1
|
Gutierrez GC, Dayton C, Attridge RL, Smedley L, Saikumar H, Everett C, Rodriguez A, Varney S. Angiotensin II Use in Treatment of Refractory Shock Due to Benazepril and Amlodipine Toxic Ingestion. J Pharm Pract 2024; 37:513-516. [PMID: 36314764 DOI: 10.1177/08971900221137389] [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: 02/16/2024]
Abstract
Introduction: Calcium channel blockers (CCB) are a leading cause of ingestion-associated fatality. Angiotensin-converting enzyme inhibitor (ACEi) overdose as part of co-ingestion is common and associated with refractory shock. Treatment options to manage this profound vasoplegia are limited. We describe the first case of use of newly formulated Angiotensin II for treatment of severe ACEi and CCB poisoning. Case Report: A 57-year-old man presented after suicide attempt by ingesting 20 tablets each of amlodipine 10 mg and benazepril 20 mg. His hypotension was initially managed with 35 mL/kg of crystalloid, norepinephrine, and hyperinsulinemic euglycemic therapy (HIET). His hemodynamics further deteriorated, and he developed lactic acidosis, electrolyte derangements, and renal dysfunction. Further complications of his ingestion included cardiac arrest, subsequent requirement for emergency cricothyrotomy, and renal replacement therapy. Maximal hemodynamic support with HIET therapy insulin drip 4.4 units/kg/hour, norepinephrine 2 mcg/kg/min, epinephrine 1 mcg/kg/min, vasopressin .06 units/hour, and intravenous lipid emulsion was unsuccessful. Ang II was started and titrated to maximal doses with dramatic improvement in hemodynamics. Within hours of starting Ang II, epinephrine was stopped and norepinephrine decreased by 50%. He was downgraded from the intensive care unit without any ongoing end-organ dysfunction. Discussion: Isolated CCB overdoses have high complication rates and well-established treatments. Therefore, management of CCB and ACEi co-ingestion is typically driven by CCB poisoning algorithm. There are multiple reports of CCB and ACEi co-ingestions causing treatment-refractory shock. Therapeutic options are limited by toxicities and availability of salvage therapies. Ang II is a safe and highly effective option to manage these patients.
Collapse
Affiliation(s)
- G Christina Gutierrez
- University Health, Pharmacotherapy and Pharmacy Services, San Antonio, TX, USA
- UT Health San Antonio, Pharmacotherapy Education and Research Center, San Antonio, TX, USA
| | - Christopher Dayton
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
- South Texas Poison Center, San Antonio, TX, USA
| | - Rebecca L Attridge
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
- University of the Incarnate Word Feik School of Pharmacy, San Antonio, TX, USA
| | - Lucas Smedley
- University Health, Pharmacotherapy and Pharmacy Services, San Antonio, TX, USA
- UT Health San Antonio, Pharmacotherapy Education and Research Center, San Antonio, TX, USA
| | - Haritha Saikumar
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
| | - Christopher Everett
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
| | - Abraham Rodriguez
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, San Antonio, TX, USA
| | - Shawn Varney
- South Texas Poison Center, San Antonio, TX, USA
- UT Health San Antonio, Joe R. and Terry Lozano Long School of Medicine, Department of Emergency Medicine, San Antonio, TX, USA
| |
Collapse
|
2
|
Huang J, Buckley NA, Isoardi KZ, Chiew AL, Isbister GK, Cairns R, Brown JA, Chan BS. Angiotensin axis antagonists increase the incidence of haemodynamic instability in dihydropyridine calcium channel blocker poisoning. Clin Toxicol (Phila) 2020; 59:464-471. [PMID: 33021397 DOI: 10.1080/15563650.2020.1826504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CONTEXT Amlodipine, a dihydropyridine calcium channel blocker (CCB), is the leading cause of cardiovascular drug-related overdose deaths in the USA. In contrast, angiotensin-II receptor blockers (ARBs) and angiotensin converting enzyme inhibitors (ACEIs) cause minimal toxicity in overdose. ACEIs/ARBs are often combined with dihydropyridines in hypertension treatment. Co-ingested ARBs/ACEIs may significantly contribute to the toxicity of dihydropyridine, but this has not been investigated. OBJECTIVE To investigate the clinical outcomes from dihydropyridine overdoses with ARBs/ACEIs versus dihydropyridine overdoses alone. METHODS This was a retrospective study of patients reported to the New South Wales Poisons Information Centre (NSW PIC) and 3 toxicology units (Jan 2016 to Jun 2019) in Australia. Patients >14 years who took an overdose of dihydropyridines (amlodipine, felodipine, lercanidipine, nifedipine) were included. Concurrent overdoses with non-dihydropyridine CCBs, alpha-blockers and beta-blockers were excluded. Patient demographics, drugs exposure details, serial vital signs, treatments and outcome were collected. RESULTS There were 100 patients. 68 took mixed overdoses of dihydropyridines with ARBs/ACEIs and 32 took single overdoses of dihydropyridines without ARBs/ACEIs. The mixed group had lower median nadir mean arterial pressures (62 vs 75 mmHg, p < 0.001), more frequently had hypotension (OR 4.5, 95%CI: 1.7-11.9) or bradycardia (OR 8.8, 95%CI: 1.1-70). Multivariable analysis indicated the mixed overdoses had an 11.5 mmHg (95%CI: 4.9-18.1) lower minimum systolic blood pressure (SBP) compared with the single group; other factors associated with a lower minimum SBP were higher doses [2.3 mmHg (95%CI: 1.1-3.5) lower per 10 defined daily doses] and younger age [2.2 mmHg (95%CI: 0.3-4.2) higher per decade]. A larger proportion of the mixed ingestion group received intravenous fluids (OR 5.7, 95%CI: 1.8-18.6) and antidotes and/or vasopressors (OR 2.9, 95%CI: 1.004-8.6). CONCLUSION Combined overdoses of dihydropyridines with ARBs/ACEIs caused more significant hypotension and required more haemodynamic support than overdoses of dihydropyridines alone.
