Acute High-Output Heart Failure with Pulmonary Hypertension and Severe Liver Injury Caused by Amlodipine Poisoning: A Case Report

Acute high-output heart failure (HOHF) with pulmonary hypertension and liver injury caused by amlodipine poisoning is very rare. We report a 52-year-old woman who suffered from severe shock after an overdose of amlodipine. Hemodynamic monitoring showed that while her left ventricular systolic function and cardiac output were elevated, her systemic vascular resistance decreased significantly. At the same time, the size of her right heart, her central venous pressure, and the oxygen saturation of her central venous circulation all increased abnormally. The patient's circulatory function and right ventricular dysfunction gradually improved after large doses of vasopressors and detoxification measures. However, her bilirubin and transaminase levels increased significantly on hospital day 6, with a CT scan showing patchy, low-density areas in her liver along with ascites. After liver protective treatment and plasma exchange, the patient's liver function gradually recovered. A CT scan 4 months later showed all her liver abnormalities, including ascites, had resolved. The common etiologies of HOHF were excluded in this case, and significantly reduced systemic vascular resistance caused by amlodipine overdose was thought to be the primary pathophysiological basis of HOHF. The significant increase in venous return and pulmonary blood flow is considered to be the main mechanism of right ventricular dysfunction and pulmonary hypertension. Hypoxic hepatitis caused by a combination of hepatic congestion and distributive shock may be the most important factors causing liver injury in this patient. Whether amlodipine has other mechanisms leading to HOHF and pulmonary hypertension needs to be further studied. Considering the significant increase of right heart preload, aggressive fluid resuscitation should be done very cautiously in patients with HOHF and shock secondary to amlodipine overdose.

Efficacy of methylene blue in a murine model of amlodipine overdose

INTRODUCTION

Amlodipine overdoses have significant cardiac toxicity and are difficult to treat. Methylene blue has potential as a treatment for overdoses.

METHODS

A randomized controlled study of methylene blue as a treatment for amlodipine toxicity was conducted in C57Bl/6 mice. A baseline echocardiography was followed by gavage administration of amlodipine (90 mg/kg). Five minutes after gavage, animals received either vehicle solution (controls) or methylene blue (20 mg/kg) by intra-peritoneal injection. Animals were continuously monitored, and cardiac parameters were acquired every 15 min up to two hours.

RESULTS

Only 50% of control animals survived to the two-hour endpoint compared to 83% that received methylene blue. Amlodipine delivery induced significant reduction in left ventricular ejection fraction (EF), fractional shortening (FS), stroke volume (SV), and cardiac output (CO) in the vehicle treated animals relative to animals in the treatment group (p < 0.05 vehicle versus Methylene blue for EF, FS, SV, CO, and HR).

DISCUSSION

The amlodipine dose induced cardiotoxicity that were effects were more pronounced in the untreated group. 50% vehicle controls quickly progressed into heart failure (within 90 min of exposure) and did not survive the two h observation endpoint. Distinctly, only one animal from the Methylene blue treatment group did not survive (83% survival) the study. Additionally, the surviving animals from the Methylene blue group displayed significantly higher ejection fraction, fractional shortening, stroke volume, and cardiac output compared to vehicle group, indicating that methylene blue preserved cardiac function.

CONCLUSION

In this mouse model of amlodipine overdose, methylene blue decreased cardiac toxicity.

Survival After Cardiac Arrest: ECMO Rescue Therapy After Amlodipine and Metoprolol Overdose

Extracorporeal membrane oxygenation (ECMO) use in poisoned patients is increasing, but is rare post cardiac arrest. We report a case of ECMO use with complete recovery in a patient who arrested twice after a cardiotoxicant overdose. A 17-year-old male presented after an unknown overdose. He rapidly became hypotensive and bradycardic and received aggressive supportive care without improvement. He was transferred to our institution and suffered a cardiac arrest shortly after arrival. Six minutes of advanced cardiac life support resulted in return of spontaneous circulation. High-dose insulin, lipid emulsion, and ECMO were initiated. While awaiting ECMO deployment, he again became pulseless. Compressions resumed, and after 30 min, ROSC was achieved, and he was cannulated for veno-arterial ECMO. Within 48 h, he was decannulated, and then weaned off epinephrine 2 days later. Upon extubation, he was neurologically intact. Amlodipine and metoprolol were later confirmed in serum. Adolescent poisoned patients represent an ideal population for ECMO due to lack of comorbidities. As experience with ECMO in overdose increases, additional research is needed to determine appropriate indications and timing for its use. ECMO is an option for patients poisoned with a cardiotoxicant drug, even following witnessed cardiac arrest.

