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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 28  |  Issue : 4  |  Page : 906-908
A case of severe carbamazepine overdose treated successfully with combined hemoperfusion and hemodialysis technique


1 Department of Internal Medicine, Evangelismos General Hospital, Athens, Greece
2 Department of Nephrology, Evangelismos General Hospital, Athens, Greece

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Date of Web Publication21-Jul-2017
 

   Abstract 


Carbamazepine intoxication manifests as altered mental status ranging from drowsiness to a coma and/or cardiac abnormalities such as sinus tachycardia, prolongation of the QRS interval, ventricular tachycardia, and hypotension. The patient may be agitated, but central nervous system (CNS) depression and presentation with coma is more common and could be lethal. Serious CNS toxicity often requires hemoperfusion and/or hemodialysis (HD). Herein, we present a case of a comatose patient, who was treated with a combination of hemoperfusion and HD in series. Our approach to treat the patient with a combination of hemoperfusion and HD was based on evidence from the literature supporting that the hemoperfusion and HD in series might provide the best clearance of carbamazepine.

How to cite this article:
Vallianou N, Giannopoulou M, Trigkidis K, Bei E, Margellou E, Apostolou T. A case of severe carbamazepine overdose treated successfully with combined hemoperfusion and hemodialysis technique. Saudi J Kidney Dis Transpl 2017;28:906-8

How to cite this URL:
Vallianou N, Giannopoulou M, Trigkidis K, Bei E, Margellou E, Apostolou T. A case of severe carbamazepine overdose treated successfully with combined hemoperfusion and hemodialysis technique. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2020 Aug 3];28:906-8. Available from: http://www.sjkdt.org/text.asp?2017/28/4/906/211332



   Introduction Top


Carbamazepine is used as a mood stabilizer and as an agent to overcome neuropathic pain and seizure disorders. Central nervous system (CNS) toxicity in cases of carbamazepine overdose could have detrimental effects. Herein, we present a patient with severe carbamazepine toxicity, who was comatose and who was successfully treated with combined hemoperfusion and hemodialysis (HD) technique.


   Case Report Top


A 40-year-old male patient was referred to the emergency department of our hospital due to the ingestion of unknown pharmaceutical agents in a suicidal attempt. From his past medical history, the patient had epilepsy treated with carbamazepine and oxcarbazepine.

On physical examination, the patient was in a coma, not responding to any stimuli, but occasionally performing involuntarily movements with his head and his arms and legs. He developed generalized seizures, which subsided after the administration of 1000 mg of levetiracetam intravenously. Notably, serum benzodiazepine levels were >2200 mmol/L, and thus no benzodiazepines were administered for the seizures. A nasogastric tube was inserted and activated charcoal was administered.

Due to his medical history of taking carbamazepine together with this bizarre clinical presentation, carbamazepine intoxication was suspected. The level of carbamazepine was >20 μg/mL (normal ranges: 4–12 μg/mL), and the patient was referred for HD. About 14 h after admission, the patient underwent a 4 h hemoperfusion session followed by a HD session of equal duration. Even after the first part of treatment, the patient showed signs of clinical improvement and carbamazepine level dropped to 19.97 μg/mL. As these levels are still considered highly toxic, we decided to perform a second 4 h hemoperfusion session and a subsequent 4 h HD session, after which the serum carbamazepine level decreased to 9.86 μg/mL. The neurologic status of the patient had completely resolved, the patient became alert and fully oriented, and the extracorporeal treatment was considered no longer necessary.


   Discussion Top


Carbamazepine was developed in the late 1950s as a tricyclic compound and is currently used as a mood stabilizer as well as for treating neuropathic pain and seizure disorders. It inhibits the release of glutamate and similar neurotransmitters through blockage of presynaptic voltage-gated sodium channels in the CNS. It also blocks N-methyl-D-aspartate and adenosine receptors.[1],[2]

Its absorption is slow with the peak serum concentration occurring 3 h after an oral dose, and it may take up to 24 h to peak with high doses.[1],[3] It is 80%–85% protein bound with a moderately large volume of distribution (Vd = 1.0–2.0 L/kg). However, with increasing concentrations, more free carbamazepine molecules and its metabolites appear in the blood.[4]