Collapse
Affiliation(s)
- Jessica Huang
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Nicholas A Buckley
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia
| | - Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Angela L Chiew
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Clinical Toxicology Unit, Prince of Wales Hospital, Randwick, Australia
| | - Geoffrey K Isbister
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Hospital, Waratah, Australia
| | - Rose Cairns
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia
| | - Jared A Brown
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia
| | - Betty S Chan
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Clinical Toxicology Unit, Prince of Wales Hospital, Randwick, Australia
| |
Collapse
|
3
|
Chan BS, Becker T, Chiew AL, Abdalla AM, Robertson TA, Liu X, Roberts MS, Buckley NA. Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome. J Med Toxicol 2018; 14:100-103. [PMID: 29134498 PMCID: PMC6013734 DOI: 10.1007/s13181-017-0637-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Management of severe vasoplegic shock in overdose can be very challenging. We describe a case of severe refractory vasodilatory shock in poisoning where methylene blue (MB) was used with success. However, the patient subsequently developed severe Serotonin Syndrome (SS) as a result of an interaction between serotonergic drugs and MB. CASE REPORT A 15-year-old male developed severe vasoplegic shock 1.5 hours after overdosing on several different medications including quetiapine slow release, quetiapine immediate release, desvenlafaxine slow release, venlafaxine, amlodipine, ramipril, fluoxetine, promethazine and lithium. His vasoplegic shock was resistant to high doses of noradrenaline and vasopressin. MB was administered 6.5 hours post ingestion and within 1 hour there was an improvement in his hemodynamic status and reduction of catecholamine requirements. Twelve hours post ingestion, he developed severe Serotonin Syndrome that lasted 5 days as a result of interaction between MB, a reversible monoamine oxidase inhibitor (MAO-I), and the antidepressants taken in overdose. MB had a calculated half-life of 38 hours. CONCLUSION MB is a useful additional strategy for severe drug induced vasodilatory shock and may be potentially life-saving. Clinicians should be aware that it can interact with other drugs and cause life-threatening Serotonin Syndrome. Lower doses or shorter durations may be wise in patients at risk of this interaction.
Collapse
Affiliation(s)
- Betty S Chan
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.
| | - Therese Becker
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Angela L Chiew
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Ahmed M Abdalla
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Tom A Robertson
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Xin Liu
- Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
- Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Nicholas A Buckley
- Department of Clinical Pharmacology, University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
4
|
Abstract
OBJECTIVE Overdoses with cardio-depressive medications can result in toxin-induced cardiogenic shock (TICS), a life-threatening condition characterized by severe hypotension and ineffective tissue perfusion. Vasopressors are often employed in the treatment of shock to increase heart rate and blood pressure. We sought to conduct a systematic review of the literature to evaluate the effectiveness of vasopressors in improving hemodynamic function and survival in the treatment of TICS. DATA SOURCES We searched PubMed, EMBASE, TOXLINE, and International Pharmaceutical Abstracts. STUDY SELECTION We included studies evaluating the use of vasopressors in humans or animals with TICS. We limited human study types to randomized controlled trials, clinical trials, observational studies, and case reports. DATA EXTRACTION Our search yielded 913 citations and 144 of these met our inclusion criteria. 130 were human case reports and 14 were animal studies. DATA SYNTHESIS Human case report data showed vasopressors were ineffective more often than they were partially or fully effective. In the majority of animal studies, vasopressor treatment failed to improve hemodynamic parameters and resulted in decreased survival. CONCLUSIONS Human case reports and controlled animal experiments lead to different conclusions about vasopressors in TICS. Most animal studies indicate that vasopressors impair hemodynamic function and increase mortality. In contrast, human case reports suggest that vasopressors are often ineffective but not necessarily harmful.
