amlodipine poisoning

1. TOPIC: NEAR FATAL CASE OF
AMLODIPINE POISONING IN AN INFANT
INDIAN JOURNAL OF PEDIATRICS
JUNE 2013 volume 80 by Somashekar M. Nimbalkar ,Dipen
vasudev patel

2. INTRODUCTION
• Infants contribute about 5.25% of poisoning
exposure. Only one case of
amlodipine poisoning is reported in infants and
the child recovered after treatment.
• The authors report an 11 month old infant with
nearly fatal amlodipine poisoning.

3. CASE REPORT
• A 11 month old infant received 6 doses of 15mg of
amlodipine which was dispensed against
prescribed amoxicillin for lower respiratory tract
infection.
• He presented with vomitting and reduced activity.
• He worsened over few hours with increased
lethargy, bradychardia, respiratory distress and
progressive loss of consiousness , irregular heart
sounds, bilateral creptations over chest and
hepatomegaly.

4. • His blood sugar was 382mg/dl.
• On admission he had anemia.
• Blood pressure remained at 70/40 mm Hg
• He was progressed to hypotensive shock within
three hours of admission.

5. INVESTIGATION ADMISSION 24HOURS 48 HOURS 72 HOURS
s.Creatinine(mg/dl)
(0.6-1.5mg/dl)
0.59 0.81 0.49 0.34
s.Urea(8-25mg/dl) - 108 56 8
s.Sodium
(135-148mmol/l)
129 124 131 146
s.Potassium
(3.5-5.5 mmol/l)
5.8 5.7 3.6 21.9
s.Calcium(8-11mg/dl) 9.34 10.6 11.05 -

6. INVESTIGATION ADMISSION 24 HRS 48 HRS 72 HRS
Alanine transaminase
(u/l)
44 - - 124
Aspartate
transaminase(u/l)
112 - - 622
s.Total bilirubin(mg/dl) 0.24 - - 0.49
Haemoglobin(g/dl) 8.2 9.7 -
HCO3(22-29 meq/l) 17 19.3 23.6 -
PCO2(41-51mm hg) 33.4 34.6 34.6 -
PO2(30-40 mm hg) 267 356.1 398.6 -

7. • His blood sugar was found increased because
Calcium channel blockers bind to alpha unit of L-
type channel results in impaired secretion of
insulin results in hyperglycemia.
• CCB poisoning also results in insulin resistance.
• The maximum therapeutic dose of amlodipine is
0.6mg/kg per day. But the 6kg infant received 15
mg three times a day.
• Amlodipine three times a day for two days (about
12.5 times maximum dose of amlodipine).

8. TREATMENT
• He received mechanical ventilation.
• Fluid therapy with normal saline was given.
• His parameters only improved after giving insulin
0.5-1 unit/kg/hr was given for (15 hours) along with
calcium gluconate infusion for (72 hours).
• He was treated with adrenaline which is a powerful
cardiac stimulant .It acts on beta receptors and
increases heart rate, cardiac output.(as CCB in
higher dose causes decrease in heart rate,
decrease cardiac output)

9. • Calcium channel blockers usually causes negative
ionotropic effect ( weaken heart contraction and
slows the heart rate).
• So positive ionotropes such as dopamine,
epinephrine are given to change the force of heart
contractions and improves the heart rate.
• To manage renal failure , oliguria(decrease in urine
output), pulmonary edema, congestive cardiac
failure peritoneal dialysis was initiated at 24 hours
of admission and continued for 48 hours.

10.  Child improved hence insulin infusion was tapered
and stopped after 15 hours.
 Ionotropes was tapered after 48 hours.
 Calcium gluconate stopped after 72 hours.
 Liver enzymes increased after 72 hours of ingestion
without develpoment of jaundice.
 Patient was discharged after 10 days .

11. DISCUSSION
• Calcium channel blockers are a potential source of
risk for children due to the high dosage from
strength ,in relation to the body weight.
• A single dose of 10 mg nifedipine tablet was
associated with the death of an infant.
• Amlodipine has large volume of distribution and
half life is 35-45 hours and overdose causes
prolonged calcium channel blockers toxicity.

12. • Animal studies have shown insulin improves
myocardial infraction during shock induced by
calcium channel blockers toxicity.
• The author’s says that insulin therapy can be
recommended as first line therapy for calcium
channel blockers toxicity.

13. CONCLUSION
• It is said that hyperinsulinemia therapy is beneficial
in patients with calcium channel blockers induced
hypotension , hyperglyceamia and acidosis.
• High dose insulin therapy and other standard
therapies discussed above are used in
combination.
• The prescribers should avoid these kind of
medication errors in order to improve patient safety.

14. REFERENCES
• Bronstein Ac, Spyker DA , Cantilena Jr ,Green JL,
Rumack BH,2008.
• Annual report of American association of poison
control centres
• National poison data system (26 th annual report).
• Spiller HA, milliner BA amlodipine poisoning in an
infant by J.Med toxicol 2012 ;8; 179-182

15. THANK YOU