Antivenomlar ve uygulama ilkeleri

Öz

Zehirli hayvanlarla temas ve ısırılma nedeni ile zehirlenme ve ölüm özellikle gelişmekte olan ülkelerde bir halk sağlığı sorunudur. Dünya genelinde 1,8-2,7 milyon yılan ısırması ve 81 bin ile 137 bin arasında ölüm bildirilmiştir. Yine benzer oranlarda akrep sokması vakası bildirilmiş olup, bildirilen vakalarda ölüm oranı yılan ısırmalarına kıyasla belirgin olarak düşüktür. Antivenomlar, zehirli hayvanların venomuna karşı üretilen antikor preparatlarıdır. On dokuzuncu yüzyıldan bu yana üretilmeye başlanan antivenomların etkililiği konusunda tartışmalı bulguların olması, anaflaksi gibi alerjik reaksiyonlara neden olabilmeleri ve yapılan çalışmaların randomize kontrollü çalışmalar olmaması nedeniyle elde edilen verilerin tüm zehirlenmelere ekstrapole edilemeyeceğini düşündürmektedir. Türkiye’de yılan ısırmalarına ve akrep sokmalarına karşı üretilen antivenomlar bulunmaktadır. Ancak örümcek antivenomu bulunmamaktadır. Ayrıca, zehirlenmeler ve tedavileri ile ilgili eğitim eksikliği nedeniyle, gerekmeyen olgularda da antivenom kullanıldığı görülmektedir. Bu nedenle, ısırma ve sokmaların yönetiminde antivenom kullanımı ile ilgili bilgilerin güncellenmesi önemlidir. Bu makalede ülkemizde sık görülen yılan, akrep ve örümcek sokmalarına karşı antivenom uygulama ilkelerinden bahsedilecektir.

Anahtar Kelimeler

• akrep sokmaları,örümcek ısırmaları,antivenom,yılan ısırmaları

ANTIVENOMS AND PRINCIPLES OF APPLICATION

Öz

Venomous animals bites, stings, and poisoning are major public health problem in the developing countries. At least 1.8-2.7 million snake bite cases are reported annually around the world and between 81,000 and 137,000 deaths have been reported. Scorpion sting was reported in similar proportions as snake bites, and the mortality rate in the reported cases was significantly lower than in snake bites. Antivenoms are antibody preparations produced against venom of venomous animals. The antivenoms have been produced since the nineteenth century. However, it is suggested that the data obtained cannot be extrapolated to all poisonings due to controversial findings about the efficacy of antivenoms, allergic reactions of antivenoms use such as anaphylaxis and the lack of randomized controlled trials on antivenoms. There are antivenoms produced against snake bites and scorpion stings in Turkey, but no antivenoms against spider bites. It is observed that antivenoms are used inappropriately due to lack of education related to poisonings and their treatment. Thus, it is important to update the information about the use of antivenoms in the management of bites and stings. In this review, antivenom practice principles in animal bites and stings in Turkey will be discussed in general.

Anahtar Kelimeler

• antivenom,snake bites,scorpion stings,spider bites

Kaynakça

1. Warrell DA, Venomous Bites, Stings, and Poisoning: An Update. Infect Dis Clin N Am. 2019; 33:17–38
2. Şahin A, Arıcı MA, Hocaoğlu Aksay N, Kalkan Ş, Tunçok Y. Antivenom use in bite and sting cases presenting to a public hospital. Ulus Travma Acil Cerrahi Derg. 2018;24:343-50.
3. Arici AK, S. Hocaoglu, N. Tuncok Y. Bites and stings reported to the Dokuz Eylul University Drug and Poison Information Center. Turkish Pharmacology Association 21st National Pharmacology Congress,2011.
4. Kasturiratne A, Wickremasinghe AR, de Silva N, The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med 2008; 5: e218.
5. Isbister GK. Antivenom efficacy or effectiveness: The Australian experience. Toxicology. 2010; 268: 148–54.
6. Gutierrez JM, Leon G, Lomonte B. Pharmacokinetic–pharmacodynamic relationships of immunoglobulin therapy for envenomation. Clin Pharmacokinet. 2003;42:721–41.
7. O’Leary MA, Isbister GK. Commercial monovalent antivenoms in Australia are polyvalent. Toxicon 2009; 54:192–5.
8. Özkan Ö. Akrep antivenom üretimi. Türk Hijyen ve Deneysel Biyoloji Dergisi. 2008;65:97-108.

