A Case of Severe, Refractory Hypotension After Amlodipine Overdose

Abstract

Calcium channel blockers (CCBs) are responsible for a substantial portion of the mortality associated with cardiovascular medication overdose cases. Amlodipine, a dihydropyridine CCB, can cause prolonged hypotension in overdose. This report describes a severe amlodipine overdose case that was refractory to multiple therapeutic approaches. A 53-year-old male presented after ingesting eighty 10 mg amlodipine tablets in a suicide attempt. The patient was initially managed with calcium boluses, glucagon, multiple vasoactive agents, lipid emulsion infusions and hyperinsulinemic euglycemic therapy. Methylene blue boluses were initiated when hypotension persisted despite conventional treatments. Refractory hypotension prompted the use of plasmapheresis in an attempt to lower serum amlodipine levels. Finally, the patient was placed on extracorporeal membrane oxygenation (ECMO) to maintain perfusion while the effects of the amlodipine ingestion dissipated. Following an episode of asystole and pulseless electrical activity prior to the start of ECMO, the patient suffered an anoxic brain injury and suspected herniation prompting the family to withdraw medical care. There is limited evidence in the literature describing the refractory treatment modalities utilized in this patient. This report is unique as it describes the clinical course of a patient when a multitude of unique treatments were combined.

Lipid emulsion attenuates extrinsic apoptosis induced by amlodipine toxicity in rat cardiomyoblasts

“…7,8 However, some case reports have suggested that lipid emulsion may have no effect on cardiovascular collapse induced by amlodipine toxicity. 9,10 Overall, the conclusions on lipid emulsion treatment for amlodipine toxicity are conflicting. 2 –5,9,10 Amlodipine toxicity results in a negative inotropic effect and bradycardia in isolated heart preparation, and apoptosis in uveal malignant melanoma and human fibroblasts.…”

“…9,10 Overall, the conclusions on lipid emulsion treatment for amlodipine toxicity are conflicting. 2 –5,9,10 Amlodipine toxicity results in a negative inotropic effect and bradycardia in isolated heart preparation, and apoptosis in uveal malignant melanoma and human fibroblasts. 11 –14 A previous study showed that lipid emulsion attenuated apoptosis in cardiomyoblasts induced by the phenylalkylamine calcium channel blocker verapamil at toxic doses.…”

Use of veno-venous extracorporeal membrane oxygenation to treat severe combined calcium channel blocker and angiotensin converting enzyme inhibitor overdose

“…An overdose of CCB and ACE-I can result in profound hypotension and pulmonary edema requiring vasopressor and respiratory support due to the direct effect of CCB (especially cardiotoxicity) and complications of clinical management of the overdose. 2,4,5,8,9 Current expert consensus recommends VA ECMO for refractory shock due to CCB poisoning with a cardiogenic component. 3,5,8 Consequently, Chudow et al describe VA ECMO for an overdose of amlodipine; however, the patient suffered from peri-resuscitation anoxic brain injury.…”

“…3,5,8 Consequently, Chudow et al describe VA ECMO for an overdose of amlodipine; however, the patient suffered from peri-resuscitation anoxic brain injury. 9 Weinberg et al demonstrated successful VA ECMO for an overdose of amlodipine, lisinopril and hydrochlorothiazide. 10 A similar case was described in Poland.…”

Quality evaluation and UV spectrophotometric assay of ten brands of amlodipine tablets marketed in Uyo, Nigeria

“…This affects their contractile process and in turn results in reduced blood pressure and contraction of the heart. Amlodipine is administered enterally, once a day as it has a half-life of 30-60 hours [4,5]. It reaches peak plasma concentration at 6-12 hours after oral administration, has a bioavailability of 64-90% and protein binding of 93% [6,7].…”