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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 JB, Arens AM, Laes JR, Klein LR, Bangh SA, Olives TD. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med 2018; 36:1817-1824. [DOI: 10.1016/j.ajem.2018.02.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/31/2018] [Accepted: 02/04/2018] [Indexed: 02/06/2023] Open
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Lheureux PER, Zahir S, Gris M, Derrey AS, Penaloza A. Bench-to-bedside review: hyperinsulinaemia/euglycaemia therapy in the management of overdose of calcium-channel blockers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:212. [PMID: 16732893 PMCID: PMC1550937 DOI: 10.1186/cc4938] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Hyperinsulinaemia/euglycaemia therapy (HIET) consists of the infusion of high-dose regular insulin (usually 0.5 to 1 IU/kg per hour) combined with glucose to maintain euglycaemia. HIET has been proposed as an adjunctive approach in the management of overdose of calcium-channel blockers (CCBs). Indeed, experimental data and clinical experience, although limited, suggest that it could be superior to conventional pharmacological treatments including calcium salts, adrenaline (epinephrine) or glucagon. This paper reviews the patho-physiological principles underlying HIET. Insulin administration seems to allow the switch of the cell metabolism from fatty acids to carbohydrates that is required in stress conditions, especially in the myocardium and vascular smooth muscle, resulting in an improvement in cardiac contractility and restored peripheral resistances. Studies in experimental verapamil poisoning in dogs have shown that HIET significantly improves metabolism, haemodynamics and survival in comparison with conventional therapies. Clinical experience currently consists only of a few isolated cases or short series in which the administration of HIET substantially improved cardiovascular conditions in life-threatening CCB poisonings, allowing the progressive discontinuation of vasoactive agents. While we await further well-designed clinical trials, some rational recommendations are made about the use of HIET in severe CBB overdose. Although the mechanism of action is less well understood in this condition, some experimental data suggesting a potential benefit of HIET in β-adrenergic blocker toxicity are discussed; clinical data are currently lacking.
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Affiliation(s)
- Philippe E R Lheureux
- Acute Poisoning Unit, Department of Emergency Medicine, Erasme University Hospital, 808 route de Lennik, B 1070 Brussels, Belgium.
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Mégarbane B, Karyo S, Baud FJ. The role of insulin and glucose (hyperinsulinaemia/euglycaemia) therapy in acute calcium channel antagonist and beta-blocker poisoning. ACTA ACUST UNITED AC 2005; 23:215-22. [PMID: 15898827 DOI: 10.2165/00139709-200423040-00002] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The inotropic effect of insulin has been long established. High-dose (0.5-1 IU/kg/hour) insulin, in combination with a glucose infusion to maintain euglycaemia (hyperinsulinaemia/euglycaemia therapy), has been proposed as a treatment for calcium channel antagonist (CCA) and beta-adrenoceptor antagonist (beta-blocker) poisonings. However, the basis for its beneficial effect is poorly understood.CCAs inhibit insulin secretion, resulting in hyperglycaemia and alteration of myocardial fatty acid oxidation. Similarly, blockade of beta(2)-adrenoceptors in beta-blocker poisoning results in impaired lipolysis, glycogenolysis and insulin release. Insulin administration switches cell metabolism from fatty acids to carbohydrates and restores calcium fluxes, resulting in improvement in cardiac contractility. Experimental studies in verapamil poisoning have shown that high-dose insulin significantly improved survival compared with calcium salts, epinephrine or glucagon. In several life-threatening poisonings in humans, the administration of high-dose insulin produced cardiovascular stabilisation, decreased the catecholamine vasopressor infusion rate and improved the survival rate. In a canine model of propranolol intoxication, high-dose insulin provided a sustained increase in systemic blood pressure, cardiac performance and survival rate compared with glucagon or epinephrine. In contrast, insulin had no effect on heart rate and electrical conduction in the myocardium. In another study, high-dose insulin reversed the negative inotropic effect of propranolol to 80% of control function and normalised heart rate. High-dose insulin produced a significant decrease in the left ventricular end-diastolic pressure and a significant increase in the stroke volume and cardiac output. The vasodilator effect was explained by an enhanced cardiac output leading to withdrawal of compensatory vasoconstriction. No clinical studies have yet been performed. Although not effective in all cases, we recommend hyperinsulinaemia/euglycaemia therapy in patients with severe CCA poisoning who present with hypotension and respond poorly to fluid, calcium salts, glucagon and catecholamine infusion. However, careful monitoring of blood glucose and serum potassium concentrations is required to avoid serious adverse effects. More clinical data are needed before this therapy can be recommended in beta-blocker poisoning. There is a need for large prospective clinical trials to confirm safety and efficacy of hyperinsulinaemia/euglycaemia therapy in both CCA and beta-blocker poisoning.
