Who gets antidotes? choosing the chosen few

Abstract

An understanding of mechanisms, potential benefits and risks of antidotes is essential for clinicians who manage poisoned patients. Of the dozens of antidotes currently available, only a few are regularly used. These include activated charcoal, acetylcysteine, naloxone, sodium bicarbonate, atropine, flumazenil, therapeutic antibodies and various vitamins. Even then, most are used in a minority of poisonings. There is little randomized trial evidence to support the use of most antidotes. Consequently, decisions about when to use them are often based on a mechanistic understanding of the poisoning and the expected influence of the antidote on the patient's clinical course. For some antidotes, such as atropine and insulin, the doses employed can be orders of magnitude higher than standard dosing. Importantly, most poisoned patients who reach hospital can recover with supportive care alone. In low risk patients, the routine use of even low risk antidotes such as activated charcoal is unwarranted. In more serious poisonings, decisions regarding antidote use are generally guided by a risk/benefit assessment based on low quality evidence.

An Appraisal of Antidotes’ Effectiveness: Evidence of the Use of Phyto-Antidotes and Biotechnological Advancements

“…Risk assessments of antidotes need to be reiterated to ensure optimal use of available antidotes for improved benefits (uncertain and time-dependent). This would prevent the unnecessary use and abuse of antidotes by clinicians and/or healthcare professionals who administer them [26,158].…”

Diagnostic accuracy for drug detection using liquid chromatography/mass spectroscopy in overdose patients

“…Information about the overdosed drugs is essential for appropriate treatment, because clinical symptoms and complications vary among drugs, and antidotes are available for some drugs. 4,5 The availability of information about causative drugs permits the use of "drug-specific treatments" in addition to general medical care. However, patients sometimes cannot provide information about overdosed drugs due to disturbed consciousness or an unwillingness to cooperate with treatment because of their desire for self-harm, and witnesses are unavailable in many cases.…”

“…Overdose patients are frequently found to have ingested many tablets, sometimes more than 100 at a time, and have often simultaneously abused several kinds of drugs to harm themselves owing to the effects of various psychiatric diseases. Information about the overdosed drugs is essential for appropriate treatment, because clinical symptoms and complications vary among drugs, and antidotes are available for some drugs . The availability of information about causative drugs permits the use of “drug‐specific treatments” in addition to general medical care.…”

Consensus statements on the approach to patients in a methanol poisoning outbreak

“…Large outbreaks typically overwhelm local health care facilities. Here, prompt triage is important but complicated [12,13]. For example, symptoms may be minimal at the time of assessment for early presentations, despite a high risk of severe toxicity.…”

“…For example, symptoms may be minimal at the time of assessment for early presentations, despite a high risk of severe toxicity. In contrast, other patients may present with such severe toxicity that very poor outcomes are anticipated regardless of the treatment received [13].…”