Delayed elimination half-life of amlodipine in a case of drug overdose

A 75 year-old-female was transferred to our ICU by an ambulance for refractory hypotension. The patient was suspected to have acute amlodipine (AML) overdose based on the information obtained from patient's family. Serum AML concentration was 355.6 ng/mL on the 1st hospital day. The patient's blood pressure was gradually elevated by intravenous administration of noradrenaline, calcium chlo- ride and insulin, and the patient was transferred to another hospital on the 9th hospital day. The analysis of serum AML concentration showed delayed elimination half life in the early period after the inges- tion. It was thought that decrease in the hepatic clearance of AML by the saturation of metabolism could contribute to the delayed elimination. Severe AML overdose may cause prolonged elimination half-life.

[A CASE OF SEVERE AMLODIPINE POISONING]

The article is devoted to the actual problem--poisoning by calcium channel blockers. The case of the departure of the patient amlodipine, clinical picture, treatment and its effectiveness. In the discussion described pharmacological characteristics of the group of calcium channel blockers, mechanisms of development syndromes developing in this type of shipment and pathogenetic approach to therapy.

Continuous venovenous hemodiafiltration along with charcoal hemoperfusion for the management of life-threatening lercanidipine and amlodipine overdose

Overdose with calcium channel blockers is uncommon, but is associated with high mortality. The management includes fluid resuscitation, calcium gluconate, glucagon, vasopressors, and high-dose insulin-euglycemia therapy. We describe a rare case of massive overdose of lercanidipine with shock, refractory to conventional therapies and multi-organ failure. Charcoal hemoperfusion with continuous venovenous hemodiafiltration was then used successfully and the patient showed remarkable recovery.

[Case of olmesartan and amlodipine intoxication]

Although angiotensin II receptor blocker (ARB) is one of the most common drugs for hypertension in Japan, there are few reports of ARB intoxication. We report a case of persistent hypotension caused by intoxication of olmesartan and amlodipine. A 55-year-old female was transferred to our emergency center 4 hours after taking 180 mg of olmesartan and 140 mg of amlodipine. Continuous hypotension occurred after admission. We used norepinephrine up to 0.33 microg/kg/min to keep her systolic blood pressure > 80 mmHg. We also used calcium gluconate as a treatment for amlodipine intoxication. Although it is predicted the abnormality of electrolyte balance, acid-base balance and renal dysfunction, she had recovered with no remarkable disability. With stabilization of her circulation, we reduced the dose of norepinephrine and stopped it on day 3, and she is discharged on day 5. Her serum olmesartan level was 3,980 ng/mL (normal C(max): 273.5 ng/mL), and serum amlodipine level was 104.9 ng/mL (normal C(max): 2.51 ng/mL). We suggest that it is important to stabilize vital sign to treat ARB intoxication as same as other drug intoxication.

Acute amlodipine overdose treated by high dose intravenous calcium in a patient with severe renal insufficiency

Calcium salts are frequently used in the treatment of calcium antagonist poisoning. Different dosing regimens have been employed. The major risk of high dose calcium therapy is iatrogenic hypercalcemia, especially in patients with diminished renal function. Repeated doses of calcium are therefore often avoided; however, inadequate use of intravenous calcium may cause treatment failure in severe calcium antagonist overdose. We report our experience of using high dose intravenous calcium chloride effectively and safely to treat severe amlodipine overdose in a patient with severe renal insufficiency.

A case of amlodipine overdose

A case of severe amlodipine overdose with only mild symptoms is described. Plasma concentrations of amlodipine were measured in serial samples by gas chromatography. There was no concomitant overdose. The present case is compared with previous reported cases of amlodipine overdose where patients all developed severe symptoms. We conclude that amlodipine overdose does not always cause severe symptoms.

Two Cases of Fatal Amlodipine Overdose

Two fatal overdoses of the calcium channel blocker amlodipine are described. Postmortem samples were screened for volatiles and therapeutic and abused drugs. Amlodipine was measured by liquid chromatography-atmospheric pressure photoionization-mass spectrometry. The heart blood amlodipine concentrations for the two cases were 2.4 and 0.95 mg/L, and amlodipine was quantified in all other tissues. In the first case, venlafaxine and norvenlafaxine were also found, and the angiotensin receptor antagonist olmesartan was tentatively identified. The concentrations of amlodipine are compared with previously reported fatal and nonfatal overdoses. The medical examiners ruled in both cases that the manner of death was suicide and the causes of death were mixed drug intoxication and amlodipine intoxication.

Metaraminol (Aramine) in the management of a significant amlodipine overdose

OBJECTIVE

To report a patient with a significant amlodipine self-poisoning who failed to clinically respond to conventional treatment and was managed with metaraminol (Aramine).

