Two Cases of Fatal Amlodipine Overdose

Sklerov, Jason H.; Levine, Barry; Ingwersen, Kathleen M; Aronica-Pollack, Patricia A; Fowler, David

doi:10.1093/jat/30.5.346

Cited by 21 publications

(10 citation statements)

References 21 publications

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“…The postmortem heart blood amlodipine concentration in our patient was 1,300 ng/ml. This level is in the range of previous postmortem amlodipine concentrations after intentional large ingestions [6][7][8][9][10][11] (Table 1). Therapeutic levels of amlodipine are reported to be 1 to 24 ng/ml [1,9,12].…”

Section: Resultssupporting

confidence: 55%

“…There have been no previous reports of a fatal outcome after amlodipine ingestion in a young child [3,5]. Previous reported fatalities have occurred following intentional overdoses with suicidal intent; primarily in adults with a single pediatric fatality related to amlodipine overdose in a 15-year-old female [6][7][8][9][10][11] (see Table 1). The postmortem heart blood amlodipine concentration in our patient was 1,300 ng/ml.…”

Section: Resultsmentioning

confidence: 99%

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Amlodipine Fatality in an Infant with Postmortem Blood Levels

Spiller

Milliner

2012

J. Med. Toxicol.

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Section: Resultssupporting

confidence: 55%

Section: Resultsmentioning

confidence: 99%

Amlodipine Fatality in an Infant with Postmortem Blood Levels

Spiller

Milliner

2012

J. Med. Toxicol.

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“…8,11,[17][18][19][20] In our patient, the measurement of amlodipine levels before and immediately after plasmapheresis indicated a marked reduction in circulating levels of the drug. Serum amlodipine levels decreased by 51% after a single cycle of plasmapheresis, and no adverse side effects occurred.…”

Section: Discussionmentioning

confidence: 55%

Conventional and Unconventional Lifesaving Therapies in an Adolescent With Amlodipine Ingestion

Reuter‐Rice

Peterson

2016

Critical Care Nurse

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Amlodipine, a dihydropyridine calcium channel blocker, is commonly prescribed for the treatment of hypertension. Ingestion of an overdose leads to severe hypotension; if the hypotension is not treated, death may be imminent. Conventional and unconventional interventions were used to treat an adolescent who ingested a life-threatening dose of amlodipine. Severe hypotension resistant to conventional treatment with intralipids and hyperinsulinemia-euglycemia therapy led to the use of plasmapheresis and a pneumatic antishock garment as lifesaving measures. Plasmapheresis has been described in only one other case of severe amlodipine overdose, and the use of a pneumatic antishock garment has never been described in the management of a calcium channel blocker overdose. Because short-term use of a pneumatic antishock garment has associated risks, the critical care nurse's anticipation of side effects and promotion of safe use of the garment were instrumental in the patient's care and outcome. A standard daily dose is 2.5 to 10 mg, and the mean half-life is 30 to 55 hours.1 When inappropriate amounts are accidentally or intentionally ingested, severe hypotension and slow metabolic clearance often lead to fatality.2 The mechanism of action of amlodipine lowers the systemic vascular resistance and reduces the influx of extracellular calcium, resulting in inotropic and chronotropic effects on the myocardium. Amlodipine overdoses have been associated with near-fatal and fatal instances of hypotension and reflex tachycardia, hyperglycemia, metabolic acidosis, and pulmonary edema.3-12 Conventional therapies include calcium replacement, vaso pressors, intralipids, high-dose insulin-euglycemia therapy, and plasmapheresis to maintain end-organ perfusion. [5][6][7]10,11,[13][14][15] Critical care nurses are expected to understand conventional multimodal therapies for patients with amlodipine overdose while providing life-sustaining bedside care. At times, unconventional therapies may be used to maintain life support.

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“…Although some may view dihydropyridine poisoning as inconsequential when compared to the non-dihydropyridines, morbidity and mortality with the dihydropyridine CCBs are not uncommon, perhaps due to their widespread therapeutic availability. 10–13 …”

Section: Introductionmentioning

confidence: 99%

Efficacy of Methylene Blue in an Experimental Model of Calcium Channel Blocker–Induced Shock

Jang

Donovan

Nelson

et al. 2015

Annals of Emergency Medicine

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BACKGROUND Calcium channel blocker poisonings account for a substantial number of reported deaths from cardiovascular drugs. While supportive care is the mainstay of treatment, experimental therapies such as high dose insulin-euglycemia and lipid emulsion have been studied in animal models and used in humans. In the most severe cases even aggressive care is inadequate and deaths occur. In both experimental models and clinical cases of vasodilatory shock, methylene blue improves hemodynamic measures. Methylene blue acts as both a nitric oxide scavenger and inhibits guanylate cyclase that is responsible for the production of cGMP. Excessive cGMP production is associated with refractory vasodilatory shock in sepsis and anaphylaxis. The aim of this study was to determine the efficacy of methylene blue in an animal model of amlodipine-induced shock. METHODS Sprague-Dawley rats were anesthetized, ventilated and instrumented for continuous blood pressure and heart rate monitoring. The dose of amlodipine that produced death within 60 minutes was 17 mg/kg/hour (LD50). Rats were divided into 2 groups: amlodipine followed by methylene blue or amlodipine followed by normal saline (NS) with 15 rats in each group. Rats received methylene blue at 2 mg/kg over 5 mins or an equivalent amount of NS in three intervals from the start of the protocol: Minute 5, 30, and 60. The animals were observed for a total of 2 hours after the start of the protocol. Mortality risk and survival time were analyzed using Fisher’s exact test and Kaplan Meier survival analysis with the log rank test. RESULTS Overall, 1/15 (7%) rats in the saline-treated group survived to 120 minutes compared with 5/15 (33%) rats in the methylene blue-treated group (difference −26%, 95% CI –54%, 0.3%). The median survival time for the NS group was 42 min (95% CI, 28.1,55.9) and the methylene blue group was 109 min (95% CI, 93.9,124.1). Heart rate and MAP differences between groups were analyzed until 60 minutes. Heart rate was significantly higher in the methylene blue-treated group starting 25 min after the start of the amlodipine infusion (95% CI, 30–113) that was analyzed until 60 minutes. MAP was significantly higher in the methylene blue-treated group starting 25 min after the amlodipine infusion (95% CI, 2–30) that was analyzed up until 60 minutes. CONCLUSIONS Methylene blue did not result in a significant difference in mortality risk. There was an increase heart rate, MAP and median survival time in the methylene blue group.

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Two Cases of Fatal Amlodipine Overdose

Cited by 21 publications

References 21 publications

Amlodipine Fatality in an Infant with Postmortem Blood Levels

Amlodipine Fatality in an Infant with Postmortem Blood Levels

Conventional and Unconventional Lifesaving Therapies in an Adolescent With Amlodipine Ingestion

Efficacy of Methylene Blue in an Experimental Model of Calcium Channel Blocker–Induced Shock

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