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Alhussein RM, Alamri NA, Alhashem HM, Alarifi MI, Alyahya B. Successful management of massive digoxin overdose using DIGIFab and therapeutic plasma exchange: a case report. J Med Case Rep 2024; 18:135. [PMID: 38439066 PMCID: PMC10913407 DOI: 10.1186/s13256-024-04386-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/15/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Despite the efficacy and safety of DIGIFab, it is relatively expensive and has limited availability. In addition, alternative interventions, such as therapeutic plasma exchange, may need to be considered in massive digoxin overdoses. Although few case reports describe its efficacy. CASE PRESENTATION We report a case of a 17-year-old white male patient brought by family members to our emergency department in Riyadh, Saudi Arabia. After intentionally ingesting 48 mg of digoxin tablets to commit suicide, the patient's initial digoxin serum level was 8.04 ng/mL. The patient was resuscitated in the emergency department. After admission to the intensive care unit, the patient underwent therapeutic plasma exchange, because of insufficient DIGIFab doses. Afterward, the serum digoxin levels drastically decreased, and his symptoms reverted. The patient was successfully managed and discharged 7 days after admission. CONCLUSION Despite insufficient evidence and a limited number of case reports describing the use of extracorporeal treatment in digoxin overdose, we noted the significant impact of therapeutic plasma exchange on our patient. However, therapeutic plasma exchange's use in routine treatment requires stronger evidence to confirm its benefits.
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Affiliation(s)
- Reema M Alhussein
- Department of Emergency Medicine, King Saud University, Medical City, Riyadh, Saudi Arabia.
| | - Nawaf A Alamri
- Department of Emergency Medicine, King Saud University, Medical City, Riyadh, Saudi Arabia
| | - Hussain M Alhashem
- Department of Emergency Medicine, King Saud University, Medical City, Riyadh, Saudi Arabia
| | - Mohammed I Alarifi
- Department of Critical Care Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Bader Alyahya
- Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Preston H, Cannon E, Watson S. Plasma exchange for the management of digoxin toxicity in an individual with an acute kidney injury: A case report. J R Coll Physicians Edinb 2024; 54:55-58. [PMID: 38499459 DOI: 10.1177/14782715241239372] [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: 03/20/2024] Open
Abstract
Digoxin toxicity can be life-threatening. Digoxin-specific antibody (DSA) fragments are used in severe digoxin toxicity, binding to serum-free digoxin and enabling increased renal excretion. In severe renal impairment, clearance of these complexes is prolonged, leading to rebound toxicity. Digoxin and DSA complexes are not dialysable. We present a case of a gentleman with severe digoxin toxicity and acute kidney injury (AKI). Despite receiving DSA doses, his digoxin levels rebounded and symptoms persisted. Based on published case reports, plasma exchange (PEX) after further dosing was arranged. PEX facilitated the removal of digoxin-DSA complexes, bypassing renal excretion. During PEX, clinical signs improved and were sustained. He did not require further dialysis or PEX, renal function recovered and he was discharged. This case highlights challenges in the management of severe digoxin toxicity in patients with a concurrent AKI. The use of PEX enabled digoxin-DSA complex removal and should be considered in these circumstances.
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Affiliation(s)
- Hannah Preston
- The Department of Renal Medicine, The Royal Infirmary of Edinburgh, Little France, Edinburgh, UK
| | - Emma Cannon
- The Department of Renal Medicine, The Royal Infirmary of Edinburgh, Little France, Edinburgh, UK
| | - Simon Watson
- NHS Lothian, The Department of Renal Medicine, The Royal Infirmary of Edinburgh, Little France, Edinburgh, UK
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Digoxin-specific Fab and therapeutic plasma exchange for digitalis intoxication and renal failure. Am J Emerg Med 2019; 37:798.e3-798.e5. [PMID: 30770242 DOI: 10.1016/j.ajem.2019.01.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/29/2018] [Accepted: 01/21/2019] [Indexed: 01/19/2023] Open
Abstract
Treatment of chronic digitalis intoxication includes suspension of drug intake, which may be sufficient in case of mild manifestations, and supportive measures. Severe bradycardia requires the administration of atropine or isoproterenol; placement of a temporary pacemaker may be required in case of absent response to pharmacological therapy. Severe and life-threatening manifestations should be treated with digoxin-specific fragment antigen binding antibodies (Fab). Therapeutic plasma exchange has been suggested, in addition to Fab therapy, to maximize the clearance of Fab-digoxin complexes in patients with renal failure. To date, few case reports have described the use of such a therapeutic approach; currently, extracorporeal methods are not recommended as part of the treatment of digitalis intoxication, and stronger evidence is required to establish their benefit.
