High-dose versus low-dose antivenom in the treatment of poisonous snake bites: A systematic review

Abstract

Though snake antivenom (SAV) is the mainstay of therapy for poisonous snake bites, there is no universally accepted standard regimen regarding the optimum dose (low vs. high). We therefore, undertook this systematic review to address this important research question. We searched all the published literature through the major electronic databases till August 2014. Randomized clinical trials (RCTs) were included. Eligible trials compared low versus high dose SAV in poisonous snake bite. The review has been registered at PROSPERO (Registration number: CRD42014009700). Of 36 citations retrieved, a total of 5 RCTs (n = 473) were included in the final analyses. Three trials were open-label, 4 conducted in Indian sub-continent and 1 in Brazil. The doses of SAV varied in the high dose group from 40 ml to 550 ml, and in the low dose group from 20 ml to 220 ml. There was no significant difference between the two groups for any of the outcomes except duration of hospital stay, which was lower in the low dose group. The GRADE evidence generated was of “very low quality.” Low-dose SAV is equivalent or may be superior to high-dose SAV in management of poisonous snake bite. Low dose is also highly cost-effective as compared to the high dose. But the GRADE evidence generated was of “very low quality” as most were open label trials. Further trials are needed to make definitive recommendations regarding the dose and these should also include children <9 years of age.

Interventions for the management of snakebite envenoming: An overview of systematic reviews

“…Effectiveness and safety of SAVs : Six SRs evaluated different types of SAV for envenoming taking a snake species or genus specific approach [ 14 , 16 , 17 , 19 , 24 , 25 ], while three took a more broad non-species-specific approach [ 20 , 22 , 23 ].…”

“…The SRs which took a snake-species specific approach included 81 studies of various designs. Among the studies which took a non-species-specific approach one was an empty review [ 23 ], while the other two SRs included 31 studies in total [ 20 , 22 ].…”

Surgical Management of Snake Envenomation in Children

“…Globally, between 1.2 million and 5.5 million snakebites occur annually leading to as high as 1,84,1000 envenomings and 94,000 deaths. (1) Snake envenomation in children is a neglected tropical condition. In comparison to adults where the bite is predominantly accidental and outdoors, in children the bite is predominantly indoors.…”

Management of snakebite victims using low dose antisnake venom in a tertiary hospital in Southern Nigeria: A 5-year Retrospective study

“…This approach to snake bite management requires that victims receive polyvalent ASV at initial doses of 50mls for mild envenomations, 100mls for moderate envenomations, and 150mls for severe envenomations, despite the challenges of availability, accessibility and cost. This has led to a number of studies utilizing low dose ASV regimen (6)(7)(8), as against the conventional high doses with comparable efficacy in patient outcome. The burden of snake bite in Nigeria is highest in the northern regions especially the Benue valley where incidence as high as 467 per 100,000 PPY has been reported (9).…”