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Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup

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  • Marc Ghannoum
  • Christopher Yates
  • Tais F Galvao
  • Kevin M Sowinski
  • Thi Hai Vân Vo
  • Andrew Coogan
  • Sophie Gosselin
  • Valery Lavergne
  • Thomas D Nolin
  • Robert S Hoffman
  • EXTRIP workgroup (Lotte Christine Groth Høgberg, members)
  • Lotte Christine Groth Høgberg (Member of study group)
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CONTEXT: 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.

OBJECTIVES: 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).

CONCLUSION: 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.

Original languageEnglish
JournalClinical toxicology (Philadelphia, Pa.)
Volume52
Issue number10
Pages (from-to)993-1004
Number of pages12
ISSN1556-3650
DOIs
Publication statusPublished - Dec 2014

ID: 45000046