Sulpiride intoxication: Case report of a rare intoxication.

Intoxications with sulpiride, an antipsychotic, are rare, and only limited literature is available. We describe a successful treatment of a sulpiride intoxication. A 67-year-old female, with a history of intentional suicide attempt, was admitted to the emergency department (ED) because of a suspected out-of-hospital cardiac arrest. At presentation, she was haemodynamically unstable, with a Glasgow Coma Scale of 3 and slight prolongation of QTc time. History taken from her husband raised suspicion of a suicide attempt with medication. Consultation of the on-call pharmacist and performance of a toxicology screening accelerated the diagnosis of a sulpiride intoxication. The patient was intubated because of respiratory insufficiency, admitted to the Intensive Care Unit (ICU) and treated with activated charcoal, laxatives and sodium bicarbonate. The following day, she was extubated with stable haemodynamics and a normalized ECG. Treatment of sulpiride intoxications is mainly symptomatic and consists of supportive care. An important note is the avoidance of antiarrhythmic drugs, except for lidocaine, epinephrine and dopamine, as they might worsen arrhythmia and hypotension.

Prolonged QT Risk Assessment in Antipsychotic Overdose Using the QT Nomogram.

STUDY OBJECTIVE: Antipsychotic drugs are frequently reported to cause QT prolongation and torsade de pointes. We aim to investigate the potential risk of torsade de pointes in antipsychotic overdose by assessing the QT interval with the QT nomogram. METHODS: All presentations to a toxicology service between January 1987 and May 2013 were reviewed. Admissions with single ingestions of an antipsychotic greater than maximum daily dose were extracted. Demographics, dose, ECG, and outcomes (arrhythmias and death) were obtained. QT intervals in multiple leads were manually measured and the median taken. QT-heart rate (QT-HR) pairs were plotted on the QT nomogram and defined as prolonged if above the abnormal line. The QTcF (Fridericia's HR correction) was calculated and compared with dose. RESULTS: From 2,356 antipsychotic overdoses, 494 were included. There were no abnormal QT-HR pairs in 4 aripiprazole, 31 pericyazine, 14 trifluoperazine, and 7 haloperidol overdoses. Abnormal QT intervals occurred in 9 of 16 amisulpride overdoses (56%; 95% confidence interval [CI] 31% to 79%), 16 of 57 thioridazine overdoses (28%; 95% CI 17% to 42%), and 5 of 29 chlorpromazine overdoses (17%; 95% CI 7% to 36%). Abnormal QT intervals occurred in 5 of 41 risperidone overdoses (12%; 95% CI 5% to 27%), 10 of 202 quetiapine overdoses (5%; 95% CI 3% to 9%), and 2 of 76 olanzapine overdoses (3%; 95% CI 0.5% to 10%), but there was no correlation between dose and QTcF, and most abnormal QT intervals were at fast HR. An additional 186 single antipsychotic ingestions with noncardiotoxic coingestants had similar proportions of abnormal QT. There was 1 case of torsade de pointes in a thioridazine overdose. CONCLUSION: There appeared to be significant risk of QT prolongation with amisulpride and thioridazine overdoses. Although there were abnormal QT intervals for quetiapine, olanzapine, and risperidone overdoses, they were associated with tachycardia and not dose dependent, and so were unlikely to be associated with increased torsade de pointes risk.

Poisoning: fact or fiction?

Analytical toxicology is a complex discipline. Simply detecting a poison in a biological sample does not necessarily mean that the individual from whom the sample was obtained had been poisoned. An analysis can prove exposure and perhaps give an indication of the magnitude of exposure, but the results have to be placed in proper context. Even if sampling was ante-mortem an analysis does not necessarily prove the effects that the drug or poison had on the victim immediately before or at the time of sampling. Tolerance is one big issue, the mechanism of exposure (how the drug got into the body) is another, and of course with post-mortem work there are always additional considerations such as site of sample collection and the possibility of post-mortem change in analyte concentration. There are also questions of quality and reliability, and whether a particular analysis and the interpretation placed upon the result are appropriate in a particular case.

[Sulpiride poisoning--case report confirmed with the quantitative determination of the xenobiotic serum level]. / Zatrucie sulpirydem--opis przypadku potwierdzony ilosciowym oznaczeniem stezenia ksenobiotyku w surowicy.

Despite above 40 years the presence of sulpride on the pharmaceutical market, the acute poisonings are poorly reported in the medical literature. The discussed case of sulpiride intoxication concerns ingestion probably dose of 12 g, that exceeded 10-fold maximum therapeutic dose. 16-year-old girl, with no previous sulpiride treatment, was admitted to the Toxicology Department about 3 hours after ingestion. In clinical picture she presented quantitative consciousness disturbances with maximum 10 scores in GCS scale, with tendency to low BP (minimum 88/45 mmHg) and episode of orthostatic hypotension. The ECG demonstrated: normogram, sinus tachycardia with a heart rate of 125 beats/min, PQ = 120 ms, QRS = 80 ms, prolongation of QTc to 519,6 ms and unspecific changes of ST-T syndrome. The qualitative toxicological test confirmed the presence of chlorprothixene in urine, but the serum therapeutic concentration (0.126 microg/ml) excluded the overdose. The quantitative determination of sulpiride serum concentration confirmed acute sulpiride poisoning. The measured sulpiride toxic concentration on admission and in the consecutive hours were from 13.2 to 8.2 microg/ml. Sulpiride toxicokinetic parameters such as t max = about 3 h, t 1/2 = 24.02 h, k(el) = 0.029 h(-1) were also estimated. They point out that the absorption rate is similar and the elimination is prorogated in sulpiride acute poisoning compared to therapeutic doses.

