Massive ingestion of cardiac drugs: toxicokinetic aspects of digoxin and sotalol during hemofiltration

Mulder, Verena C.; Straaten, Heleen M.H. Oudemans-Van; Zandstra, D. F.; Franssen, Eric J. F.

doi:10.3109/15563650903544132

Cited by 5 publications

(4 citation statements)

References 6 publications

(7 reference statements)

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“…Data for continuous kidney replacement therapy (CKRT) are sparse: in 3 cases of atenolol overdose, CKRT removed between 8 and 25% of total body burden adjusted for a 6-h period [ 120 , 123 , 128 ], with atenolol clearance ranging from 20 to 48 mL/min. In one sotalol overdose, CKRT clearance was estimated as 53 mL/min [ 122 ]. These clearances are considerably inferior to those achievable during high-efficiency intermittent hemodialysis (Table 2 ).…”

Section: Resultsmentioning

confidence: 99%

“…For sotalol, resolution of dysrhythmias/torsade de pointes was rapid with intermittent hemodialysis, often occurring during or just after treatment [ 13 , 15 , 35 , 115 , 116 , 121 ], while this was more protracted with slower techniques like peritoneal dialysis (PD) [ 114 ] or CKRT [ 122 ]. For atenolol (n = 9), when hemodialysis was used, an increase in blood pressure was noted after the first treatment, with one exception [ 129 ].…”

Section: Resultsmentioning

confidence: 99%

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Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

et al. 2021

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Background β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. Methods We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. Results A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. Conclusions BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

et al. 2021

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“…A case report of a patient with digoxin overingestion estimated that approximately 10% of digoxin was cleared via CVVH in five days of renal replacement therapy. 18 Data from 1977 showed that hemofiltration was able to account for >50% of normal digoxin clearance and that continuous hemofiltration could be utilized for digitalis overdosage. 19 In neither of these reports was a digoxin C uf value obtained or an Sc value calculated.…”

Section: Discussionmentioning

confidence: 98%

Management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration

Benken

Lizza

Yamout

et al. 2013

American Journal of Health-System Pharmacy

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“…In the case of Digoxin, there is quite a long initial distribution phase of about 4-8 hours that lasts 4-8 hours indicating distribution from the central compartment to peripheral tissues compartments. The elevated digoxin plasma concentrations during the distribution phase are mostly clinically irrelevant and might prompt clinicians to unnecessary actions such as adjusting the digoxin dose (Mulder et al, 2010).…”

Section: Discussionmentioning

confidence: 99%

Correlation between Serum Digoxin Concentration and Impaired Renal or/and Hepatic Functions in Cardiac Patients

Ragab

Al-Mazroua²,

Abdel-Rahman

2013

Ain Shams Journal of Forensic Medicine and Clinical Toxicology

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Digitalis toxicity is characterized by gastrointestinal, neurologic and non-specific cardiac manifestations with striking similarities to the clinical picture of primary congestive heart failure (CHF) making diagnosis of chronic digitalis toxicity in particular relatively difficult. Serum digoxin measurement is today becoming a crucial subject of concern because of the narrow therapeutic window of digoxin besides increasing mortality and morbidity due to its intoxication. The present work is focused on evaluating the clinical value of serum digoxin concentrations (SDCs) in relation to appropriate assessment of chronic digitalis toxicity in cardiac patients. The current study was conducted in the form of a cross-sectional electronic medical record (EMR) review study of patients presently on continuous prescriptions for digoxin with there being zero gaps in therapy for at least 10 days prior to SDC result entered into the Online Analytical Toxicology Request Result (OTARR). There was also a complete clinical examination report as well as a review of the results of serum potassium concentration, liver and kidney functions. This study comprised of 217 adult patients (78 males and 139 females) with mean age ± SD (63.18 ±19 years). There were high concentrations of digoxin which led to unstable renal and liver functions. About 12% of the total cases showed an abnormal serum potassium concentration of electrolyte fluctuations. From this, one can conclude that a regular monitoring of serum digoxin concentration would be seen as mandatory for the verification of digoxin's therapeutic effects and then the subsequent prevention and early diagnosis of chronic toxicity.

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Massive ingestion of cardiac drugs: toxicokinetic aspects of digoxin and sotalol during hemofiltration

Abstract: CVVH has little influence on the clearance of Fab-bound digoxin from the body. In contrast, sotalol is efficiently cleared by CVVH.

Cited by 5 publications

References 6 publications

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

Management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration

Correlation between Serum Digoxin Concentration and Impaired Renal or/and Hepatic Functions in Cardiac Patients

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