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Mowry JB, Burdmann EA, Anseeuw K, Ayoub P, Ghannoum M, Hoffman RS, Lavergne V, Nolin TD, Gosselin S. Extracorporeal treatment for digoxin poisoning: systematic review and recommendations from the EXTRIP Workgroup. Clin Toxicol (Phila) 2016; 54:103-14. [DOI: 10.3109/15563650.2015.1118488] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- James B. Mowry
- Indiana Poison Center, Indiana University Health, Indianapolis, IN, USA
| | - Emmanuel A. Burdmann
- Division of Nephrology, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA, Campus Stuivenberg, Antwerpen, Belgium
| | - Paul Ayoub
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, Canada
| | - Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Verdun, Canada
| | - Robert S. Hoffman
- Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology, New York University School of Medicine, New York, NY, USA
| | - Valery Lavergne
- Department of Medical Biology, Sacré-Coeur Hospital, University of Montreal, Montreal, Canada
| | - Thomas D. Nolin
- Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Sophie Gosselin
- Department of Medicine and Emergency Medicine, McGill University Health Centre, McGill University, Montreal, Canada
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Rajpal S, Beedupalli J, Reddy P. Recrudescent digoxin toxicity treated with plasma exchange: a case report and review of literature. Cardiovasc Toxicol 2013; 12:363-8. [PMID: 22618329 DOI: 10.1007/s12012-012-9171-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A 53-year-old woman presented with digitalis toxicity caused by acute overdose that manifested as atrial tachycardia with block, sinus pauses, and competing AV junctional rhythm with atrial fibrillation. Patient admitted to overdosing with digoxin 15-20 h before presentation with intent to commit suicide. Serum digoxin level was 35.6 ng/ml and renal function was normal. Patient was treated with 1,040 mg of digoxin-specific antibody Fab fragment with prompt resolution of arrhythmias and restoration of sinus rhythm. Four hours after digoxin antibody administration, serum digoxin level declined to 0.2 ng/ml. Eighteen hours after treatment with Fab fragment, patient developed premature ventricular complexes, atrial tachycardia with and without atrioventricular block, and non-sustained ventricular tachycardia followed by ventricular fibrillation from which she was successfully resuscitated. Electrocardiogram showed no evidence of acute myocardial infarction, and emergent coronary angiogram did not reveal significant coronary artery disease. Repeat digoxin level was 20.4 ng/ml. A diagnosis of recrudescent digoxin toxicity was made and the patient was treated with one session of plasma exchange with resolution of arrhythmias. Immediately after plasma exchange, digoxin level decreased to 10.4 ng/ml, and after 10 h, the level further decreased to 6.6 ng/ml. The following day, digoxin level had decreased to 2.9 ng/ml. Our experience with this case would suggest that plasma exchange should be considered as a treatment modality for recrudescent digoxin toxicity.
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Affiliation(s)
- Saurabh Rajpal
- Department of Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71105, USA.
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Abstract
Digitalis toxicity produces a toxidrome characterized by gastrointestinal, neurologic, electrolyte, and nonspecific cardiac manifestations. Chronic toxicity remains much more difficult to recognize compared with an acute presentation because of the nonspecific manifestations; therefore, serum glycoside levels are essential for diagnosis in this population. The mainstay of management continues to be rapid toxidrome identification followed by digoxin-specific antibody fragment therapy with supportive care. Several controversies still remain, including therapy for patients dependent on hemodialysis, appropriateness of calcium therapy for hyperkalemia, ideal agents for arrhythmia therapy, and the potential utility of plasmapheresis for removal of bound digoxin-antibody fragment complexes.
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Schutt RC, Ronco C, Rosner MH. The role of therapeutic plasma exchange in poisonings and intoxications. Semin Dial 2012; 25:201-6. [PMID: 22353434 DOI: 10.1111/j.1525-139x.2011.01033.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Poisonings, intoxications, and drug overdoses are common occurrences and rapid lowering of the toxin level is a cornerstone of all effective therapies. Therapeutic plasma exchange (TPE) has several unique characteristics that allow it to be a potentially effective therapy in rapidly achieving this goal. Specifically, TPE allows for the removal of large molecular weight, protein-bound molecules that have a small volume of distribution. Due to the nature of poisonings, intoxications, and drug overdoses, no randomized controlled trials studying the efficacy of TPE in these situations exist. Thus, careful interpretation and analysis of case reports and series are required to assess the potential efficacy of this therapy. Recent data suggest that TPE may also be effective in the therapy of patients receiving biologic treatments who develop life-threatening complications due to therapy.
