CALCIUM CHANNEL BLOCKER TOXICITY - A CASE REPORT WITH TREATMENT OVERVIEW

Öz

A 75 years old male presented to the Emergency Department (ED) with an unexplained hypotension. With a wide differential diagnosis we concluded it could be attributed to an unusually high antihypertensives dosage the patient was receiving, we started treating it as a calcium channel blocker (CCB) toxicity with success. The case report reviews the case with measured levels of medications and reviews treatment of CCB toxicity with current guidelines for treatment.

Anahtar Kelimeler

• Calcium channel blockers
• drug overdose
• toxicity
• drug induced hypotension
• drug induced bradicardia

Kaynakça

1. 1. Centralna baza zdravil (CBZ). [online] Available at: http://www.cbz.si/cbz/bazazdr2.nsf/Search/$searchForm?SearchView [Accessed 5 August 2022]
2. 2. Dunleavy CA. The renal drug handbook: The ultimate prescribing guide for renal practitioners. 5th Ed. Boca Raton: CRC Press Taylor & Francis Group; 2018:60,364,1059-61.
3. 3. Chakraborty RK, Hamilton RJ. Calcium channel blocker toxicity. [Updated 2022 Feb 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537147/
4. 4. Regenthal R, Krueger M, Koeppel C, et al. Drug levels: therapeutic and toxic serum/plasma concentrations of common drugs. J Clin Monit Comput. 1999 Dec;15(7-8):529-44. doi: 10.1023/a:1009935116877
5. 5. Schulz M, Iwersen-Bergmann S, Andresen H, et al. Therapeutic and toxic blood concentrations of nearly 1000 drugs and other xenobiotics. Crit Care. 2012 Jul 26;16(4):R136. doi: 10.1186/cc11441
6. 6. Lindeman E, Ålebring J, Johansson A, et al. The unknown known: non-cardiogenic pulmonary edema in amlodipine poisoning, a cohort study. Clin Toxicol (Phila). 2020 Nov;58(11):1042-9. doi:10.1080/15563650.2020.1725034
7. 7. Hofer CA, Smith JK, Tenholder MF. Verapamil intoxication: a literature review of overdoses and discussion of therapeutic options. Am J Med. 1993;95(4):431-8. doi: 10.1016/00029343(93)90314-f
8. 8. Ashraf M, Chaudhary K, Nelson J, Thompson W. Massive overdose of sustained-release verapamil: a case report and review of literature. Am J Med Sci. 1995;310(6):258-63.

