title: Pediatric thioridazine poisoning as a result of a pharmacy compounding error.
abstract: The adverse effects or overdose of thioridazine including sudden death, fatal arrhythmia, or retinopathy, in addition to the neurological signs have been reported. A three-year-old boy with bronchitis was prescribed erythromycin by a local clinic, but he started to complain of severe drowsiness and became unconscious. It was decided that this was a result of a compounding error of thioridazine instead of erythromycin owing to their similar commercial names. The thioridazine concentration in the child's serum on admission was two to three times higher than the Cmax for adults with the same dosage. The concentration of the lavage saline on admission was only 0.3% of the ingested amount, indicating that the lavage was not effective in our case. Pharmacokinetic analysis revealed the parameters as Tmax, 1.5 hr; Cmax, 1700 ng/mL; Ka, 2.01 L/hr; Vd, 3.6 L/kg; and T1/2, 6.8 hr. Further investigations on clinical cases with a pharmacokinetic analysis should be done to confirm the pharmacokinetic evidence obtained here and to give specific therapeutic guidelines for overdose management especially in children.
authors: Department of Pediatrics, Graduate School of Medicine.
authors: Zenichiro
authors: Z
authors: Kato
authors: Mitsuhiro
authors: M
authors: Nakamura
authors: Yuka
authors: Y
authors: Yamagishi
authors: Takahide
authors: T
authors: Teramoto
authors: Naomi
authors: N
authors: Kondo
references: Clin Pharmacol Ther. 1996 Nov;60(5):543-53
references: 8941027
references: Eur J Clin Pharmacol. 1977 Jan 3;11(2):135-40
references: 320014
references: Vet Hum Toxicol. 1993 Apr;35(2):147-50
references: 8470359
references: J Pharm Sci. 1989 Oct;78(10):796-801
references: 2600782
references: Br J Clin Pharmacol. 2005 May;59(5):608
references: 15842564
references: Clin Pharmacol Ther. 2007 Nov;82(5):548-54
references: 17410120