title: Mixed amlodipine/valsartan overdose treated by the molecular adsorbent recirculating system (MARS™).
abstract: METHODS
  We describe the case of a 58-year-old woman who developed a severe distributive shock following the intentional ingestion of a large overdose of amlodipine (480 mg) combined with valsartan (3680 mg). Extreme vasoplegia remained refractory to maximal standard therapy including fluid resuscitation, intravenous calcium, vasopressors at very high doses, hyperinsulinemia-euglycemia therapy, lipid emulsion, and methylene blue administration. Besides, the patient exhibited hyperglycemia refractory to very high doses of insulin. Due to its theoretical ability to effectively remove protein-bound drugs such as amlodipine from the circulation, albumin dialysis with the molecular adsorbent recirculating system (MARS™) was performed during two consecutive sessions. Blood was drawn for toxicokinetic calculations. Amlodipine elimination half-life during the first MARS™ session was calculated at 7.6 h. In addition, there was a rapid fall in blood glucose, requiring the introduction of a continuous infusion of glucose in order to achieve euglycemia. Moreover, a few hours after the initiation of the MARS™ therapy, the hemodynamic status was not significantly modified but a significant tapering of epinephrine infusion was possible, together with a progressive decrease of blood lactate level. However, the need for vasopressors in decreasing doses was present until day 5 post-ingestion. Eventually, the patient fully recovered and was discharged home 8 days after admission.
  
  
  CONCLUSIONS
  The role of the MARS™ in the treatment of severe poisoning of calcium channel blockers is still to be defined. We were able to demonstrate a relatively short elimination half-life of amlodipine. A decreased insulin resistance and a reduction of epinephrine infusion were also observed.
authors.affiliation: Department of Intensive Care, Cliniques St-Luc, Université catholique de Louvain , Brussels , Belgium.
authors.forename: Ludovic
authors.initials: L
authors.lastname: Gérard
authors.forename: Anne-Cécile
authors.initials: AC
authors.lastname: Galloy
authors.forename: Arnaud
authors.initials: A
authors.lastname: Capron
authors.forename: Philippe
authors.initials: P
authors.lastname: Hantson
mesh_terms: D017311:Amlodipine / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D000068838:Amlodipine, Valsartan Drug Combination; D047228:Angiotensin II Type 1 Receptor Blockers / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D000959:Antihypertensive Agents / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D002121:Calcium Channel Blockers / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D004338:Drug Combinations; D062787:Drug Overdose; D005260:Female; D006207:Half-Life; D006801:Humans; D008657:Metabolic Clearance Rate; D008875:Middle Aged; D006435:Renal Dialysis; D012769:Shock / Q000097:blood / Q000139:chemically induced / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D016060:Sorption Detoxification / Q000379:methods*; D013777:Tetrazoles / Q000097:blood / Q000493:pharmacokinetics / Q000506:poisoning*; D016896:Treatment Outcome
chemical_list: D000068838:Amlodipine, Valsartan Drug Combination; D047228:Angiotensin II Type 1 Receptor Blockers; D000959:Antihypertensive Agents; D002121:Calcium Channel Blockers; D004338:Drug Combinations; D013777:Tetrazoles; D017311:Amlodipine
keywords: Amlodipine; Blood glucose; Molecular adsorbent recirculating system; Overdose; Valsartan; Vasoplegia