Collapse
Affiliation(s)
- Cassandra A Skoog
- a College of Pharmacy, University of Minnesota , Minneapolis , MN , USA
| | | |
Collapse
|
5
|
Gérard L, Galloy AC, Capron A, Hantson P. Mixed amlodipine/valsartan overdose treated by the molecular adsorbent recirculating system (MARS™). Clin Toxicol (Phila) 2015; 53:573-7. [DOI: 10.3109/15563650.2015.1050594] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
6
|
St-Onge M, Dubé PA, Gosselin S, Guimont C, Godwin J, Archambault PM, Chauny JM, Frenette AJ, Darveau M, Le Sage N, Poitras J, Provencher J, Juurlink DN, Blais R. Treatment for calcium channel blocker poisoning: a systematic review. Clin Toxicol (Phila) 2014; 52:926-44. [PMID: 25283255 PMCID: PMC4245158 DOI: 10.3109/15563650.2014.965827] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 09/10/2014] [Indexed: 11/25/2022]
Abstract
CONTEXT Calcium channel blocker poisoning is a common and sometimes life-threatening ingestion. OBJECTIVE To evaluate the reported effects of treatments for calcium channel blocker poisoning. The primary outcomes of interest were mortality and hemodynamic parameters. The secondary outcomes included length of stay in hospital, length of stay in intensive care unit, duration of vasopressor use, functional outcomes, and serum calcium channel blocker concentrations. METHODS Medline/Ovid, PubMed, EMBASE, Cochrane Library, TOXLINE, International pharmaceutical abstracts, Google Scholar, and the gray literature up to December 31, 2013 were searched without time restriction to identify all types of studies that examined effects of various treatments for calcium channel blocker poisoning for the outcomes of interest. The search strategy included the following Keywords: [calcium channel blockers OR calcium channel antagonist OR calcium channel blocking agent OR (amlodipine or bencyclane or bepridil or cinnarizine or felodipine or fendiline or flunarizine or gallopamil or isradipine or lidoflazine or mibefradil or nicardipine or nifedipine or nimodipine or nisoldipine or nitrendipine or prenylamine or verapamil or diltiazem)] AND [overdose OR medication errors OR poisoning OR intoxication OR toxicity OR adverse effect]. Two reviewers independently selected studies and a group of reviewers abstracted all relevant data using a pilot-tested form. A second group analyzed the risk of bias and overall quality using the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) checklist and the Thomas tool for observational studies, the Institute of Health Economics tool for Quality of Case Series, the ARRIVE (Animal Research: Reporting In Vivo Experiments) guidelines, and the modified NRCNA (National Research Council for the National Academies) list for animal studies. Qualitative synthesis was used to summarize the evidence. Of 15,577 citations identified in the initial search, 216 were selected for analysis, including 117 case reports. The kappa on the quality analysis tools was greater than 0.80 for all study types. RESULTS The only observational study in humans examined high-dose insulin and extracorporeal life support. The risk of bias across studies was high for all interventions and moderate to high for extracorporeal life support. High-dose insulin. High-dose insulin (bolus of 1 unit/kg followed by an infusion of 0.5-2.0 units/kg/h) was associated with improved hemodynamic parameters and lower mortality, at the risks of hypoglycemia and hypokalemia (low quality of evidence). Extracorporeal life support. Extracorporeal life support was associated with improved survival in patients with severe shock or cardiac arrest at the cost of limb ischemia, thrombosis, and bleeding (low quality of evidence). Calcium, dopamine, and norepinephrine. These agents improved hemodynamic parameters and survival without documented severe side effects (very low quality of evidence). 4-Aminopyridine. Use of 4-aminopyridine was associated with improved hemodynamic parameters and survival in animal studies, at the risk of seizures. Lipid emulsion therapy. Lipid emulsion was associated with improved hemodynamic parameters and survival in animal models of intravenous verapamil poisoning, but not in models of oral verapamil poisoning. Other studies. Studies on decontamination, atropine, glucagon, pacemakers, levosimendan, and plasma exchange reported variable results, and the methodologies used limit their interpretation. No trial was documented in humans poisoned with calcium channel blockers for Bay K8644, CGP 28932, digoxin, cyclodextrin, liposomes, bicarbonate, carnitine, fructose 1,6-diphosphate, PK 11195, or triiodothyronine. Case reports were only found for charcoal hemoperfusion, dialysis, intra-aortic balloon pump, Impella device and methylene blue. CONCLUSIONS The treatment for calcium channel blocker poisoning is supported by low-quality evidence drawn from a heterogeneous and heavily biased literature. High-dose insulin and extracorporeal life support were the interventions supported by the strongest evidence, although the evidence is of low quality.
Collapse
Affiliation(s)
- M St-Onge
- Ontario and Manitoba Poison Centre , Toronto, ON , Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|