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Affiliation(s)
- Robert Clark Schutt
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia 22908-0466, USA
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Ibrahim RB, Balogun RA. Medications in patients treated with therapeutic plasma exchange: prescription dosage, timing, and drug overdose. Semin Dial 2012; 25:176-89. [PMID: 22321259 DOI: 10.1111/j.1525-139x.2011.01030.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Therapeutic plasma exchange (TPE) is an extracorporeal process commonly used in clinical medicine for the treatment of a variety of neurological, renal, hematological, dermatological, and other diseases. Inherent to the procedure, patients' plasma removal may lead to the extraction of drugs they are concurrently receiving. This review discusses the published literature assessing TPE's influence on different drug classes' disposition and, when applicable, sets forth management recommendations in cases where the drugs are used at the usual doses and in cases of drug overdose.
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Affiliation(s)
- Rami B Ibrahim
- Department of Pharmacology and Toxicology, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA
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Kozikowski TA, Magdesian KG, Puschner B. Oleander intoxication in New World camelids: 12 cases (1995-2006). J Am Vet Med Assoc 2009; 235:305-10. [PMID: 19650704 DOI: 10.2460/javma.235.3.305] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize the clinical and clinicopathologic effects and evaluate outcome associated with oleander toxicosis in New World camelids. DESIGN Retrospective case series. ANIMALS 11 llamas and 1 alpaca. PROCEDURES Medical records from a veterinary medical teaching hospital from January 1, 1995, to December 31, 2006, were reviewed. Records of all New World camelids that had detectable amounts of oleandrin in samples of serum, urine, or gastrointestinal fluid were included in the study. Descriptive statistics were used to evaluate the history, physical examination findings, clinicopathologic data, and outcome of affected camelids. RESULTS 11 llamas and 1 alpaca met the inclusion criteria of the study. Either oleander plants were present where the camelids resided (n = 7) or oleander plant material was identified in the hay fed to the camelids (5). One llama was dead on arrival at the hospital, and another was euthanized upon admission because of financial concerns. Of the 10 treated camelids, 9 had evidence of acute renal failure, 7 had gastrointestinal signs, and 4 had cardiac dysrhythmias on initial evaluation. The overall mortality rate was 25%, but the mortality rate for the 10 camelids that were medically treated was 10%. CONCLUSIONS AND CLINICAL RELEVANCE In New World camelids, oleander intoxication was associated with a triad of clinical effects (ie, renal, gastrointestinal, and cardiovascular dysfunction). Oleander intoxication often represented a herd problem but carried a fair to good prognosis if treated promptly. Oleander toxicosis should be considered a differential diagnosis in sick camelids.
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Affiliation(s)
- Tania A Kozikowski
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, CA 95616, USA
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Unal S, Bayrakci B, Yasar U, Karagoz T. Successful treatment of propafenone, digoxin and warfarin overdosage with plasma exchange therapy and rifampicin. Clin Drug Investig 2007; 27:505-8. [PMID: 17563131 DOI: 10.2165/00044011-200727070-00008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We report here the successful treatment of a 16-year-old female who ingested 20 tablets of digoxin each containing 0.25 mg (total dose ingested equivalent to 0.1 mg/kg), 32 tablets of warfarin each containing 5mg (equivalent to 3.2 mg/kg), and approximately 15 tablets of propafenone each containing 300 mg (equivalent to 90 mg/kg). The patient developed hypotension and sinus bradycardia necessitating external cardiac pacing 17 hours after drug ingestion. In addition to gastric lavage, activated charcoal, blood alkalinisation, administration of vitamin K and temporary cardiac pacing, the authors performed plasma exchange for drug removal and administered rifampicin in order to increase the metabolism of digoxin, propafenone and warfarin. The patient was discharged without any sequelae. Plasma exchange may be lifesaving in drug ingestions where there is a low volume of distribution and high plasma protein binding. Rifampicin, an inducer of cytochrome p450, may be used in intoxications for elimination of drugs with inactive metabolites.
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Affiliation(s)
- Sule Unal
- Department of Pediatrics, Division of Pediatric Hematology, Hacettepe University, Faculty of Medicine, Ankara, Turkey.
