Glucagon in tricyclic overdose
Date First Published:
June 28, 2002
Last Updated:
May 15, 2003
Report by:
Stewart Teece, Clinical Research Fellow (Manchester Royal Infirmary)
Search checked by:
Kerstin Hogg, Manchester Royal Infirmary
Three-Part Question:
In [overdose with tricyclic antidepressants] does [the addition of glucagon to standard treatments] improve [clinical outcome]?
Clinical Scenario:
A 27 year old woman attends the emergency department with a suspected amitriptyline overdose. She has a Glasgow Coma Score of 7, is trypsilating, and has a broad complex tachycardia and a blood pressure of 70/30. After intubation and ventilation and sodium bicarbonate she remains tachycardic at 130 although her complexes have narrowed somewhat and her BP is still low at 80/40. You have heard that tricyclic overdoses may respond to glucagon and wonder whether there is any evidence for this.
Search Strategy:
Medline 1966-02/03 using the OVID interface.
Search Details:
[(exp antidepressive agents OR exp antidepressive agents, tricyclic OR exp desipramine OR exp amitriptyline OR tricyc$.af OR amitriptyline.af OR amoxapine.af OR clomipramine.af OR doxepin.af OR dothiepin.af OR imipramine.af OR lofepramine.af OR nortriptyline.af OR trimipramine.af) AND (exp glucagon OR glucagon.af)] Limit to human AND English.
Outcome:
Altogether 31 papers found, 28 failed to answer the 3 part question, the 3 relevant papers are case reports summarised below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Management of tricyclic antidepressant ingestion in children with special reference to the use of glucagon. Ruddy JM, Seymour JL, Anderson NG. 1972, Australia | 4 year old ingested approx 1000mg imipramine, episode of PEA 1.5 hours duration | Case report | Cardiac status | Improved with 1 mg boluses glucagon | Case report Pt also received pyridostigmine, sodium bicarbonate, isoprenaline, digoxin, lignocaine and mannitol |
| Response to glucagon in imipramine overdose. Sener EK, Gabe S, Henry JA. 1995, UK | 25 year old woman. Plasma toxicology - imipramine 3.0mg/l, desipramine 0.18 mg/l, diazepam 2.9mg/l, nordiazepam 2.2mg/l, chlorpromazine 0.3mg/l, temazepam 0.25mg/l | Case report | Blood pressure | No response to 1mg bolus glucagon. 40mmHG systolic rise after glucagon | Multiple drugs ingested in overdose Pt also received sodium bicarbonate, phenytoin and isoprenaline and fluid resuscitation |
| Cardiac rhythm | No response to 1mg bolus glucagon. Broad complex reverted to sinus after 10mg bolus | ||||
| High dose intravenous glucagon in severe tricyclic poisoning. Sensky PR and Olczak SA. 1999, UK | 36 year old OD-admission toxicology dothiepin 2.58mg/l, desmethyldothiepin 0.51mg/l, paracetamol 135mg/l, diazepam 0.33mg/l, nordiazepam 0.12mg/l | Case report | Blood pressure | No response to 1mg bolus glucagon. 30mmHG systolic rise after glucagon | Case Report Multiple drugs ingested in overdose Pt also received n-acetylcysteine, adrenaline, noradrenaline, ephedrine, dobutamine, and aminophylline with fluid restriction |
| Cardiac rhythm | No response to 1mg bolus glucagon. Broad complex reverted to sinus after 10mg bolus |
Author Commentary:
Although all 3 patients received multiple treatments the authors state the improvement in condition was immediately after high dose glucagon administration. TNo reports of failure to response to glucagon are found in the literature. This is most probably attributable to reporting bias. Further research is required.
Bottom Line:
There is not enough evidence currently available to support the use of glucagon in tricyclic overdose.
References:
- Ruddy JM, Seymour JL, Anderson NG.. Management of tricyclic antidepressant ingestion in children with special reference to the use of glucagon.
- Sener EK, Gabe S, Henry JA.. Response to glucagon in imipramine overdose.
- Sensky PR and Olczak SA.. High dose intravenous glucagon in severe tricyclic poisoning.