Severe suicidal digoxin and propranolol toxicity with insulin overdose

Garg, Ashish; Panda, Soutik; Dalvi, Pradip; Mehra, Saurabh; Ray, Sumit; Singh, Vinod

doi:10.4103/0972-5229.128709

Cited by 8 publications

(2 citation statements)

References 8 publications

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“…Dysrhythmias recurred in two patients, within two hours of ECTR cessation, requiring another session [ 13 , 15 ]. Although nine patients were reported for propranolol, the clinical impact of ECTR could only be analyzed in two patients: one improved slowly after hemoperfusion [ 125 ] while the other improved after TPE but had recurrence of hypotension shortly after [ 130 ]. For acebutolol, four patients were described, three of which improved during ECTR [ 109 , 113 , 117 ], while this was uncertain in one patient who received hemoperfusion [ 112 ].…”

Section: Resultsmentioning

confidence: 99%

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

et al. 2021

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Background β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. Methods We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. Results A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. Conclusions BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.

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Section: Resultsmentioning

confidence: 99%

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

et al. 2021

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“…In clinical practice, there is a high probability of accidental intoxication with digitalis owing to the narrow therapeutic window [ 2 ]. However, the number of reported suicide cases using digoxin was significant [ 3 – 6 ]. Compared with other medications, massive digoxin intoxication after a suicide attempt is uncommon [ 1 ].…”

Section: Introductionmentioning

confidence: 99%

Successful management of massive digoxin overdose using DIGIFab and therapeutic plasma exchange: a case report

Alhussein,

Alamri,

Alhashem

et al. 2024

J Med Case Reports

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Background Despite the efficacy and safety of DIGIFab, it is relatively expensive and has limited availability. In addition, alternative interventions, such as therapeutic plasma exchange, may need to be considered in massive digoxin overdoses. Although few case reports describe its efficacy. Case presentation We report a case of a 17-year-old white male patient brought by family members to our emergency department in Riyadh, Saudi Arabia. After intentionally ingesting 48 mg of digoxin tablets to commit suicide, the patient’s initial digoxin serum level was 8.04 ng/mL. The patient was resuscitated in the emergency department. After admission to the intensive care unit, the patient underwent therapeutic plasma exchange, because of insufficient DIGIFab doses. Afterward, the serum digoxin levels drastically decreased, and his symptoms reverted. The patient was successfully managed and discharged 7 days after admission. Conclusion Despite insufficient evidence and a limited number of case reports describing the use of extracorporeal treatment in digoxin overdose, we noted the significant impact of therapeutic plasma exchange on our patient. However, therapeutic plasma exchange’s use in routine treatment requires stronger evidence to confirm its benefits.

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Intentional Insulin Overdose and Depression in Subjects with and Without Diabetes Mellitus: A Commentary

Gouveri,

Gkouveri,

Popovic

et al. 2024

Diabetes Ther

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Insulin is an essential medication for people with type 1 diabetes mellitus and for some people with type 2 diabetes. Interestingly, insulin abuse has been reported as a mode of suicide, not only among people with diabetes, but also among their relatives, and among medical and paramedical personnel who have access to insulin. The aim of the present commentary was to raise awareness of potential depression-related intentional insulin overdose and its complications, as well as of the diagnosis and treatment of this entity. Insulin overdose may lead to severe and prolonged hypoglycemia, hypoglycemic coma, and death. Moreover, hypokalemia, hypomagnesemia, hypophosphatemia, and elevated liver enzymes are common. Insulin overdose should be suspected among people with diabetes in case of unexplained prolonged hypoglycemia and among people without diabetes who exhibit hypoglycemia and may have access to diabetic medications. The ratio of insulin to C-peptide helps distinguish exogenous insulin administration from endogenous secretion. The cornerstone of therapy is prompt administration of concentrated glucose infusions for days with simultaneous oral intake, when possible, and intense glucose monitoring to prevent hypoglycemia. Moreover, monitoring of serum electrolyte levels is recommended. Finally, psychiatric evaluation aiming at early identification of depression and suicidality is of paramount importance.

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Severe suicidal digoxin and propranolol toxicity with insulin overdose

Cited by 8 publications

References 8 publications

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

Successful management of massive digoxin overdose using DIGIFab and therapeutic plasma exchange: a case report

Intentional Insulin Overdose and Depression in Subjects with and Without Diabetes Mellitus: A Commentary

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