title: Anti-digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial.
abstract: BACKGROUND
  Severe cardiac glycoside cardiotoxicity after ingestion of yellow oleander seeds is an important problem in rural areas of Sri Lanka. Currently, patients must be transferred to the capital for temporary cardiac pacing. We did a randomised controlled trial to investigate whether anti-digoxin Fab could reverse serious oleander-induced arrhythmias.
  
  
  METHODS
  After a preliminary dose-finding study, 66 patients who presented to hospital with a serious cardiac arrhythmia were randomised to receive either 1200 mg of anti-digoxin Fab or a saline placebo. A 12-lead electrocardiogram, 3 min rhythm strip, and blood sample for measurement of electrolytes and cardiac glycosides were taken before treatment and at 12 timepoints thereafter.
  
  
  RESULTS
  34 patients received anti-digoxin Fab and 32 received placebo. The presenting arrhythmia had resolved completely after 2 h in 15 antibody-treated patients and two controls (p<0.001); 24 and five patients, respectively, were in sinus rhythm at 8 h (p<0.001). Kaplan-Meier analysis of time to first reversal showed a significant response to anti-digoxin Fab. The heart rate increased in cases, from 49.1 per min at baseline to 66.8 at 2 h, but not in controls (50.6 per min at baseline to 51.5; p<0.001). Mean serum potassium concentrations decreased from 4.9 mmol/L to 4.1 mmol/L at 2 h in cases; no such decrease occurred in controls.
  
  
  CONCLUSIONS
  Anti-digoxin Fab fragments are a safe and effective treatment for serious cardiac arrhythmias induced by yellow oleander. Their use in small rural hospitals in Sri Lanka should minimise costly transfer of patients and reduce the numbers of deaths; however, further study will be required to confirm this reduction.
authors.affiliation: Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, UK.
authors.forename: M
authors.initials: M
authors.lastname: Eddleston
authors.forename: S
authors.initials: S
authors.lastname: Rajapakse
authors.lastname: Rajakanthan
authors.forename: S
authors.initials: S
authors.lastname: Jayalath
authors.forename: L
authors.initials: L
authors.lastname: Sjöström
authors.forename: W
authors.initials: W
authors.lastname: Santharaj
authors.forename: P N
authors.initials: PN
authors.lastname: Thenabadu
authors.forename: M H
authors.initials: MH
authors.lastname: Sheriff
authors.forename: D A
authors.initials: DA
authors.lastname: Warrell
mesh_terms: D000328:Adult; D001145:Arrhythmias, Cardiac / Q000139:chemically induced* / Q000188:drug therapy*; D002301:Cardiac Glycosides / Q000506:poisoning*; D004311:Double-Blind Method; D005260:Female; D006801:Humans; D007140:Immunoglobulin Fab Fragments / Q000627:therapeutic use*; D008297:Male; D010947:Plants, Toxic / Q000506:poisoning*; D012639:Seeds / Q000506:poisoning; D013188:Sri Lanka
chemical_list: D002301:Cardiac Glycosides; D007140:Immunoglobulin Fab Fragments