9. 9. Proano L, Chiang WK, Wang RY. Calcium channel blocker overdose. Am J Emerg Med. 1995;13(4):444-50. doi: 10.1016/0735-6757(95)90137-X.
10. 10. Kerns W 2nd, Kline J, Ford MD. Beta-blocker and calcium channel blocker toxicity. Emerg Med Clin North Am. 1994;12(2):365-90.
11. 11. Isbister GK. Delayed asystolic cardiac arrest after diltiazem overdose; resuscitation with high dose intravenous calcium. Emerg Med J. 2002;19(4):355-7. doi: 10.1136/emj.19.4.355
12. 12. Lam YM, Tse HF, Lau CP. Continuous calcium chloride infusion for massive nifedipine overdose. Chest. 2001;119(4):1280-2. doi: 10.1378/chest.119.4.1280
13. 13. Mahr NC, Valdes A, Lamas G. Use of glucagon for acute intravenous diltiazem toxicity. Am J Cardiol. 1997;79(11):1570-1. doi: 10.1016/s0002-9149(97)90000-x
14. 14. Walter FG, Frye G, Mullen JT, et al. Amelioration of nifedipine poisoning associated with glucagon therapy. Ann Emerg Med. 1993;22(7):1234-7. doi: 10.1016/s0196-0644(05)809989
15. 15. Doyon S, Roberts JR. The use of glucagon in a case of calcium channel blocker overdose. Ann Emerg Med. 1993;22(7):1229-33. doi: 10.1016/s0196-0644(05)80997-7
16. 16. Levine M, Curry SC, Padilla-Jones A, et al. Critical care management of verapamil and diltiazem overdose with a focus on vasopressors: a 25-year experience at a single center. Ann Emerg Med. 2013;62(3):252-8. doi: 10.1016/j.annemergmed.2013.03.018
17. 17. Kline JA, Tomaszewski CA, Schroeder JD, Raymond RM. Insulin is a superior antidote for cardiovascular toxicity induced by verapamil in the anesthetized canine. J Pharmacol Exp Ther. 1993;267(2):744-50.
18. 18. Boyer EW, Shannon M. Treatment of calcium-channel blocker intoxication with insulin infusion. N Engl J Med. 2001;344(22):1721-2. doi: 10.1056/NEJM200105313442215
19. 19. Greene SL, Gawarammana I, Wood DM, et al. Relative safety of hyperinsulinaemia/euglycaemia therapy in the management of calcium channel blocker overdose: a prospective observational study. Intensive Care Med. 2007 Nov;33(11):2019-24. doi: 10.1007/s00134-007-0768-y
20. 20. Patel NP, Pugh ME, Goldberg S, et al. Hyperinsulinemic euglycemia therapy for verapamil poisoning: a review. Am J Crit Care. 2007;16(5):498-503.
21. 21. Young AC, Velez LI, Kleinschmidt KC. Intravenous fat emulsion therapy for intentional sustained-release verapamil overdose. Resuscitation. 2009;80(5):591-3. doi: 10.1016/j.resuscitation.2009.01.023
22. 22. Sirianni AJ, Osterhoudt KC, Calello DP, et al. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med. 2008;51(4):412-5, 415.e1. doi: 10.1016/j.annemergmed.2007.06.004
23. 23. Gueret G, Pennec JP, Arvieux CC. Hemodynamic effects of intralipid after verapamil intoxication may be due to a direct effect of fatty acids on myocardial calcium channels. Acad Emerg Med. 2007;14(8):761. doi: 10.1197/j.aem.2007.04.006
24. 24. Wolf LR, Spadafora MP, Otten EJ. Use of amrinone and glucagon in a case of calcium channel blocker overdose. Ann Emerg Med. 1993;22(7):1225-8. doi: 10.1016/s01960644(05)80996-5
25. 25. Varpula T, Rapola J, Sallisalmi M, et al. Treatment of serious calcium channel blocker overdose with levosimendan, a calcium sensitizer. Anesth Analg. 2009;108(3):790-2. doi: 10.1213/ane.0b013e3181931737
26. 26. Kurola J, Leppikangas H, Magga J, et al. Effect of levosimendan in experimental verapamil-induced myocardial depression. Scand J Trauma Resusc Emerg Med. 2010;18:12. doi: 10.1186/1757-7241-18-12
27. 27. Salhanick SD, Shannon MW. Management of calcium channel antagonist overdose. Drug Saf. 2003;26(2):65-79. doi: 10.2165/00002018-200326020-00001
28. 28. Durward A, Guerguerian AM, Lefebvre M, et al. Massive diltiazem overdose treated with extracorporeal membrane oxygenation. Pediatr Crit Care Med. 2003;4(3):372-6. doi: 10.1097/01.PCC.0000074273.50306.F5
29. 29. Vignesh C, Kumar M, Venkataraman R, et al. Extracorporeal Membrane Oxygenation in Drug Overdose: A Clinical Case Series. Indian J Crit Care Med. 2018;22(2):111-115. doi: 10.4103/ijccm.IJCCM_417_17
30. 30. Nimmo WS. Drugs, diseases and altered gastric emptying. Clin Pharmacokinet. 1976;1(3):189-203. doi: 10.2165/00003088197601030-00002. PMID: 797497.
31. 31. Usai-Satta P, Bellini M, Morelli O, et al. Gastroparesis: New insights into an old disease. World J Gastroenterol. 2020 May 21;26(19):2333-2348. doi: 10.3748/wjg.v26.i19.2333. PMID: 32476797; PMCID: PMC7243643.