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Affiliation(s)
- Bruno Mégarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière - Université Paris 7, Paris, France.
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Grossini E, Battaglia A, Bona G, Mary DASG, Molinari C, Vacca G. The effects of insulin on mesenteric blood flow in anaesthetized pigs. Exp Physiol 2004; 89:363-71. [PMID: 15123556 DOI: 10.1113/expphysiol.2004.027334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Infusion of insulin in anaesthetized pigs has been shown to cause an increase in renal blood flow and a decrease in coronary blood flow, which were the net result of a vasoconstriction involving sympathetic alpha-adrenoceptor-mediated mechanisms and of a local vasodilatation involving the endothelial release of nitric oxide. In the present study, the effect of insulin on superior mesenteric blood flow was examined in pentobarbitone-anaesthetized pigs at constant heart rate, aortic blood pressure, left ventricular contractility and blood levels of glucose and potassium. In 10 pigs, infusion of 0.004 IU kg(-1) min(-1) of insulin increased mesenteric flow. In five of these pigs, intravenous phentolamine enhanced the increase in mesenteric flow elicited by insulin, a response which was abolished by the subsequent injection of N(omega)-nitro-L-arginine methyl ester (L-NAME) into the mesenteric artery. In the remaining five pigs, infusion of insulin after intramesenteric injection of L-NAME caused a decrease in mesenteric flow. This response was abolished by the subsequent intravenous administration of phentolamine. The present study showed that infusion of insulin in anaesthetized pigs primarily caused a mesenteric vasodilatation, which was the net result of two opposite effects, namely a predominant vasodilatation mediated by the endothelial release of nitric oxide and a sympathetic vasoconstrictor mechanism mediated by alpha-adrenoceptors.
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Affiliation(s)
- E Grossini
- Dipartimento di Scienze Mediche, Facoltà di Medicina e Chirurgia, Università del Piemonte Orientale 'A. Avogadro', Novara, Italy.
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Yuan TH, Kerns WP, Tomaszewski CA, Ford MD, Kline JA. Insulin-glucose as adjunctive therapy for severe calcium channel antagonist poisoning. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 37:463-74. [PMID: 10465243 DOI: 10.1081/clt-100102437] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CASE REPORT This case series documents the clinical courses of 4 patients after verapamil overdose and 1 patient after amlodipine-atenolol overdose. All subjects had hypodynamic circulatory shock (hypotension, bradycardia, and acidosis) that was not adequately responsive to conventional treatment. After initiation of insulin-dextrose infusion, the hemodynamic status of all 5 patients stabilized and all patients survived. Plasma drug concentrations are reported for all cases and verapamil levels were extremely high in 2 patients (3710 ng/mL and 3980 ng/mL). However, because patients were not treated according to a standard protocol, each patient received variable other supportive measures and inotropic agents, and the infusion rates of insulin were variable among patients. This report provides preliminary evidence toward a larger trial of insulin-dextrose to treat hypodynamic shock from calcium channel blocker overdose.
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Affiliation(s)
- T H Yuan
- Carolinas Medical Center, Charlotte, North Carolina 28232, USA
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Reikerås O, Nordstrand K. Effects of glucose-insulin-potassium infusion on glycogen levels in cardiac and skeletal muscles in rats. Clin Nutr 1989; 8:213-5. [PMID: 16837292 DOI: 10.1016/0261-5614(89)90077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/1988] [Indexed: 11/27/2022]
Abstract
The effects of loading with glucose-insulin-potassium on the glycogen contents of the heart and peripheral musculature were studied in rats. One group of animals was given intravenous infusion of high concentrations of glucose containing insulin and potassium for 3 days. A control group received the same volume of saline. The hearts and rectus femoris muscles were then analysed for levels of glycogen. It was found that loading with glucose-insulin-potassium induced a decrease in cardiac stores of glycogen while there were no changes in glycogen stores of peripheral musculature as compared to the control animals.
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Affiliation(s)
- O Reikerås
- Institute of Clinical Medicine and Institute of Medical Biology, University of Tromsø, Tromsø, Norway
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