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Limited Efficacy of Gastrointestinal Decontamination in Severe Slow-Release Carbamazepine Overdose

Senior Staff Member, Israel Poison Information Center; Fellow, Unit of Clinical Pharmacology, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel

Yedidia Bentur, MD

Director, Israel Poison Information Center

Yishai Levy, MD

Director, Department of Internal Medicine D, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology

Elena Baum, MSc

Senior Laboratory Technician, Laboratory of Clinical Toxicology and Pharmacology, Israel Poison Information Center

Norberto Krivoy, MD

Director, Unit of Clinical Pharmacology, Rambam Health Care Campus, The Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology

Reprints: Dr. Lurie, Israel Poison Information Center, Rambam Health Care Campus, PO Box 9602, Haifa 31096, Israel, fax 972-4-8542092, y_lurie{at}rambam.health.gov.il

OBJECTIVE: To report the limited efficacy of both multiple doses of activated charcoal (MDAC) and whole bowel irrigation (WBI) in a patient with severe overdose of slow-release carbamazepine.

CASE SUMMARY: A 25-year-old man was admitted in a comatose state with seizures after a suicide attempt with slow-release carbamazepine. Serum carbamazepine concentration on admission (16 h postingestion) was 52.08 µg/mL. The patient was mechanically ventilated and treated with MDAC and a 4 hour charcoal hemoperfusion. Carbamazepine concentration at the end of hemoperfusion was 27.16 µg/mL. Despite continuous treatment with MDAC, a rebound in carbamazepine concentration to 36 µg/mL was observed 32 hours after hemoperfusion (58 h postingestion). WBI was performed over a 10 hour period. The carbamazepine concentration continued to increase to 38.55 µg/mL and seizures recurred. After WBI was performed, MDAC was reinstituted; 33 hours later (102 h postingestion), the carbamazepine concentration began to decline. The hospitalization course was complicated by pneumonia, which necessitated continuation of mechanical ventilation and administration of antibiotics. The patient recovered completely and was discharged without sequelae 15 days after admission.

DISCUSSION: Serum carbamazepine concentration and toxicity were effectively reduced by hemoperfusion. The role of MDAC coadministered during hemoperfusion cannot be ruled out. However, a rebound in carbamazepine concentration with recurrent seizures was observed despite MDAC and WBI. The most likely explanation for this rebound (65 h postingestion, 39 h posthemoperfusion) is prolonged absorption, possibly from a pharmacobezoar. Redistribution cannot be excluded, but this is not supported by the concentration-time course and previous reports.

CONCLUSIONS: Both MDAC and WBI may be ineffective in reducing absorption and enhancing elimination in overdose of slow-release carbamazepine. Repeated hemoperfusion or other elimination enhancement techniques should be considered when the clinical and toxicokinetic course suggests the presence of a refractory pharmacobezoar.

Key Words: activated charcoal, charcoal hemoperfusion, carbamazepine, overdose

Published Online, July 31, 2007. www.theannals.com, DOI 10.1345/aph.1K162

This article has been cited by other articles:

				O. A Odujebe, Y. Kato, and R. S Hoffman Comment: Limited Efficacy of Gastrointestinal Decontamination in Severe Slow-Release Carbamazepine Overdose Ann. Pharmacother., January 1, 2008; 42(1): 145 - 146. [Full Text] [PDF]