Antidotes for acute cardenolide (cardiac glycoside) poisoning

BACKGROUND

Cardenolides are naturally occurring plant toxins which act primarily on the heart. While poisoning with the digitalis cardenolides (digoxin and digitoxin) are reported worldwide, cardiotoxicity from other cardenolides such as the yellow oleander are also a major problem, with tens of thousands of cases of poisoning each year in South Asia. Because cardenolides from these plants are structurally similar, acute poisonings are managed using similar treatments. The benefit of these treatments is of interest, particularly in the context of cost since most poisonings occur in developing countries where resources are very limited.

OBJECTIVES

To determine the efficacy of antidotes for the treatment of acute cardenolide poisoning, in particular atropine, isoprenaline (isoproterenol), multiple-dose activated charcoal (MDAC), fructose-1,6-diphosphate, sodium bicarbonate, magnesium, phenytoin and anti-digoxin Fab antitoxin.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, the Controlled Trials Register of the Cochrane Collaboration, Current Awareness in Clinical Toxicology, Info Trac, www.google.com.au, and Science Citation Index of studies identified by the previous searches. We manually searched the bibliographies of identified articles and personally contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials where antidotes were administered to patients with acute symptomatic cardenolide poisoning were identified.

DATA COLLECTION AND ANALYSIS

We independently extracted data on study design, including the method of randomisation, participant characteristics, type of intervention and outcomes from each study. We independently assessed methodological quality of the included studies. A pooled analysis was not appropriate.

MAIN RESULTS

Two randomised controlled trials were identified, both were conducted in patients with yellow oleander poisoning. One trial investigated the effect of MDAC on mortality, the relative risk (RR) was 0.31 (95% confidence interval (CI) 0.12 to 0.83) indicating a beneficial effect. The second study found a beneficial effect of anti-digoxin Fab antitoxin on the presence of cardiac dysrhythmias at two hours post-administration; the RR was 0.60 (95% CI 0.44 to 0.81). Other benefits were also noted in both studies and serious adverse effects were minimal. Studies assessing the effect of antidotes on other cardenolides were not identified. One ongoing study investigating the activated charcoal for acute yellow oleander self-poisoning was also identified.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that MDAC and anti-digoxin Fab antitoxin may be effective treatments for yellow oleander poisoning. However, the efficacy and indications of these interventions for the treatment of acute digitalis poisoning is uncertain due to the lack of good quality controlled clinical trials. Given pharmacokinetic differences between individual cardenolides, the effect of antidotes administered to patients with yellow oleander poisoning cannot be readily translated to those of other cardenolides. Unfortunately cost limits the use of antidotes such as anti-digoxin Fab antitoxin in developing countries where cardenolide poisonings are frequent. More research is required using relatively cheap antidotes which may also be effective.

Cardiovascular effects of yellow oleander ingestion

Yellow oleander (Thevetia neriifolia) is a commonly grown tree found widely in Eastern India. The seeds of yellow oleander are highly poisonous and contain three glycosides--thevetin, thevetoxin and peruvoside. Yellow oleander seed ingestion is usually with suicidal intent in Eastern India. Manifestations range from mild to potentially fatal. It has significant cardiovascular effects with varying rhythm abnormalities. Effects of yellow oleander seed ingestion (YOI) were studied in 300 patients from 1986 to 1990 at BS Medical College, Bankura. Majority i.e., 246 (82%) were females and 226 (75.33%) were young in the age group 11-20 years. Most reported for treatment 6 to 8 hours after ingestion of seeds. The number of seeds swallowed varied from half to fifteen. Two hundred and ninety-two (97.33%) ingested seeds in the crushed form; 156 (52%) were asymptomatic, 92 (30.66%) had vomiting and 36 (12%) had palpitation. In electrocardiogram (ECG), 138 (46%) revealed varying types of arrhythmias including sinus bradycardia in 68 cases (49.27%). Ischaemic changes were present in 118 cases (39.33%). Number of seeds ingested did not bear any relationship with ECG changes in YOI. All 14 cases of death were autopsied. Subendocardial and perivascular haemorrhage with focal myocardial oedema was present in all. Median hospital stay was 5 days (range 2 to 24). During discharge, 256 (85.33%) had normal ECG, 14 (4.66%) had sinus bradycardia and 16 (5.33%) demonstrated ischaemic changes.