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Camphausen C, Haas NA, Mattke AC. Successful treatment of oleander intoxication (cardiac glycosides) with digoxin-specific Fab antibody fragments in a 7-year-old child. ACTA ACUST UNITED AC 2005; 94:817-23. [PMID: 16382383 DOI: 10.1007/s00392-005-0293-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2005] [Accepted: 06/30/2005] [Indexed: 11/27/2022]
Abstract
UNLABELLED A 7-year-old girl presented six hours after ingestion of a yellow oleander seed (Thevetia peruviana) with severe emesis, change in colour vision and complete heart block. Initial treatment with phenytoin and isoprenalin infusion led to intermittent supraventricular and ventricular tachycardia. The patient was then treated with two intravenous doses of 190 mg of digoxin-specific Fab antibody fragments (Digibind). Subsequently the patient's rhythm reverted to sinus rhythm and the symptoms resolved within 2 hours. CONCLUSION administration of digoxin-specific Fab antibody fragments in an otherwise healthy child after oleander intoxication is safe and without adverse reactions.
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Affiliation(s)
- C Camphausen
- The Prince Charles Hospital, Rode Road, Chermside 4065, Australien.
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Menduiña MJ, Candel JM, Alaminos P, Gómez FJ, Vílcheza J. Taquicardia ventricular bidireccional por intoxicación digitálica. Rev Esp Cardiol (Engl Ed) 2005. [DOI: 10.1157/13078139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
This review provides current information on the use of antigen-binding fragments (Fab) from cleaved antibodies to treat poisoning with digoxin and other potent, low formula mass poisons, such as colchicine and tricyclic antidepressants. Anti-digoxin Fab fragments have been used successfully for many years in the management of severe poisoning with digoxin, digitoxin, and a range of other structurally related compounds, including cardiotoxins from Nerium and Thevetia sp. (oleander) and Bufo sp. (toads). However, their main use remains treating digoxin poisoning. Equimolar doses of anti-digoxin Fab fragments completely bind digoxin in vivo. The approximate dose of Fab fragments (mg) is 80 times the digoxin body burden (mg). If neither the dose ingested nor the plasma digoxin/digitoxin concentration is known, in an adult 380 mg of anti-digoxin Fab fragments should be given. The dose for elderly patients or those with renal impairment should be similar to that for those with normal renal function. Fab fragments have a plasma half-life of 12-20 hours, but this can be prolonged in patients with renal impairment. Analysis of serum ultrafiltrate using an immunoassay shown not to have matrix bias remains the most accurate approach to measuring free digoxin in the presence of anti-digoxin Fab fragments. The antibody fragments are given intravenously over 15-30 minutes after dilution to at least 250 mL with plasma protein solution, 0.9% (w/v) sodium chloride, or deionised water, except in infants where the volume infused can be reduced. Factors limiting the efficacy of Fab fragments are the dose, the duration of the infusion and any delay in administration. Guidelines for Fab fragment administration in children include (i) dilution to a final Fab concentration of 10 g/L in either 5% (w/v) dextrose or 0.9% (w/v) sodium chloride; (ii) infusion through a 0.22 microm filter; (iii) administration of the total dose over a minimum of 30 minutes; and (iv) avoiding coadministration of other drugs and/or electrolyte solutions. Fab fragments are generally well tolerated. Adverse effects attributable to Fab treatment include hypokalaemia and exacerbation of congestive cardiac failure; renal function could be impaired in some patients. Fab fragment preparations for treating acute colchicine and tricyclic antidepressant poisoning have been developed, but are not available commercially. Colchicine poisoning is rare in Western countries, and pharmacological management together with supportive care is usually effective even in severe tricyclic antidepressant overdosage. Attempts have been made to produce anti-paraquat antibodies capable of enhancing paraquat elimination from the lung, but thus far all such attempts have proved unsuccessful.
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Affiliation(s)
- Robert J Flanagan
- Medical Toxicology Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Tiftik N, Kiykim A, Altintas E, Sezer K, Doruk N, Sezgin O, Seyrek E, Buyukafsar K, Oral U. Therapeutic plasma exchange for multidrug intoxication: A case report. J Clin Apher 2003; 18:132-3. [PMID: 14569605 DOI: 10.1002/jca.10057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Naci Tiftik
- Department of Internal Medicine, Mersin University Medical School, Mersin, Turkey.
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