Calcium channel blocker toxicity

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Calcium channel blocker toxicity
Other namesCalcium channel blocker poisoning, calcium channel blocker overdose
LipidEmulsion.JPG
A 20% lipid emulsion commonly used for calcium channel blocker toxicity
Specialty Emergency medicine
Symptoms Slow heart rate, low blood pressure, nausea, vomiting, sleepiness [1] [2]
Complications Cardiac arrest [2]
Usual onsetWithin 6 hours [2]
CausesToo much calcium channel blockers either by accident or on purpose [3]
Differential diagnosis Beta blocker toxicity [1]
Treatment Activated charcoal, whole bowel irrigation, intravenous fluids, calcium gluconate, glucagon, high dose insulin, vasopressors, lipid emulsion [1] [2]
Prognosis High risk of death [2]
Frequency> 10,000 (US) [2]

Calcium channel blocker toxicity is the taking of too much of the medications known as calcium channel blockers (CCBs), either by accident or on purpose. [3] This often causes a slow heart rate and low blood pressure. [1] This can progress to the heart stopping altogether. [2] Some CCBs can also cause a fast heart rate as a result of the low blood pressure. [4] Other symptoms may include nausea, vomiting, sleepiness, and shortness of breath. [2] Symptoms usually occur in the first six hours but with some forms of the medication may not start for 24 hours or more. [2]

Contents

There are a number of treatments that may be useful. [1] These include efforts to reduce absorption of the drug including: activated charcoal taken by mouth if given shortly after the ingestion or whole bowel irrigation if an extended release formula was taken. [1] Efforts to bring about vomiting are not recommended. [1] Medications to treat the toxic effects include: intravenous fluids, calcium gluconate, glucagon, high dose insulin, vasopressors and lipid emulsion. [1] [2] Extracorporeal membrane oxygenation may also be an option. [1]

More than ten thousand cases of calcium channel blocker toxicity were reported in the United States in 2010. [2] Along with beta blockers and digoxin, calcium channel blockers have one of the highest rates of death in overdose. [2] These medications first became available in the 1970s and 1980s. [2] They are one of the few types of medication in which one pill can result in the death of a child. [2]

Signs and symptoms

Most people who have taken too much of a calcium channel blocker, especially diltiazem, get slow heart rate and low blood pressure (vasodilatory shock). [1] This can progress to the heart stopping altogether. [2] CCBs of the dihydropyridine group, as well as flunarizine, predominantly cause reflex tachycardia as a reaction to the low blood pressure. [4] [5] [6]

Other potential symptoms include: nausea and vomiting, a decreased level of consciousness, and breathing difficulties. [2] Symptoms usually begin within 6 hours of taking the medication by mouth. [2] With extended release formulations symptoms may not occur for up to a day. [2] Seizures are rare in adults but in children occur more often. [2] Hypocalcaemia may also occur. [7]

Cause

Calcium channel blockers, also known as calcium channel antagonists, are widely used for a number of health conditions. [8] Thus they are commonly present in many people's homes. In young children one pill may cause serious health problems and potentially death. [8] The calcium channel blocker that caused the greatest number of deaths in 2010 in the United States was verapamil. [2] This agent is believed to cause more heart problems than many of the others. [2]

Diagnosis

A blood or urine test to diagnose overdose is not generally available. [2] CCB overdose may cause high blood sugar levels, and this is often a sign of how severe the problem will become. [1]

Electrocardiogram

CCB toxicity can cause a number of electrocardiogram abnormalities with a low sinus rhythm being the most common. [1] Others include: QT prolongation, bundle branch block, first-degree atrioventricular block, and even sinus tachycardia. [1]

Differential

It may not be possible to tell the difference between beta blocker toxicity and calcium channel blocker overdose based on signs and symptoms. [1]

Management

The medical management of CCB toxicity may be difficult. [1] It may not improve with the usual treatments used for a low blood pressure and a slow heart rate. [9] Those who have no symptoms or signs six hours following taking an immediate release formulation and 24 hours after taking an extended release formulation generally need no further medical treatment. [2]

Detoxification

Activated charcoal is recommended if it can be given within an hour or two of taking the calcium channel blockers. [1] In those who have taken an extended release formulation of a CCB but are otherwise doing fine, whole bowel irrigation with polyethylene glycol may be useful. [1] Causing vomiting by the use of medications such as ipecac is not recommended. [1]

