Repeat charcoal hemoperfusion treatments in life threatening carbamazepine overdose

Abstract

A 16-month-old female experienced a massive carbamazepine ingestion resulting in a peak serum carbamazepine concentration of 55 microg/ml. Clinical manifestations included generalized seizures, coma, shock, and gastrointestinal hypomotility. Gut decontamination was attempted using multiple-dose activated charcoal and cathartics. Because of the severity of illness, charcoal hemoperfusion was initiated. The patient underwent three sessions of charcoal hemoperfusion, each utilizing a fresh cartridge, with one session immediately following the other. Serum carbamazepine and carbamazepine-10,11-epoxide concentrations decreased from 54 microg/ml to 23 microg/ml, and 30 microg/ml to 17 microg/ml, respectively, during charcoal hemoperfusion. There were no complications. The patient recovered completely and was discharged on the 4th hospital day. Charcoal hemoperfusion should be considered for life-threatening carbamazepine intoxication, especially when drug-induced gastrointestinal hypomotility prevents elimination via the gut.

Overdose with antiepileptic drugs: the efficacy of extracorporeal removal techniques

“…This technique promotes blood circulation through an activated charcoal-containing cartridge added to the circuit of a HD machine 4 24. It has the advantage of removing toxins that are highly bound to serum proteins as activated charcoal competes with plasma proteins for drug binding 10 16 18 24. In our case, CHP led to a reduction of 53% in CBZ and 68% in VPA concentration, similar to other described cases 7 13 17.…”

“…CBZ has a molecular weight of 236 Da and a slow absorption rate that, in cases of overdose, becomes erratic and can be largely extended with peak levels occurring up to 100 h after ingestion 5 12–14 21. Additionally, elevated serum concentrations of CBZ may persist due to a continued absorption from the gut because of gastrointestinal hypomotility (anticholinergic side effect of this drug) 6 10 13 14 19. CBZ is 75 to 90% protein bound but, in concentrations higher than therapeutic, the percentage of free molecules circulating in blood is greater 5 6 19.…”

“…CHP is preferred since it is the most effective way of removing CBZ and VPA, although it is not easily accessible 5–7 10 11 13 14 17 19–23…”

Is Conventional Hemodialysis Enough to Manage Carbamazepine Intoxication?

“…However, in case of overdose, the proportion of free drug increases, theoretically making this approach more effective. Charcoal hemoperfusion may represent some side effects [5]. There is limited data on the effectiveness of plasmapheresis and plasma exchange on extracorporeal removal of CBZ [6].…”

Intoxicaciones medicamentosas (II): Analgésicos y anticonvulsivantes

“…La hemoperfusión con carbón, aunque se ha constatado que aclara CMZ del torrente sanguíneo, dada su escasa proporción y las frecuentes dificultades técnicas asociadas, ha quedado relegada a situaciones extremas de elevados niveles plasmáticos, coma persistente y patente inestabilidad hemodinámica 134 .…”