9. Wang JD, Tsan YT, Yan-Chiao M, Wang LM. Venomous snakebites and antivenom treatment according to a protocol for pediatric patients in taiwan. J Venom Anim Toxins incl Trop Dis. 2009; 15: 667-79.
10. Jayakrishnan MP, Geeta MG, Krishnakumar P, Rajesh TV, George B. Snake bite mortality in children: beyond bite to needle time. Arch Dis Child. 2016;102:445-9.
11. Krifi MN, El Ayeb M, Dellagi K. The Improvement and Standardization of Antivenom Production in Developıng Countries: Comparing Antivenom Quality, Therapeutical Efficiency, and Cost. J Venom Anim Toxins incl Trop Dis. 1999;5:128-41.
12. Isbister GK, Graudins A, White J, Warrell D. Antivenom treatment in arachnidism. J Toxicol Clin Toxicol. 2003;41:291-300.
13. EMEA. The European Agency for the Evaluation of Medical Products, Evaluation of Medicines for Human Use. Note for guidance on production and quality control of animal immunoglobulins and immunosera for human use. CPMP/BWP/3354/99. London,2002.
14. Üstünes L. İnteraktif İlaç Bilgi Kaynağı. Rx Media Pharma, 2019.
15. Gümüştekin M. [Environmental toxins: Animal biting and stings.] T Klin J Pharmacol Toksikoloji Özel sayısı. 2003;1:53-7.
16. Clark RF. Snakebite. In: Olson KR, ed. Poisoning and Drug Overdose. Appleton and Lange, publishing, Stamford,Connecticut; 2013. p.374-8.
17. Baran İ, Atatür MK. [Herpetofauna of Turkey (Frog and reptiles).] TC Çevre Bakanlığı Basımevi, Ankara; 1998. p.191-202.
18. Başoğlu M, Baran İ. [Turkey reptiles, Part II snakes.] , Ege Üniversitesi Basımevi; 1998. p.145-58.
19. Lamb T, de Haro L, Lonati D, Brvar M, Eddleston M. Antivenom for European Vipera species envenoming. Clin Toxicol (Phila). 2017;55:557-68.
20. Monzavi SM, Dadpour B, Afshari R. Snakebite management in Iran: devising a protocol. J Res Med Sci 2014;19:153e163.
21. Gutiérrez JM, Calvete JJ, Habib AG, Harrison RA, Williams DJ, Warrell DA. Snakebite envenoming. Nat Rev Dis Primers. 2017;3:17063.
22. Ahmed SM, Ahmed M, Nadeem A, Mahajan J, Choudhary A, Pal J. Emergency treatment of a snake bite: Pearls from literature. J Emerg Trauma Shock 2008;1:97–105.
23. Gerardo CJ, Lavonas EJ, McKinney RE. Ethical considerations in design of a study to evaluate a US Food and Drug Administration–approved indication: antivenom versus placebo for copperhead envenomation. J Clin Trials. 2014;11:560-64.
24. Warrell D. Guidelines for the management of snakebites. 2nd ed. WHO/Regional Office for South-East Asia, 2016.
25. Özkan O, Yağmur EA. Neutralization Capacity of Monovalant Antivenom Against Existing Lethal Scorpions in the Turkish Scorpiofauna. Iran J Pharm Res 2017;16:653-60.
26. Abroug F, Elatrous S, Nouira S, Haguiga H, Touzi N, Bouchoucha S. Serotherapy in scorpion envenomation: a randomised controlled trial. Lancet 1999;354:906–9.
27. Clark RF. Scorpions. In: Olson KR, ed. Poisoning and Drug Overdose. Appleton and Lange, publishing, Stamford,Connecticut; 2013. p.365-67
28. Clark RF. Spiderbite In: Olson KR, ed. Poisoning and Drug Overdose. Appleton and Lange, publishing, Stamford,Connecticut; 2013. p.378-81
29. Isbister GK, Fan HW. Spider bite. Lancet. 2011;378:2039-47.