Insulin

High doses of intravenous insulin with glucose may be useful and are a first line treatment in overdoses. [1] [10] As this treatment may cause a drop in blood sugar and blood potassium levels, these should be monitored closely. [11]

Other

Intravenous calcium gluconate or calcium chloride is considered a specific antidote. [12] Slow heart rate can be treated with atropine and sympathomimetics. Low blood pressure is treated with vasopressors such as adrenaline. [6] [13]

There is tentative clinical evidence and good theoretical evidence of the benefit of lipid emulsion in severe overdoses of CCBs. [14] Methylene blue may also be used for those with low blood pressure that does not respond to other treatments. [10]

Epidemiology

More than 10,000 cases of potential calcium channel blocker toxicity occurred in the United States in 2010. [2] When death occurs in medicine overdose, heart medications are the cause more than 10% of time. [2] The three most common types of heart medications that result in this outcome are calcium channel blockers along with beta blockers and digoxin. [2]

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Palatnick, Wesley (Feb 2014). "Emergency Department Management of Calcium-Channel Blocker, Beta Blocker, and Digoxin Toxicity". Emergency Medicine Practice. 16 (2): 1–19, quiz 19-20. PMID   24883458. Archived from the original on 2014-05-14.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Marx, John A. Marx (2014). "Cardiovascular Drugs". Rosen's emergency medicine: concepts and clinical practice (8th ed.). Philadelphia, PA: Elsevier/Saunders. pp. Chapter 152. ISBN   978-1455706051.
  3. 1 2 "Calcium channel blocker overdose". ADAM. 2011-01-19. Archived from the original on 5 April 2014. Retrieved 9 May 2014.
  4. 1 2 Wolfson, Allan B. (2010). Harwood-Nuss' clinical practice of emergency medicine (5th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. p. 1454. ISBN   9780781789431. Archived from the original on 15 August 2016. Retrieved 28 July 2016.
  5. ↑ Mutschler, Ernst (2013). Arzneimittelwirkungen (in German) (10 ed.). Stuttgart: Wissenschaftliche Verlagsgesellschaft. p. 1037. ISBN   978-3-8047-2898-1.
  6. 1 2 Haberfeld, H, ed. (2015). Austria-Codex (in German). Vienna: Österreichischer Apothekerverlag. Adalat; Norvasc; Sibelium; Zanidip.
  7. ↑ Soar, J; Perkins, GD; Abbas, G; Alfonzo, A; Barelli, A; Bierens, JJ; Brugger, H; Deakin, CD; Dunning, J; Georgiou, M; Handley, AJ; Lockey, DJ; Paal, P; Sandroni, C; Thies, KC; Zideman, DA; Nolan, JP (October 2010). "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution". Resuscitation. 81 (10): 1400–33. doi:10.1016/j.resuscitation.2010.08.015. PMID   20956045.
  8. 1 2 Olson, Kent (2011). "Calcium Channel Antagonists". Poisoning & drug overdose (6th ed.). New York: McGraw-Hill Medical. pp. Chapter 40. ISBN   978-0071668330.
  9. ↑ Shepherd, G (Oct 1, 2006). "Treatment of poisoning caused by beta-adrenergic and calcium-channel blockers". American Journal of Health-System Pharmacy. 63 (19): 1828–35. doi:10.2146/ajhp060041. PMID   16990629.
  10. 1 2 Graudins, A; Lee, HM; Druda, D (7 September 2015). "Calcium channel antagonist and beta-blocker overdose: antidotes and adjunct therapies". British Journal of Clinical Pharmacology. 81 (3): 453–61. doi:10.1111/bcp.12763. PMC   4767195 . PMID   26344579.
  11. ↑ Engebretsen, KM; Kaczmarek, KM; Morgan, J; Holger, JS (Apr 2011). "High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning". Clinical Toxicology. 49 (4): 277–83. doi:10.3109/15563650.2011.582471. PMID   21563902. S2CID   32138463.
  12. ↑ "Calcium channel blocker poisoning". UpToDate. Retrieved 2019-07-09.
  13. ↑ Haberfeld, H, ed. (2015). Austria-Codex (in German). Vienna: Österreichischer Apothekerverlag. Verapabene.
  14. ↑ Rothschild, L; Bern, S; Oswald, S; Weinberg, G (Oct 5, 2010). "Intravenous lipid emulsion in clinical toxicology". Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 18: 51. doi: 10.1186/1757-7241-18-51 . PMC   2958894 . PMID   20923546.
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