Prediction of torsade de pointes from the QT interval: analysis of a case series of amisulpride overdoses.

Electrocardiograms (ECGs) from a case series of 86 amisulpride overdose events in 66 patients were reviewed for abnormal QT intervals and torsade de pointes (TdP). Eight patients exhibited TdP. In this investigative case series, the magnitude of prolongation of the QT interval was a stronger predictor of TdP than the mere presence of a prolongation per se.

Amisulpride overdose: suggested management of prolonged QTc.

A case of amisulpride overdose is presented and its effect on prolonging the QT (corrected) interval is discussed. Amisulpride is used for the treatment of schizophrenia and part of its safety profile is that is has no effect on the QT interval in therapeutic doses. The efficacy of intravenous calcium in restoring the QT to normal is proposed.

Amisulpride overdose is frequently associated with QT prolongation and torsades de pointes.

This study aimed to describe the effects of the antipsychotic amisulpride in overdose, including the frequency of QT prolongation and torsades de pointes. Cases of amisulpride overdose (>1 g) were recruited from 2 state poison centers and a tertiary toxicology unit over 5 years. A 1-page clinical research form was used to collect clinical information. Copies of all electrocardiograms were obtained. Electrocardiogram parameters (QRS and QT intervals) were manually measured as previously described, and plots of QT-heart rate (HR) pairs were compared with the QT nomogram. There were 83 patients with amisulpride overdoses with a median age of 29 years (interquartile range [IQR], 23-40 years), and 42 (51%) were female. The median dose ingested was 6 g (IQR, 3-13 g, range, 1.2-120 g). The median HR was 66 beats/min (IQR, 60-81 beats/min). Bradycardia occurred in 20 cases (24%), and hypotension in 19 (23%). From 440 electrocardiograms (average of 5 per case; range, 1-15), an abnormal QT-HR pair occurred in 61 cases (73%). Torsades de pointes developed in 6 cases (7%), with doses of 4, 4.6, 18, 24, 32, and 80 g. The patient taking 32 g died after a cardiac arrest. Widened QRS did not occur except transient rate-dependent bundle-branch block in 3 cases. There were significant associations of bradycardia, hypokalemia, and hypocalcaemia, with QT prolongation and torsades de pointes. Central nervous system effects were uncommon with coma in 7 cases, seizures in 2, and dystonic reactions in 2. Amisulpride overdose commonly causes QT prolongation, bradycardia, and hypotension. Torsades de pointes occurred commonly enough to suggest that amisulpride is highly cardiotoxic in overdose.

[Toxicity of sulpiride]. / Toksycznosc sulpirydu.

Sulpiride is a benzamide neuroleptic used in the treatment of some psychiatric and gastroenterological disorders. Its antipsychotic, antiautistic, activizing and antidepressive properties result from antagonistic action to dopaminergic D2, D3 and D4 receptors in the central nervous system (CNS). The oral bioavailability of sulpiride is poor and it does not appear to have an extensive first-pass metabolism, nor is it extensively protein-bound. Elimination of sulpiride appears to depend primarily on the kidneys. The acute sulpiride poisoning includes mainly neuropsychiatric (i.e., agitation, hallucinations, and CNS depression) as well as cardiac effects (i.e., hypotension, dysrhythmias, and sinus tachycardia). The life-threatening conditions with sometimes fatal outcome after sulpiride poisoning are prolongation of QTc interval with consequent torsade de pointes (TdP) and neuroleptic malignant syndrome (NMS). The quantitative methods for the measurement of sulpiride blood concentration are not routinely available and the toxic blood concentration is probably higher than 2 mg/L. Treatment of acute sulpiride poisoning includes standard protocols of gastrointestinal decontamination and further symptomatic and supportive measures, among them TdP (magnesium sulphate, isoproterenol, electrotherapy) and NMS treatment (benzodiazepines, bromocriptine, dantrolene, physical cooling).

Long QT syndrome and torsades de pointes induced by acute sulpiride poisoning.

Sulpiride, a selective dopamine D2 antagonist and a substituted benzamide derivative, is considered a safe antipsychotic and antidepressant agent with few adverse effects on the cardiovascular system. Sulpiride-induced torsades de pointes is rare. We report a case of long QT syndrome and torsades de pointes induced by ingestion of 1.5 g of sulpiride. Ventricular arrhythmia was initially treated with amiodarone, without success. Eventually, lidocaine and magnesium sulfate successfully terminated the ventricular arrhythmia. The patient was discharged uneventfully after 3 days of hospitalization. This case illustrates the fact that acute sulpiride poisoning may lead to life-threatening ventricular arrhythmia. Early recognition followed by effective therapy is crucial. Intensive cardiac monitoring is recommended for sulpiride poisoning.

