Reactions 1202 - 17 May 2008

O SClomipramine overdose

Pharmacobezoars: 2 case reportsTwo women developed pharmacobezoars after ingesting an

overdose of clomipramine in a suicide attempt. Thepharmacobezoars were successfully endoscopically removedin both women.

The first woman, aged 28 years, ingested 60 tablets of slow-release clomipramine 75mg (total dose 4.5g). She was treatedwith activated charcoal 30 minutes postingestion while beingtransported to hospital. There was no evidence of tablets influid from gastric lavage performed after arrival, and additionalactivated charcoal was administered. An abdominal x-rayperformed 4 hours postingestion suggested a largepharmacobezoar in her stomach. She was anaesthetised andintubated, and an estimated 40–50 tablets wereendoscopically crushed and extracted via suction. Sheremained asymptomatic during 24 hours of observation afterthe procedure.

The second woman, aged 25 years, ingested 80 tablets ofslow-release clomipramine [‘Anaframil-Retard’] 75mg (totaldose 6g) and 21 tablets of oxazepam. She was admittedapproximately 4 hours later after vomiting once. Her level ofconsciousness was reduced, but she was responsive to strongpainful stimuli. Her HR was 120 beats/min, her BP was150/90mm Hg and an ECG revealed sinus tachycardia withnonspecific ST-T changes. She was intubated for a plannedgastric lavage, which could not be performed due an apparentobstruction. Gastroscopy performed 5.5 hours postingestionwas used to remove a large amount of tablet residue andgranular material from 10–15cm below her larynx, a cement-like obstruction (which had to be crushed first) from her distaloesophagus and some additional tablet residue from herstomach. After the procedure, activated charcoal wasadministered via a nasogastric tube and mechanical ventilationwas started. She was extubated 20 hours postingestion andshe slowly woke up. She had returned to normal status 24hours later.

Author comment: "[T]he present report provides furtherevidence that slow release clomipramine may be capable offorming a pharmacobezoar which may be radio-opaque.Moreover, the clinical courses of our two cases suggest thattablet removal by gastroscopy should be considered inselected cases of drug poisoning."Hojer J, et al. Endoscopic removal of slow release clomipramine bezoars in twocases of acute poisoning. Clinical Toxicology 46: 317-319, No. 4, 2008 -Sweden 801080944

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Reactions 17 May 2008 No. 12020114-9954/10/1202-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved