Correspondence Hemodialysis in an infant with propoxyphene intoxication

To the Editor: Mauer and colleagues 7 recently reported the limitations of hemodialysis in the treatment of a child with acute poisoning by propoxyphene. Their report confirmed earlier experience with an adult patient. 2 Although dialysis does not appear to offer benefit, we do not agree that "a satisfactory approach to the management of propoxyphene poisoning has yet to be described. " The narcotic antagonists nalorphine and levallorphan have been used with varying degrees of success in reversing the cardiorespiratory depressant effects of propoxyphene. However, these antagonists have agonist properties as well, and physicians confronted by a patient who had ingested an unknown drug were appropriately reticent to administer a drug that could further depress the patient who had in fact taken a non-narcotic. Similarly, if no favorable response was observed following administration of an antagonist to a patient known to have ingested a narcotic, the physician was appropriately reluctant to administer repeatedly nallorphine or levallorphan. A relatively new narcotic antagonist, naloxone, has been shown to be effective in counteracting the depressant effects of narcotics and certain narcotic-like agents. However, unlike the older antagonists, naloxone exerts no known respiratory or cardiovascular depressant properties. The safe and effective use of this drug has been described in the management of overdoses of propoxyphene3 , 5, 6 as well as methadone, 4 meperidine,! pentazocine,! and diphenoxylate. 8 The object of therapy with naloxone is to achieve a distribution of the antagonist that is sufficient to displace the ingested narcotic from its receptors. The efficacy of the antagonist is manifested clinically by (I) dilatation of con-

stricted pupils, (2) increase in the depth and rate of respiration, (3) reversal of hypotension, and (4) improvement in level of consciousness. Because it has no known agonist properties, naloxone can be used safely in patients with suspected but unconfirmed propoxyphene ingestion. In propoxyphene poisoning, one would expect to see the clinical effects of naloxone within 2 to 3 min after intravenous administration of 0.01 mg/kg. If a large amount of propoxyphene had been taken, a second or third dose (about 5 min apart) may be needed before even a minimal response is observed. If nonnarcotic depressants had been taken along with the narcotic, the only reliable sign of naloxone's effect may be dilatation of previously constricted pupils. It should be emphasized that once a favorable response to naloxone is noted, the antagonist should be used as often as necessary to maintain satisfactory cardiorespiratory function. As Drs. Mauer and colleagues noted, naloxone has a short half-life relative to that of propoxyphene, and symptoms of propoxyphene toxicity can recur at any time within the first 12 hr following ingestion. If naloxone therapy is initiated at the first sign of narcotic toxicity (usually progressive drowsiness and pupillary constriction) , the frequency of complications such as aspiration of gastric contents, cardiorespiratory depression, and seizures, may be minimized. Thus in the absence of anoxic brain damage, a patient who has taken large doses of propoxyphene can be managed satisfactorily by the appropriate use of naloxone. Allen A. Mitchell, M.D. Frederick H. Lovejoy, Jr., M.D. Clinical Pharmacology Unit Children's Hospital Medical Center Boston, Mass. 627

628

Correspondence

References 1. Evans, L. E. J., Swainson, C. P., Roscoe, P., and Prescott, L. F.: Treatment of drug overdosage with naloxone, a specific narcotic antagonist, Lancet 1:452-455, 1973. 2. Gary, N. E., Maher, J. F., DeMyttenaere, M. H., Liggero, S. H., Scott, K. G., Matusiak, W., and Schreiner, G. E.: Acute propoxyphene hydrochloride intoxication, Arch. Intern. Med. 121: 453-457, 1968. 3. Kersh, E. S.: Treatment of propoxyphene overdosage with naloxone, Chest 63:112-114,1973. 4. Lee, K. D., Lovejoy, F. H., Jr., and Haddow, J. E.: Childhood methadone intoxication, Clinical Pediatr. 13:66-68, 1974. 5. Lovejoy, F. H., Jr.: Indications for maloxone in Lomotil poisoning, Pediatrics 54:658, 1974. 6. Lovejoy, F. H., Jr., Mitchell, A. A., and Goldman, P.: The management of propoxyphene poisoning, J. Pediatr. 85:98-100, 1974. 7. Mauer, S. M., Paxson, C. L., vonHartizsch, B., Buselmeier, T. M., and Kjellstrand, C. M.: Hemodialysis in an infant with propoxyphene intoxication, CLIN. PHARM. THER. 17:88-92, 1975. 8. Rumack, G. H., and Temple, A. R.: Lomotil poisoning, Pediatrics 53:495-500, 1974.

Reply

We agree with the key point of Drs. Mitchell and Lovejoy's letter i.e., naloxone, a narcotic antagonist having "no cardiovascular or depressant properties," may have major advantages over nalorphine or levallorphan and is probably the drug of choice. Further, we did

Clinical Pharmacology and Therapeutics

stress that "narcotic antagonists are the specific antidotes for propoxyphene." However, there are reported cases of propoxyphene poisoning with failure to respond to nalorphine, despite its repeated administration. In each instance, as in our patient, the propoxyphene overdose was enormous. 1-3 It remains to be demonstrated that the patient who is unresponsive to the repeated administration of nalorphine would respond to naloxone. It is our feeling that, although most patients can be successfully managed with intensive supportive care and narcotic antagonists, there remains a group of massively poisoned patients for whom "a satisfactory approach to the management of propoxyphene poisoning has yet to be described." S. Michael Mauer, M.D. Department of Pediatrics University of Minnesota Minneapolis, Minn.

References 1. Bogartz, L. J., and Miller, W. C.: Pulmonary edema associated with propoxyphene intoxication, J. A. M. A. 215:259-262, 1971. 2. Frasier, S. D., Crudo, F. S., Jr., and Johnson, D. H.: Dextropropoxyphene hydrochloride poisoning in two children, J. Pediatr. 63:158-159, 1963. 3. Karliner, J. S.: Propoxyphene hydrochloride poisoning. Report of a case treated with peritoneal dialysis, J. A. M. A. 199: 1006-1009, 1967.

Hemodialysis in an infant with propoxyphene intoxication.

Correspondence Hemodialysis in an infant with propoxyphene intoxication To the Editor: Mauer and colleagues 7 recently reported the limitations of he...
250KB Sizes 0 Downloads 0 Views