PATIENT

A 43-year old male presenting after ingestion of 560 mg amlodipine, who failed to respond clinically to treatment with fluid resuscitation, calcium salts, glucagon and norepinephrine/epinephrine inotropic support.

MAIN RESULTS

Following a loading bolus of 2 mg and intravenous infusion (83 microg/min) of metaraminol (Aramine) there was improvement in his blood pressure, cardiac output and urine output.

CONCLUSIONS

This is the first case report of the beneficial use of metaraminol (aramine) in the management of significant amlodipine poisoning unresponsive to conventional therapy.

[Toxicological analysis of selected 1,4-dihydropyridine calcium channel blockers in the diagnosis of intoxications]

This study is aimed at evaluating effective techniques of qualitative and quantitative analysis of selected 1,4-dihydropyridine calcium channel blockers, useful both for thanatological diagnosis of intoxications as well as monitoring therapy. The studies took advantage of gas chromatography (GLC) and high performance liquid chromatography (HPLC). Isolation of studied compounds from biological material was performed using classical and solid phase extraction procedures (SPE) such as Bond Elut LRC (Varian), Abselut Nexus (Varian), STRATA C - 18 E (Phenomenex). The program included analysis of nine of the most frequently prescribed derivatives: nifedipine, felodipine, amlodipine, nicardipine, nimodypine, nilvadipine, nitrendipine, nisoldipine, isradipine.

Near-fatal amlodipine poisoning

Amlodipine poisoning is very rare and only few cases have been reported in English literature. We report here a case of severe amlodipine poisoning with non-cardiogenic pulmonary edema.

Vasopressinanaloga als Ultima ratio bei einer schweren Intoxikation mit Vasodilatanzien

HISTORY AND CLINICAL FINDINGS

A 78-year-old woman was admitted to the intensive care unit 9 hours after ingestion of 2 g of isosorbitmononitrate, 430 mg of amlodipine, 250 mg of benazepril and 600 mg of mirtazapin in suicidal intent.

INVESTIGATIONS

Clinical findings and invasive monitoring showed signs of a hyperdynamic hemodynamic cardiovascular failure caused by toxic vasodilatation.

TREATMENT AND COURSE

Despite of primary detoxication, intravenous volume infusion with calcium gluconate, glucagon and naloxone and administration (norepinephrine up to 2 micro g/kg/min) no hemodynamic stabilization was achieved. Only when the vasopressin-analogue argipressin was given peripheral vasodilatation was overcome and hemodynamic stabilization resulted. 10 hours after discontinuing argipressin and norepinephrine the patient developed a mesenteric ischemia, and she finally died on the third day after admission.

CONCLUSION

In circulatory shock due to toxic vasodilatation the use of vasopressin analogue argipressin can be helpful as an ultima therapeutic measure in catecholamine refractory shock caused by vasodilatation. Attention must be paid to overwhelming vasoconstrictor effects resulting in mesenteric ischemia.

Severe intoxication after an intentional overdose of amlodipine

Intoxication with 280 mg of amlodipine caused severe hypotension, third-degree heart block and hyperkalaemia in a 36-year-old female patient. The patient was initially treated with fluids, dopamine, calcium chloride, and epinephrine without effect. The patient was then given a bolus injection of insulin and glucose as a temporary mean to treat the hyperkalaemia. We observed a rise in blood pressure (BP) after insulin was given and the BP was subsequently responsive to epinephrine. A possible positive inotropic effect of insulin therapy in patients with calcium channel blocker intoxication is in accordance with previous findings. In conclusion, it is suggested that hyperinsulinaemia-euglycaemia therapy may be considered as a first-line therapy in calcium channel blocker intoxication.

Acute barium intoxication and hemodiafiltration

We report a case of severe hypokalemia and flaccid muscle paralysis following a suicide attempt associating the calcium channel blocker amlodipine, the antidepressant fluoxetine and barium carbonate. Despite rapid correction of severe, life-threatening hypokalemia, areflexic quadriplegia persisted, suggesting a direct effect of barium on muscle cells. Continuous veno-venous hemodiafiltration (CVVHDF) was initiated. We determined barium concentration in the urine, plasma, and hemodiafiltrate during CVVHDF. We subsequently calculated the amounts of barium eliminated both by the CVVHDF and the kidneys. CVVHDF triples the measured barium elimination, reduced serum barium half-life by a factor of three, stabilized serum potassium levels, and rapidly improved motor strength, with complete neurological recovery within 24 h. Presentation and treatment of barium intoxication are discussed.