Fatality due to amisulpride toxicity: a case report.

Amisulpride is an atypical antipsychotic agent effective in the treatment of schizophrenia. There are few cases in the literature relating to the toxicity of this agent and reported fatalities are rare. Drug induced prolongation of the QT interval of the electrocardiograph (ECG) is increasingly recognised with various classes of drugs and in particular with antipsychotics. Cardiotoxicity can manifest as ventricular tachyarrhythmia, including torsades de pointes (TdP), complicating QT prolongation. We report a case of fatal amisulpride toxicity where the post-mortem blood concentration was 48 mg/L. Hitherto under-recognised toxic effects of novel chemotherapeutic agents can pose challenges for the forensic pathologist charged with performing medico-legal autopsies in cases of sudden unexpected death in young adults and particularly in those with schizophrenia. A knowledge of the ability of antipsychotic agents to induce fatal cardiac arrhythmias should inform the approach to the autopsy (including determination of the cause and mechanism of death) in such cases, as should an appreciation of the dangers inherent in the interpretation of post-mortem toxicology.

Hemoperfusion in the treatment of acute clozapine intoxication in China.

BACKGROUND AND AIMS: No systematic study has focused on the characteristics and outcome of acute clozapine intoxication, although clozapine is the most widely used antipsychotic agent in China. The study reported herein examined the features of clozapine intoxication and the therapeutic effect of hemoperfusion (HP). METHODS: In a retrospective chart review, the notes of 47 patients who attempted suicide by ingesting large amounts of clozapine and were treated at the only psychiatric emergency service in Beijing were analyzed. Of the 20 unconscious patients with plasma clozapine concentrations of more than 2000 ng/mL, 14 received a combination of HP and symptomatic treatment, whereas the other 6 and the remaining 27 patients received only symptomatic treatment. Patients' psychiatric conditions and both plasma clozapine and norclozapine concentrations were closely monitored and registered. RESULTS: One patient died of pulmonary edema and subsequent heart failure, but the rest of the patients recovered without any sequelae. Patients who received HP regained consciousness significantly faster than their counterparts with the same level of clozapine plasma concentration (>2000 ng/mL) who did not receive HP. CONCLUSIONS: A combination of HP and symptomatic treatment is the best therapeutic option when plasma clozapine concentration is high.

Amisulpride deliberate self-poisoning causing severe cardiac toxicity including QT prolongation and torsades de pointes.

Although clinical trials of the antipsychotic amisulpride revealed no cardiac adverse effects, four patients with severe cardiac toxicity after overdose were reported to Australian poisons information centres in 2004-2005. All four had QT prolongation over 500 ms, two had rate-dependent bundle branch block, two developed torsades de pointes, and one died after cardiac arrest. Pending further studies, we recommend electrocardiogram assessment until at least 16 h after amisulpride overdose and, if QT interval is prolonged, cardiac monitoring until the patient is clinically well and conduction intervals are normal.

Rapid high-performance liquid chromatographic measurement of amisulpride in human plasma: application to manage acute intoxication.

Amisulpride, a substituted benzamide derivative, is a second-generation (atypical) antipsychotic and is effective as maintenance therapy in patients with schizophrenia. For toxicological purpose, a rapid RP-HPLC assay was developed for the determination of amisulpride in human plasma. A linear response was observed over the concentration range 100-1000 ng/ml. A good accuracy (< or =5%) was achieved for all quality controls, with intra- and inter-day variation coefficients equal or inferior to 4.9%. The lower limit of quantification was 20 ng/ml, without interferences of endogenous components. This rapid method (run time <5 min) was used to monitor eight intoxications involving amisulpride.

Toxicological analysis of sulpiride in a lethal poisoning case.

A fatality following ingestion of sulpiride is presented. The drug was identified and quantitated in postmortem blood by gas chromatography-mass spectrometry and high-performance liquid chromatography with diode-array detection. The concentration was 38 microg/mL, which was in excess of 34 times the therapeutic concentration of sulpiride. For other associated drugs, their concentrations were in their therapeutic ranges.

Amisulpride poisoning: a report on two cases.

The first two observations of human poisoning involving the recently developed neuroleptic amisulpride are described. In both cases drug determination was performed using reversed-phase HPLC coupled with diode array detection. Case 1 was a nonfatal overdosage in which the ingestion of 3.0 g amisulpride induced an attack of seizures, then light coma with agitation, hyperthermia, mydriasis, minimal extrapyramidal features, tachycardia and slight prolongation of the QT interval; the blood concentration of amisulpride was 9.63 micrograms ml-1. Case 2 was a fatality attributed to amisulpride in which the measured blood concentration was 41.70 micrograms ml-1. Our results are discussed in the light of data previously reported on the toxicity of substituted benzamides.