Reactions 1481, p14 - 7 Dec 2013

O SClomipramine/doxepin overdose

Fatal intoxication and various other toxicities due togastric pharmacobezoar: case report

A 42-year-old woman developed fatal intoxication andvarious other toxicities due to gastric pharmacobezoarformation following a massive overdose of clomipramine[Anafranil SR] and doxepin.

The woman, who had a 2-year history of depression, wasadmitted to a toxicology unit due to an overdose with suicidalintent. A letter found in her pocket by ambulance staffsuggested that she had ingested 60 sustained-releaseclomipramine 75mg tablets and 30 doxepin 25mg capsules14 hours earlier. She was deeply unconscious at hospitaladmission, with a Glasgow Coma Scale score of 5, and a BP of90/50mm Hg.

The woman was placed on controlled mechanicalventilation. Her serum concentration of tricyclicantidepressants was measured at 1955 ng/mL. Her BP wasstabilised with crystalloids and hydroxyethyl starch. Gastriclavage did not produce any tablet mass, and she wasadministered activated charcoal and sodium bicarbonate. Herclinical condition improved over the next 12 hours, shebecame conscious and mechanical ventilation was withdrawn.Her serum concentration of tricyclic antidepressantsdecreased to 999 ng/mL. However, she began to deteriorateafter another 10 hours. Disturbed consciousness occurred,and respiratory insufficiency and convulsions emerged; thesewere controlled with diazepam. She was given dopamine andepinephrine [adrenaline] for circulatory insufficiency. Herserum concentration of tricyclic antidepressants was now2011 ng/mL. Polyethylene glycols were started, anddobutamine was added. However, over the next 4 hours, shecontinued to deteriorate, becoming deeply unconscious withconvulsions reoccurring. Paralytic ileus developed, and a chestx-ray showed a possible pharmacobezoar. This was confirmedvia a CT scan, and the pharmacobezoar was surgicallyremoved. Upon crushing, the pharmacobezoar was found tobe formed entirely of tablets, corresponding to clomipramine.Her serum concentration of tricyclic antidepressants fellgradually following surgery, but no clinical improvement wasnoted. Circulatory insufficiency worsened, and indicators ofrenal and hepatic failure were seen. She died 32 hours aftersurgery to remove the pharmacobezoar. The cause of deathwas irreversible toxicity complicated by multi-organinsufficiency.

Author comment: "This paper presents a case of acuteintoxication after massive doxepin and sustained-releaseclomipramine overdosage." "Although the surgical removal ofthe pharmacobezoar resulted in gradual decrease of blood[tricyclic antidepressants] level, the patient died from multi-organ failure in [the] course of an irreversible toxicity causedby severe [tricyclic antidepressants] intoxication".Magdalan J, et al. Suicidal overdose with relapsing clomipramine concentrationsdue to a large gastric pharmacobezoar. Forensic Science International 229:e19-e22, No. 13, Jan 2013. Available from: URL: http://dx.doi.org/10.1016/j.forsciint.2013.03.025 - Poland 803096441

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Reactions 7 Dec 2013 No. 14810114-9954/13/1481-0001/$14.95 Adis © 2013 Springer International Publishing AG. All rights reserved