Toxicity from carbamazepine overdose was first described in 1967.[5] Carbamazepine intoxication manifests as altered mental status ranging from drowsiness to a coma and/or cardiac abnormalities such as sinus tachycardia, prolongation of the QRS interval, ventricular tachycardia, and hypotension, while anticholinergic signs may be present, too.[5],[6] CNS toxicity typically manifests as altered mental status. The patient may be agitated, but CNS depression is more common.[6],[7] Consciousness may fluctuate abruptly from alert to comatose.[6],[7] Ataxia, choreoathetosis, and dysmetria (loss of coordinated movement) are common.[6],[7] Seizures may occur, particularly in patients with underlying epilepsy. Serious CNS toxicity often requires HD, as did our patient, who became fully oriented and able to perform even subtle movements, despite the fact that he was in a coma with choreoathetosis before the HD treatment.

Gastrointestinal decontamination with activated charcoal is commonly used. The multiple dose regimen although proposed to enhance clearance in cases of severe poisoning has not been demonstrated to improve clinical outcome.[8] Several modalities have been used for the treatment of severe poisoning by carbamazepine overdose.[8],[9],[10] The Extracorporeal Treatments in Poisoning Workgroup (EXTRIP) was created to provide standardized clinical recommendations based on a review of all available evidence. According to the EXTRIP recommendations, carbamazepine is dialyzable and intermittent HD is the preferred modality suggested in cases of prolonged coma as was the case of our patient.[10]

In our patient, despite the above recommendation, we decided to perform a combination of hemoperfusion and HD. Hemoperfusion was traditionally considered the gold standard to eliminate highly bound substances as carbamazepine. Recent data show that HD with high-flux dialyzers has at least comparable carbamazepine clearance. Our approach to treat the patient with a combination of hemoperfusion and HD was based on evidence from the literature supporting that the hemoperfusion and HD in series might provide the best clearance.[8],[9],[10]


   Conclusion Top


We consider that dialysis techniques can be beneficial in a case of severe carbamazepine poisoning with prolonged coma and can help avoid further complications such as intubation and even death. The benefit of using hemoperfusion in combination with HD should be weighed against the cost and the higher risk of detrimental effects from carbamazepine toxicity. In our opinion, given the experience of our department, the use of both modalities was considered the optimal approach for the rapid elimination of the drug and the favorable outcome of this comatose patient.

Conflict of interest: None declared.



 
   References Top

1.
Verret S. New drugs for epilepsy: A review. Can Fam Physician 1983;29:115-8.  Back to cited text no. 1
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2.
Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care 2001;17:452-6.  Back to cited text no. 2
[PUBMED]    
3.
Hojer J, Malmlund HO, Berg A. Clinical features in 28 consecutive cases of laboratory confirmed massive poisoning with carbamazepine alone. J Toxicol Clin Toxicol 1993;31: 449-58.  Back to cited text no. 3
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4.
Brahmi N, Kouraichi N, Thabet H, Amamou M. Influence of activated charcoal on the pharmacokinetics and the clinical features of carbamazepine poisoning. Am J Emerg Med 2006;24:440-3.  Back to cited text no. 4
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5.
Güntelberg E. Carbamazepine Tegretol poisoning. A review and case report. Ugeskr Laeger 1967;129:161-3.  Back to cited text no. 5
    
6.
Spiller HA, Carlisle RD. Status epilepticus after massive carbamazepine overdose. J Toxicol Clin Toxicol 2002;40:81-90.  Back to cited text no. 6
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7.
Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf 1993;8:81-8.  Back to cited text no. 7
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8.
Payette A, Ghannoum M, Madore F, Albert M, Troyanov S, Bouchard J. Carbamazepine poisoning treated by multiple extracorporeal treatments. Clin Nephrol 2015;83:184-8.  Back to cited text no. 8
[PUBMED]    
9.
Ghannoum M, Yates C, Galvao TF, et al. Extracorporeal treatment for carbamazepine poisoning: Systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2014;52:993-1004.  Back to cited text no. 9
[PUBMED]    

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Correspondence Address:
Natalia Vallianou
Department of Internal Medicine, Evangelismos General Hospital, Athens
Greece
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PMID: 28748895

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
 

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