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Successful treatment of severe quetiapine intoxication with CytoSorb hemoadsorption
Caterina Reuchsel Falk A. Gonnert | Department of Anesthesiology and Intensive Care Medicine, SRH Klinikum Gera, Gera, Germany | Journal of Clinical Pharmacy and Therapeutics 2022: epub
05/25/2022
New!Peer Reviewed Published DataSafetyStandalone (HP)Anticoagulation OthersCase of the weekCase reportCritical CareDrug removalIntoxication
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Summary
CoW 21/2022 – A 64-year-old female was admitted to the Emergency Department after she was found somnolent by her daughter.
Summary
In this case report a 64 yr old woman who had attempted suicide by ingesting an unknown amount of the tricyclic antidepressant, quetiapine, was admitted to intensive care in a deeply somnolent state. CytoSorb hemoadsorption was started on the second day of admission due to her not improving clinically, and potentially lethal levels of quetiapine being found in her blood and urine. Pre and post CytoSorb adsorber blood samples confirmed direct removal and there was a clear and rapid decrease in plasma levels of the drug over the following few hours. The following day the patient could be extubated and was alert and cooperative. CytoSorb was discontinued after 2 days, whereby the patient was discharged in to the care of psychiatry. The authors describe CytoSorb as an alternative novel therapeutic option for life threatening complications of quetiapine intoxication. In order to maintain optimal removal capacity it is recommended that the adsorber be changed after 8 – 12 hrs.
Case presentation
Due to a severe episode of recurrent depression, the patient had been undergoing partial day-care treatment in a peripheral hospital with several changes to her antidepressant therapy. As she did not show up for routine treatment and as no contact could be established by telephone, her daughter was contacted via the police, who then found her mother somnolent in her apartment
Upon arrival of the emergency doctor, a Glasgow-Coma-Scale (GCS) score of 10 was determined, accompanied by a blood pressure of 153/80 mmHg, normofrequent sinus rhythm, no widening of the QRS complex on the electrocardiogram (ECG), an SpO2 of 93% on room air, deep breathing, partly snoring, pupils isocoric and miotic
After a closer search of the apartment the next day, empty blisters of quetiapine tablets were found. In the Emergency Department, the patient was still soporific (GCS 8) with preserved protective reflexes, respiratory and hemodynamically stable, and unremarkable arterial blood gas analysis
Chest X-ray showed no clear pulmonary consolidations, no major pleural effusions or higher-grade congestions
Native and angio-computed tomography showed no occlusions of the brain-supplying arteries, inconspicuous basilar artery, and unspecific patchy milky opacity in the upper lobe of the lung
Subsequently, the patient was admitted to the intensive care unit (ICU)
Due to subfebrile temperatures up to 37.7°C, suspected infiltrates and nitrite-negative leukocyturia found on the chest X-ray and CT, blood cultures, urine and tracheal secretions were taken for microbiological diagnosis and a calculated antibiotic treatment was started with ampicillin plus sulbactam
The following day, additional blood and urine were sent for analysis revealing quetiapine intoxication with levels in the potentially lethal range (>1mg/l), other psychotherapeutic drugs were within the normal range
For primary toxin elimination and because of possible bezoar formation with the risk of mucosal ulceration, a gastroscopy was performed on the same day with recovery of small tablet remnants
For this, the patient was analgosedated, intubated and ventilated
Minor ulcerations of the gastric mucosa were found, hence pantoprazole (40 mg 2 x daily) was started
Since quetiapine is in principle not dialysable, a hemoadsorption procedure with CytoSorb was deemed a potential therapeutic option, which was then started the same day following placement of a Shaldon catheter into the right femoral vein
Treatment
In total, 2 hemoadsorbers were used for 40 consecutive hours
Hemoadsorption treatment was run in conjunction with a Multifiltrate machine (Fresenius Medical Care, Germany)
Blood flow rate: 100 ml/min
Enoxaparin was used for anticoagulation
Measurements
Quetiapine and norquetiapine levels pre- and post adsorber cartridge
Results
Measurements showed the pronounced direct removal of both substances, as well as a clear and rapid decrease in plasma quetiapine levels over the next few hours
Patient Follow-up
The next day, analgesia was stopped and the patient was alert and cooperative, so that she could be extubated without problems
Prior to this, a bronchoscopy was performed in which purulent secretions were aspirated from the left lung
CytoSorb treatment was discontinued after 2 days
One day later, the patient could be transferred to a psychiatric clinic
Conclusion
In this case, the use of CytoSorb following application of all available standard therapeutic measures helped to quickly and efficiently reduce quetiapine and norquetiapine to non-toxic serum levels and to stabilize the patient’s clinical condition
The decision to use CytoSorb in this patient was based on the rationale of its highly absorptive capacity and potential capability to bind excess levels of these substances
Compared to previous data (Giuntoli et al., IJAO 2019), this report confirms the direct removal of the drug based on pre and post cartridge measurements and might help to understand the pharmacokinetics of quetiapine overdose, particularly when hemoadsorption is applied for acceleration of the elimination process
Based on the observation of a potential saturation effect after around 8 hours, routine adsorber changes within 8-12 hours max might be recommended to maintain optimal removal capacity
Therefore, in the absence of a proven beneficial treatment regimen, the use of CytoSorb might represent an alternative treatment for life threatening complications of quetiapine intoxication.
