rafeq R, Salzman M. Use of Concentrated Insulin in the Management of Calcium Channel Blocker Overdose: A Case Report. J Pharm Pract 2023; 36:1519-1522. [PMID: 35862179 DOI: 10.1177/08971900221116189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Hyperinsulinemia-euglycemia therapy [HIE] is a first line therapy recommended in symptomatic calcium channel blocker overdose patients. HIE, particularly if administered in concentrations typically used for glycemic control, would result in a substantial amount of hypotonic fluid administration, which places patients at risk of volume overload. Therefore, it may be beneficial to utilize a concentrated insulin as a strategy to mitigate fluid overload risks. We report the case of a 73 years old, 69.9 kg female, who presented to the emergency department after an accidental ingestion of 70 mg amlodipine and was treated with HIE utilizing a uniquely concentrated insulin infusion. CASE PRESENTATION HIE at 10 units/kg/hr. was used for approximately 17 hours. Insulin was changed from a 1 unit/mL concentration to 16 unit/mL. Dextrose 10% infusion was initiated up to a max of 650 mL/hr. and norepinephrine infusion up to a max of 10 mcg/min. DISCUSSION Approximate fluid requirements from the 16 unit/mL concentration of insulin totaled 1 L as compared to a 1 unit/mL concentration which would have required 17 L, a total savings of 16 L. This savings potentially decreased the risk of cerebral or pulmonary edema associated with fluid overload. CONCLUSION Use of a concentrated insulin in the setting of a calcium channel blocker or beta blocker overdose provides a unique strategy to mitigate the effects associated with fluid overload.
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Affiliation(s)
- Rachel Rafeq
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA
| | - Matthew Salzman
- Department of Emergency Medicine, Cooper University Hospital, Camden, NJ, USA
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Stanton MT. Part
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: Interactive case: Toxicology and poison control. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila) 2022; 60:1205-1213. [DOI: 10.1080/15563650.2022.2131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Jon B. Cole
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Samantha C. Lee
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Nathan M. Kunzler
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
| | | | - Brian E. Driver
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Travis D. Olives
- Minnesota Poison Control System, Department of Pharmacy, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Cole JH, Hughey SB, Geiger PG, Rapp-Santos KJ, Booth GJ. Hemodynamic Effects of Cardiovascular Medications in a Normovolemic and Hemorrhaged Yorkshire-cross Swine Model. Comp Med 2021; 72:38-44. [PMID: 34876241 DOI: 10.30802/aalas-cm-21-000080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Yorkshire-cross swine model is a valuable translational model commonly used to study cardiovascular physiologyand response to insult. Although the effects of vasoactive medications have been well described in healthy swine, the effects of these medications during hemorrhagic shock are less studied. In this study, we sought to expand the utility of the swine model by characterizing the hemodynamic changes that occurred after the administration of commonly available vasoactive medications during euvolemic and hypovolemic states. To this end, we anesthetized and established femoral arterial,central venous, and pulmonary arterial access in 15 juvenile Yorkshire-cross pigs. The pigs then received a series of rapidlymetabolized but highly vasoactive medications in a standard dosing sequence. After completion of this sequence, each pigunderwent a 30-mL/kg hemorrhage over 10 min, and the standard dosing sequence was repeated. We then used standard statisticaltechniques to compare the effects of these vasoactive medications on a variety of hemodynamic parameters betweenthe euvolemic and hemorrhagic states. All subjects completed the study protocol. The responses in the hemorrhagic state wereoften attenuated or even opposite of those in the euvolemic state. For example, phenylephrine decreased the mean arterialblood pressure during the euvolemic state but increased it in the hemorrhagic state. These results clarify previously poorlydefined responses to commonly used vasoactive agents during the hemorrhagic state in swine. Our findings also demonstratethe need to consider the complex and dynamic physiologic state of hemorrhage when anticipating the effects of vasoactivedrugs and planning study protocols.
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Gawedzki P, Paloucek FP. Additional Considerations for Persistent Hyperinsulinemia. J Med Toxicol 2021; 17:233-234. [PMID: 33606186 DOI: 10.1007/s13181-021-00828-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/08/2021] [Accepted: 01/29/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Paula Gawedzki
- Department of Pharmacy, University of Chicago, Chicago, IL, 60612, USA. .,Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, Chicago, IL, 60612, USA.
| | - Frank P Paloucek
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, Chicago, IL, 60612, USA
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Corcoran JN, Jacoby KJ, Olives TD, Bangh SA, Cole JB. Persistent Hyperinsulinemia Following High-Dose Insulin Therapy: A Case Report. J Med Toxicol 2020; 16:465-469. [PMID: 32656624 DOI: 10.1007/s13181-020-00796-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Overdoses of beta-adrenergic antagonists and calcium channel antagonists represent an uncommonly encountered but highly morbid clinical presentation. Potential therapies include fluids, calcium salts, vasopressors, intravenous lipid emulsion, methylene blue, and high-dose insulin. Although high-dose insulin is commonly used, the kinetics of insulin under these conditions are unknown. CASE REPORT We present a case of a 51-year-old male who sustained a life-threatening overdose after ingesting approximately 40 tablets of a mixture of amlodipine 5 mg and metoprolol tartrate 25 mg. Due to severe bradycardia and hypotension, he was started on high-dose insulin (HDI) therapy; this was augmented with epinephrine. Despite the degree of his initial shock state, he ultimately recovered, and HDI was discontinued. Insulin was infused for a total of approximately 37 hours, most of which was dosed at 10 U/kg/hour; following discontinuation, serial serum insulin levels were drawn and remained at supraphysiologic levels for at least 24 hours and well above reference range for multiple days thereafter. CONCLUSION The kinetics of insulin following discontinuation of high-dose insulin therapy are largely unknown, but supraphysiologic insulin levels persist for some time following therapy; this may allow for simple discontinuation rather than titration of insulin at the end of therapy. Dextrose replacement is frequently needed; although the duration is often difficult to predict, prolonged infusions may not be necessary.
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Affiliation(s)
- Justin N Corcoran
- Minnesota Poison Control System, 701 Park Ave RL.240, Minneapolis, MN, 55415, USA.
| | | | - Travis D Olives
- Minnesota Poison Control System, 701 Park Ave RL.240, Minneapolis, MN, 55415, USA
| | - Stacey A Bangh
- Minnesota Poison Control System, 701 Park Ave RL.240, Minneapolis, MN, 55415, USA
| | - Jon B Cole
- Minnesota Poison Control System, 701 Park Ave RL.240, Minneapolis, MN, 55415, USA
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