Efficacy of digoxin specific Fab fragments (Digibind) in the treatment of toad venom poisoning

Chan Su, a traditional Chinese medication, and Love Stone, a topical aphrodisiac, are both made from dried venom of the toad bufo bufo gargarizans and contain bufalin, cinobufotalin, cinobufagin, and other cardioactive steroids of the bufadienolide class. Deaths have occurred following ingestion of these products and the clinical course resembles digoxin toxicity. The purpose of this study was to determine the efficacy of digoxin specific Fab fragments in treating Chan Su poisoning. An ethanolic extract was prepared from Chan Su. Digoxin specific Fab fragments were reconstituted in normal saline to a concentration of 80 mg/ml. An approximate LD90 dose was determined in preliminary experiments. Mice were then randomly divided into a treatment group of 15 mice and a control group of 30 mice. The treatment group was pretreated with 20 ml/kg of digoxin specific Fab fragment solution by intraperitoneal injection at t = 0, followed by 10 ml/kg of digoxin specific Fab fragments intraperitoneal at t = 30 min. The control group was pretreated with equal volumes of intraperitoneal normal saline at the same times. Immediately following the 30 min injection, both groups were given the estimated LD90 dose of Chan Su extract by subcutaneous injection. An endpoint of survival at 6 h was chosen after preliminary results showed that all deaths occurred in the first 4 h. All 30 of the control mice had seizures followed by death compared to 11 seizures and 7deaths in the 15 treatment mice. These results were statistically significant by Fisher's exact test (p = 0.00003 for mortality and p = 0.009 for seizures). Digoxin specific Fab fragments are effective in the treatment of Chan Su poisoning in mice and may be effective for poisoning by other cardioactive steroids of the bufadienolide class.

Rapid quantitative analysis of oleandrin in human blood by high-performance liquid chromatography

A simple and rapid method for quantitation of oleandrin in human blood has been developed using an Extrelut column and high-performance liquid chromatography (HPLC). Blood samples spiked with oleandrin were mixed with distilled water and applied to an Extrelut column for elution with ethyl acetate before HPLC. The HPLC separation of the compound from endogeneous impurities was generally satisfactory with the use of a reversed-phase column. Oleandrin showed excellent linearity in the range of 0.05-10 micrograms/g and the limit of detection was 0.02 microgram/g for human blood. The recovery of the compound, which had been spiked to human blood, was more than 90%. The present method is simple and more rapid than those so far reported, and seems useful for analysis of oleandrin in the cases of oleander poisoning.

A quest for oleandrin in decayed human tissue

This forensic case taught us several lessons. First, there is a need for improved sample cleanup and treatment of severely decayed tissue samples when trace determinations of target analytes are needed. With the exception of a few reports the literature is lacking in information with regard to the most modern sample preparation techniques. Second, the coupling of LC/LC with tandem MS provides an effective means of "on-line" samples cleanup for complex sample matrices. The improvements in selectivity shown in Figure 3 reveal the analytical power available when these techniques are combined. Third, once we decided to use LC/LC/MS/MS, we were able to analyze more than 50 samples in a semi-automated fashion over approximately three days. The reliability and ruggedness of the combined techniques and equipment suggest this approach may have merit for common applications in which large numbers of biological samples (e.g., plasma and urine) must be analyzed. As a postscript, when this project was completed we proposed that the use of antibodies for isolating oleandrin and its relatives might be a more selective means for trace enrichment of the target analytes. For example, a high-pressure immunoaffinity column could have been coupled on line as column 1 in Figure 4. After pumping a relatively high volume of aqueous tissue extract through an immunoaffinity column during trapping and trace enrichment conditions, the column could be rinsed with phosphate-buffered saline. Then the pH could be lowered to unfold the antibody protein and allow release of the trapped analyte from this column with subsequent trapping on column 2 in Figure 4.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of oleander poisoning in a cat]

This case history describes clinical symptoms and pathological changes in a cat that are consistent with those of oleander intoxication. The clinical symptoms were characterized by vomiting, diarrhoea, and ventricular extrasystoles. On post-mortem examination focal degeneration and necrosis of the myocardium was seen, as well as haemorrhage of myocardium and wall of the gastrointestinal tract. An overview is given of the literature on the diagnosis, pathogenesis, and treatment of oleander intoxication in different animals and in humans.

[Determination of zimarin in urine]

Private technique of extraction isolation and purification, chromatographic detection and photometric determination of zimarin in urine is suggested. Detection limit is 0.01 mg, determination limit is 0.1 mg of glycoside in 100 ml of urine. Method makes it possible to detect 66-80% of zimarin added to 100 ml of urine in quantities 0.5-0.1 mg.

Oleandrin distribution in a fatality from rectal and oral Nerium oleander extract administration

In a fatal (cardiotoxic) case of oleander extract poisoning of a young female, ethanol extracts of blood and tissue homogenates were purified by lead acetate. After removal of excess lead by ammonium sulfate, oleandrin was extracted into chloroform. Oleandrin in the extract concentrates was detected by thin-layer chromatography, with location by fluorescence and chromogenically by means of p-anisaldehyde. Quantitation was performed on dried extracts reconstituted in water/methanol, reacted with hydrogen peroxide, ascorbic acid, and hydrochloric acid, and analyzed by fluorescence spectrophotometry. Excitation was at 355 nm, and fluorescence scanning from 340 to 580 nm. The fluorescence peak at 460 nm was used for the quantitative measurement. The concentrations of oleandrin measured in blood, stomach wall, colon tissue, liver, heart, lung, brain, spleen, and kidney ranged from 10 to 39 micrograms/g, with 200 micrograms/mL in the total gastric content residue submitted for analysis.