Refractory Shock from Amlodipine Overdose Overcomed with Hyperinsulinemia

Abstract

Intoxication from calcium channel blockers exhibits almost 50% mortality rates. Amlodipine is a long-acting dihydropyridine and inappropriate dosage poses a great threat for profound vasodilation, hypotension, and refractory vasopressor-resistant shock. A 72-year-old woman with unremarkable medical history presented to the emergency department due to amlodipine overdose after a suicide attempt attributed to COVID-19 pandemic severe anxiety disorder. Vital signs at presentation: heart rate 82 beats/ min, arterial pressure 72/55 mmHg, and oxygen saturation 98%. Resuscitation was initiated with intravenous infusion of normal saline 0,9%, noradrenaline, and calcium chloride, while activated charcoal was orally administrated; however, blood pressure remained at 70/45 mmHg. Abruptly, she experienced acute pulmonary edema and was finally intubated. We commenced high-dose insulin infusion with Dextrose 10% infusion to maintain euglycemic hyperinsulinemia. Hemodynamic improvement occurred after 30 min, systolic blood pressure raised to 95 mmHg, and decongestion was achieved with intravenous furosemide. Insulin effect was dose-dependent and patient’s hemodynamic status improved after insulin uptitration. Eight days later, the patient was weaned from the mechanical ventilation and she was successfully discharged after 14 days. High-dose intravenous infusion of insulin up to 10 units/kg per hour appears as an inotropic agent possibly through alterations in myocardial metabolism of fatty acids and augmentation of insulin secretion and uptake. This regimen possibly exhibits additional vasotropic properties. We conclude that euglycemic hyperinsulinemia is a potentially advantageous treatment in CCB toxicity.

The use of hyperinsulinemia-euglycemia therapy in the treatment of amlodipine overdose in a dog.

“…While relatively novel in veterinary medicine, HIET has the potential to significantly improve patient outcomes. In human medicine, published fatality rates for amlodipine toxicosis range from 38-50% 11,23,24 . Given the significant improvement in cardiovascular status associated with HIET therapy in the literature, it should be part of the standard of care for canine patients unresponsive to traditional therapeutic interventions or those patients who present with profound clinical signs 18,20 .…”

“…An important therapeutic intervention that has resulted in improved patient outcomes over the last 15 years in human patients is hyperinsulinemic-euglycemic therapy (HIET), with multiple publications outlining its efficacy in the human literature [10][11][12] . HIET utilizes supraphysiologic doses of insulin, with human doses ranging from 0.5-2.0 U/kg/hour, and concurrent dextrose supplementation to maintain euglycemia 12 .…”

Vasoplegic shock due to amlodipine and losartan poisoning

“…Esta terapia se denomina hiperinsulinémica euglicémica (THE) y es usada en todos los casos de intoxicación por BCC reportados en la literatura. En nuestro caso, la paciente recibió tratamiento insulínico continuo lo que aumentó su respuesta al (8,20,23) tratamiento inotrópico .…”

High‐dose insulin should NOT be used without vasopressors in calcium channel blocker toxicity

“…In addition, too early insulin withdrawal could result in recurrent hypotension in patients with CCB overdose, requiring restarting or again increasing the dose of insulin. [17][18][19] Another disadvantage of using HDI is that physicians may be unfamiliar with HDI and the implementation of this cumbersome therapy. 14 In contrast, physicians are much more familiar with the use of vasopressors in the treatment of shock.…”

“…Discontinuation of HDI and dextrose infusions requires careful monitoring. In addition, too early insulin withdrawal could result in recurrent hypotension in patients with CCB overdose, requiring restarting or again increasing the dose of insulin 17–19 …”