Successful Treatment of Severe Lamotrigine Intoxication with CytoSorb Hemoadsorption

Abstract

Severe intoxication with the anti-epileptic drug, lamotrigine can cause cardiovascular collapse, neurotoxicity – expressed as intractable seizures, and even death. As there is currently no known specific antidote, extracorporeal removal therapies such as CytoSorb hemoadsorption might represent a promising therapeutic option. We report on a deeply comatosed 60-year-old woman who was treated in our intensive care unit with severe lamotrigine intoxication. To support removal from the blood, combined treatment with continuous veno-venous hemodialysis and CytoSorb hemoadsorption was started. Pre- and post-adsorber drug level measurements showed the rapid elimination of lamotrigine accompanied by an impressive clinical improvement in the patient. Two days after treatment discontinuation, there were no more clinical signs of intoxication and the patient could be extubated, followed by transfer to the stroke unit in a stable condition the following day. In the absence of a viable antidote, for the efficient short-term removal of lamotrigine, hemoadsorption with the CytoSorb device could represent a feasible treatment option for patients with severe lamotrigine intoxication.

Quand une détoxication maximale est-elle directement indiquée?

“…Ce système de filtra tion a été conçu pour réduire les taux de cytokines/bilirubine/myoglobine et est utilisé dans différents types d' états hyperinflamma toires, ainsi que pour réduire les cytokines dans le cadre d'une ECMO. Des cas d' élimina tion réussie de différents principes actifs hydro phobes (entre autres digoxine, lamo trigine, venlafaxine) par une nette réduction des concentrations plasmatiques ont été dé crits [10][11][12]. Dans notre cas, une réduction substantielle de la concentration plasmatique a été observée après 72 heures.…”

Severe Clozapine Poisoning Treated by Extracorporeal Blood Purification Therapy

“…Not in all those cases a direct impact of the adsorber could be proven, but the use of CytoSorb in intoxications could also be reasonable to address complications like rhabdomyolysis, liver failure, or systemic hyperinflammation. Reuchsel et al [ 8 ], however, had measured pre- and post-adsorber levels when using CytoSorb in the setting of lamotrigine intoxication and also suspected saturation much earlier than after the maximum use time per adsorber of 24 h. Reduced elimination can of course also occur due to the concentration-dependency of CytoSorb removal with reduced efficacy in low(er) concentrations, but an appropriate dosing of therapy, which is the length of the overall therapy (i.e., number of adsorbers applied) as well as its intensity (i.e., time interval per adsorber), is becoming generally more and more recognized as an important aspect to ensure therapeutic success. So also in the classic field of septic/vasoplegic shock, recommendations by the manufacturer are given to exchange the adsorber after 12 h in case of ongoing (or newly developing) instability, however, a structured investigation of this approach is not yet available.…”

Extracorporeal hemoadsorption with the CytoSorb device as a potential therapeutic option in severe intoxications: Review of the rationale and current clinical experiences

“…Efficient removal of the anti‐epileptic lamotrigine using hemoadsorption has recently been shown by Reuchsel et al 15 In the absence of a known specific antidote, extracorporeal blood purification therapy (Continuous Veno‐Venous Haemodialysis plus CytoSorb) was used in a deeply comatosed 60‐year‐old patient. Measurement of pre and postadsorber drug levels suggested rapid elimination of the drug and a concomitant impressive improvement in the patient's clinical condition, primarily in vigilance.…”