Pharmaceutical drug overdose case reports. From the World Literature

All pharmaceutical drugs have the potential to be misused or wrongly administered, which can result in toxic amounts of drug being ingested. To help you keep up-to-date with the latest data on outcomes and management of overdoses, both accidental and intentional, we have selected the following case reports recently published in the international medical literature and summarised in Reactions Weekly. Any claim of first report has been verified by a search of the Adisbase (a proprietary database of Adis International) and Medline. In addition, the World Health Organization (WHO) Adverse Drug Reaction database is also searched. This database, maintained by the Uppsala Monitoring Centre in Sweden, is the largest and most comprehensive adverse drug reaction source in the world, with information obtained from the National Centres of over 70 affiliate countries.

[Deep hypotension with transient oliguria and severe heart failure in course of acute intentional poisoning with amlodipine]

A case of acute poisoning with amlodipine with deep hypotension, transient oliguria and clinical signs of acute heart failure was described. A woman of 23 years swallowed intentionally 60 tablets of amlodipine (600 mg). After eleven hours of ingestion she was admitted to Warsaw Poison Control Centre. She was in severe clinical condition; tachycardia and deep hypotension were the prominent signs of poisoning. There was not CNS depression. Intensive treatment with i.v. catecholamines (dopamine, norepinephrine), crystalloids (with continuous control of central venous pressure), and i.v. calcium salts (with control of plasma calcium concentration) was started immediately. The patient did not improve but got worse. Acute heart failure developed, especially of left ventricle, so i.v. crystalloids were stopped and dubutamin, morphine, nitroglycerin and glucagon were introduced. Because of oliguria and insufficient effect of high doses of furosemide four-hours hemodiafiltration was set in. The patient's condition slowly improve after third and forth day of hospitalization. The systolic blood pressure rose, heart work was really better and on sixth day--the stabilization of diastolic blood pressure was definitely achieved. The patient was discharge in good condition with heart ejection fraction of 65% measured echocardiographically.

Insulin-glucose as adjunctive therapy for severe calcium channel antagonist poisoning

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.

Amlodipine overdose causes prolonged calcium channel blocker toxicity

Amlodipine is a relatively new agent that has the longest half-life of all calcium channel blockers. This report describes a severe overdose that resulted in prolonged and severe hemodynamic compromise for up to 10 days, but responded to aggressive therapy with calcium, glucagon, and other vasoactive medicines.

Amlodipine overdose

OBJECTIVE

To report a nonfatal intentional overdose of amlodipine.

CASE SUMMARY

A 42-year-old woman with a history of hypertension reported ingesting 50-100 mg amlodipine besylate and at least 40 ounces of beer in a suicide attempt. The patient's symptoms were mild; BP ranged from 79/50 to 113/76 mm Hg and HR from 92 to 129 beats/min (sinus tachycardia). Laboratory studies revealed normoglycemia, mild metabolic acidosis, mild hypocalcemia, blood ethanol concentration of 263 mmol/L, and a serum amlodipine concentration of 88 ng/mL (normal 3-11) 2.5 hours after ingestion. Therapy included activated charcoal, whole bowel irrigation, and intravenous NaCl 0.9%. After receiving 1.5 L of NaCl 0.9%, the patient developed signs of mild pulmonary edema that resolved over several hours without intervention. A serum amlodipine concentration obtained 35 hours later was 79 mg/mL. The patient was discharged on day 2 in good condition.

DISCUSSION

In this case, an amlodipine overdose was associated with sustained hypotension and sinus tachycardia, as well as transient pulmonary edema following relatively low-volume fluid replacement. A previously published report described an amlodipine overdose that was fatal due to refractory hypotension and was complicated by concomitant oxazepam overdose.

CONCLUSIONS

Amlodipine overdose produces prolonged hemodynamic effects and may lead to pulmonary edema. Due to a long elimination half-life and delayed onset of effects, patients with amlodipine overdose should receive aggressive decontamination therapy and may require extended clinical monitoring and supportive care if they are hemodynamically unstable.

A fatal case of amlodipine poisoning

A fatal case attributed to amlodipine intoxication is presented. The deceased was a 15-year-old girl who allegedly ingested 14 10-mg Istin tablets. Amlodipine concentration in peripheral blood was determined (2.7 mg/L) and was compared with published therapeutic and toxic data for amlodipine and some other dihydropyridine calcium channel-blocking agents. Amlodipine concentrations in liver, blood, and stomach contents were also determined.

Fatal intoxication with amlodipine

Although poisoning with calcium channel blocking agents is frequent, to our knowledge no cases involving amlodipine have been published. We describe here a case of amlodipine intoxication, in which protracted hypotension did not respond to vasopressor therapy alone. After the addition of continuous calcium chloride and glucagon infusion, blood pressure was restored and vasopressor therapy could be tapered off substantially. When calcium and glucagon were interrupted because of severe hypercalcemia and hyperglycemia, the patient developed irreversible hypotension and died. Either glucagon or calcium or both, and to some extent vasopressors, seem to have constituted effective treatment of hypotension in this case.