The Journal of Emergency Medicine, Vol. 49, No. 1, p. 63, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
Letters to the Editor , COMMENTS ON: “TOXICITY OF ANTIHYPERTENSIVES IN UNINTENTIONAL POISONING OF YOUNG CHILDREN”
2. Olson KR, Erdman AR, Woolf AD, et al. Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila Pa) 2005;43: 797–822.
, To the Editor: We read with interest the article, “Toxicity of Antihypertensives in Unintentional Poisoning of Young Children” by Hetterich et al. (1). While we agree that poison centers should be consulted after pediatric exposures to antihypertensives, we have concerns about the conclusion that calcium channel antagonists (CCAs) do not share the same level of consideration as moxonidine and clonidine. With respect to the presented data, the authors mistakenly equate “potential exposures” with “poisonings,” as there is no description of how they concretely concluded that each exposure actually occurred, either via history (witnessed ingestion, etc.) or laboratory confirmation. Additionally, cases that were not followed at all should have been excluded from the analysis, as there is no way to determine whether or not symptoms developed. Overall, the authors fail to provide convincing evidence to contradict the evidence-based guidelines for CCA ingestions published by Olson et al. (2). Given their relatively low threshold for toxicity, combined with the lack of an effective evidence-based treatment regimen for toxic exposures to CCAs, we believe that all potential or confirmed pediatric CCA exposures in excess of the threshold amounts suggested by Olson et al. should be evaluated in an emergency department (2).
, RESPONSE TO CANTRELL AND VILLANO We understand your concern with the toxicity of calcium channel blockers in young children. However, although meticulously researched, the work of Olson et al. does not carry a high level of evidence. It shares the same limitation as all toxicological studies in that there is no “real” evidence with this kind of data. Interestingly, your comments read like the limitations section in Olson et al.’s article, and we fully agree with that. To our knowledge, the evidence-based recommendations by Olson et al. are based on fewer cases than were researched in our work. We agree that potential exposures and poisonings are not the same, however, witnessed ingestion is rare in children, and actual proof of ingestion approximates zero cases. Of note, in our study, cases that had no follow-up information available were excluded from affecting the assessment of toxicity. However, even assuming a worst case scenario, we did not find any severe cases with our data. We are well aware that toxicity data with calcium channel blocker exposures are conflicting and sometimes contradictory. Therefore, we advocate for the collection and sharing of additional data to reach a higher level of evidence and safety in handling calcium channel blocker exposures in young children.
F. Lee Cantrell, PHARM.D Janna Villano, MD California Poison Control System San Diego Division San Diego, CA
Michael Lauterbach, MD, PHD on behalf of his coauthors Krankenhaus der Barmherzigen Bru¨der Trier Trier, Germany
http://dx.doi.org/10.1016/j.jemermed.2014.09.070 REFERENCES 1. Hetterich N, Lauterbach E, Stu¨rer A, et al. Toxicity of antihypertensives in unintentional poisoning of young children. J Emerg Med 2014;47:155–62.
http://dx.doi.org/10.1016/j.jemermed.2015.01.020
63
Letters to the Editor , COMMENTS ON: “TOXICITY OF ANTIHYPERTENSIVES IN UNINTENTIONAL POISONING OF YOUNG CHILDREN”
2. Olson KR, Erdman AR, Woolf AD, et al. Calcium channel blocker ingestion: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila Pa) 2005;43: 797–822.
, To the Editor: We read with interest the article, “Toxicity of Antihypertensives in Unintentional Poisoning of Young Children” by Hetterich et al. (1). While we agree that poison centers should be consulted after pediatric exposures to antihypertensives, we have concerns about the conclusion that calcium channel antagonists (CCAs) do not share the same level of consideration as moxonidine and clonidine. With respect to the presented data, the authors mistakenly equate “potential exposures” with “poisonings,” as there is no description of how they concretely concluded that each exposure actually occurred, either via history (witnessed ingestion, etc.) or laboratory confirmation. Additionally, cases that were not followed at all should have been excluded from the analysis, as there is no way to determine whether or not symptoms developed. Overall, the authors fail to provide convincing evidence to contradict the evidence-based guidelines for CCA ingestions published by Olson et al. (2). Given their relatively low threshold for toxicity, combined with the lack of an effective evidence-based treatment regimen for toxic exposures to CCAs, we believe that all potential or confirmed pediatric CCA exposures in excess of the threshold amounts suggested by Olson et al. should be evaluated in an emergency department (2).
, RESPONSE TO CANTRELL AND VILLANO We understand your concern with the toxicity of calcium channel blockers in young children. However, although meticulously researched, the work of Olson et al. does not carry a high level of evidence. It shares the same limitation as all toxicological studies in that there is no “real” evidence with this kind of data. Interestingly, your comments read like the limitations section in Olson et al.’s article, and we fully agree with that. To our knowledge, the evidence-based recommendations by Olson et al. are based on fewer cases than were researched in our work. We agree that potential exposures and poisonings are not the same, however, witnessed ingestion is rare in children, and actual proof of ingestion approximates zero cases. Of note, in our study, cases that had no follow-up information available were excluded from affecting the assessment of toxicity. However, even assuming a worst case scenario, we did not find any severe cases with our data. We are well aware that toxicity data with calcium channel blocker exposures are conflicting and sometimes contradictory. Therefore, we advocate for the collection and sharing of additional data to reach a higher level of evidence and safety in handling calcium channel blocker exposures in young children.
F. Lee Cantrell, PHARM.D Janna Villano, MD California Poison Control System San Diego Division San Diego, CA
Michael Lauterbach, MD, PHD on behalf of his coauthors Krankenhaus der Barmherzigen Bru¨der Trier Trier, Germany
http://dx.doi.org/10.1016/j.jemermed.2014.09.070 REFERENCES 1. Hetterich N, Lauterbach E, Stu¨rer A, et al. Toxicity of antihypertensives in unintentional poisoning of young children. J Emerg Med 2014;47:155–62.
http://dx.doi.org/10.1016/j.jemermed.2015.01.020
63
