title: Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup.
abstract: BACKGROUND
  The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup was created to provide evidence and consensus-based recommendations on the use of extracorporeal treatments (ECTRs) in poisoning.
  
  
  OBJECTIVE
  To perform a systematic review and provide clinical recommendations for ECTR in carbamazepine poisoning.
  
  
  METHODS
  After a systematic literature search, the subgroup extracted the data and summarized the findings following a pre-determined format. The entire workgroup voted via a two-round modified Delphi method to reach a consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations.
  
  
  RESULTS
  Seventy-four articles met inclusion criteria. Articles included case reports, case series, descriptive cohorts, pharmacokinetic studies, and in-vitro studies; two poor-quality observational studies were identified, yielding a very low quality of evidence for all recommendations. Data on 173 patients, including 6 fatalities, were reviewed. The workgroup concluded that carbamazepine is moderately dialyzable and made the following recommendations: ECTR is suggested in severe carbamazepine poisoning (2D). ECTR is recommended if multiple seizures occur and are refractory to treatment (1D), or if life-threatening dysrhythmias occur (1D). ECTR is suggested if prolonged coma or respiratory depression requiring mechanical ventilation are present (2D) or if significant toxicity persists, particularly when carbamazepine concentrations rise or remain elevated, despite using multiple-dose activated charcoal (MDAC) and supportive measures (2D). ECTR should be continued until clinical improvement is apparent (1D) or the serum carbamazepine concentration is below 10 mg/L (42 the μ in μmol/L looks weird.) (2D). Intermittent hemodialysis is the preferred ECTR (1D), but both intermittent hemoperfusion (1D) or continuous renal replacement therapies (3D) are alternatives if hemodialysis is not available. MDAC therapy should be continued during ECTR (1D).
  
  
  CONCLUSIONS
  Despite the low quality of the available clinical evidence and the high protein binding capacity of carbamazepine, the workgroup suggested extracorporeal removal in cases of severe carbamazepine poisoning.
authors.affiliation: Division of Nephrology, Verdun Hospital, University of Montreal , Montreal, QC , Canada.
authors.forename: Marc
authors.initials: M
authors.lastname: Ghannoum
authors.forename: Christopher
authors.initials: C
authors.lastname: Yates
authors.forename: Tais F
authors.initials: TF
authors.lastname: Galvao
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Sowinski
authors.forename: Thi Hai Vân
authors.initials: TH
authors.lastname: Vo
authors.forename: Andrew
authors.initials: A
authors.lastname: Coogan
authors.forename: Sophie
authors.initials: S
authors.lastname: Gosselin
authors.forename: Valery
authors.initials: V
authors.lastname: Lavergne
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Nolin
authors.forename: Robert S
authors.initials: RS
authors.lastname: Hoffman
mesh_terms: D000293:Adolescent; D000328:Adult; D000927:Anticonvulsants / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D002220:Carbamazepine / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D002648:Child; D002675:Child, Preschool; D032921:Consensus; D003697:Delphi Technique; D062787:Drug Overdose / Q000097:blood / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D019317:Evidence-Based Medicine; D005260:Female; D006464:Hemoperfusion; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D012720:Severity of Illness Index; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000927:Anticonvulsants; D002220:Carbamazepine
keywords: Anticonvulsant; Hemodialysis; Hemoperfusion; Overdose