TY - JOUR
T1 - Extracorporeal treatment for poisoning to beta-adrenergic antagonists
T2 - systematic review and recommendations from the EXTRIP workgroup
AU - on behalf of the EXTRIP workgroup
AU - Bouchard, Josée
AU - Shepherd, Greene
AU - Hoffman, Robert S.
AU - Gosselin, Sophie
AU - Roberts, Darren M.
AU - Li, Yi
AU - Nolin, Thomas D.
AU - Lavergne, Valéry
AU - Ghannoum, Marc
AU - Ghannoum, Marc
AU - Alhatali, Badria
AU - Anseeuw, Kurt
AU - Bird, Steven
AU - Berling, Ingrid
AU - Bunchman, Timothy E.
AU - Calello, Diane P.
AU - Chin, Paul K.
AU - Doi, Kent
AU - Galvao, Tais
AU - Goldfarb, David S.
AU - Hassanian-Moghaddam, Hossein
AU - Hoegberg, Lotte C.G.
AU - Kallab, Siba
AU - Kebede, Sofia
AU - Kielstein, Jan T.
AU - Lewington, Andrew
AU - Macedo, Etienne M.
AU - MacLaren, Rob
AU - Megarbane, Bruno
AU - Mowry, James B.
AU - Nolin, Thomas D.
AU - Ostermann, Marlies E.
AU - Peng, Ai
AU - Roy, Jean Philippe
AU - Vijayan, Anitha
AU - Walsh, Steven J.
AU - Wong, Anselm
AU - Wood, David M.
AU - Yates, Christopher
N1 - Funding Information:
We would like to acknowledge the valuable help of our dedicated translators, librarian, data extractors, and meeting secretary. Official translators were Alexandra Angulo, Alla Abbott, Anant Vipat, Andreas Betz, Angelina Kovaleva, Denise Gemmellaro, Ewa Brodziuk, Helen Johnson, Junzheng Peng, Marcela Covic, Nathalie Eeckhout, Rosie Finnegan, Salih Topal, and Vilma Etchard. The librarian was Elena Guadagno. Data extractors for EXTRIP-2 included Maria Rif, François Filion, Karine Mardini, Maria Rif, Tudor Botnaru, Elizabeth Koo, and Gabrielle Wilson. The meeting secretary was Brenda Gallant. In addition to the authors of this manuscript, members of the EXTRIP Group include: Badria Alhatali, Kurt Anseeuw, Steven Bird, Ingrid Berling, Timothy E Bunchman Diane P Calello, Paul K Chin, Kent Doi, Tais Galvao, David S Goldfarb, Hossein Hassanian-Moghaddam, Lotte CG Hoegberg, Siba Kallab, Sofia Kebede, Jan T Kielstein, Andrew Lewington, Etienne M Macedo, Rob MacLaren, Bruno Megarbane, James B Mowry, Thomas D Nolin, Marlies E Ostermann, Ai Peng, Jean-Philippe Roy, Anitha Vijayan, Steven J Walsh, Anselm Wong, David M Wood, Christopher Yates, Josée Bouchard, Greene Shepherd, Robert S. Hoffman, Sophie Gosselin, Darren M. Roberts, Yi Li, Thomas D. Nolin, Valéry Lavergne and Marc Ghannoum.
Funding Information:
TDN reports personal fees from MediBeacon, CytoSorbents, and McGraw-Hill Education outside the submitted work. MG is a scholar of the Fonds de Recherche du Québec—Santé. DMR acknowledges support of St. Vincent’s Centre for Applied Medical Research Clinician “Buy-Out” Program. AV reports consulting functions for NxStage, Astute Medical, and Boehringer-Ingelheim and speaker fees from Sanofi-Aventis. MO has received speaker honoraria and research funding from Fresenius Medical and Baxter and has had consulting functions for Nxstage and Baxter. All remaining authors have nothing to disclose.
Funding Information:
EXTRIP received support consisting of an unrestricted grant of $60,633 Canadian from the Verdun Research Fund (the institution of Marc Ghannoum) solely for the reimbursement of travel expenses for the in-person guideline meeting and payment to dedicated translators for retrieval and translation of foreign language articles. The funding source did not have a role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.
Publisher Copyright:
© 2021, The Author(s).
PY - 2021/12
Y1 - 2021/12
N2 - Background: β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. Methods: We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. Results: A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. Conclusions: BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.
AB - Background: β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. Methods: We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. Results: A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. Conclusions: BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.
KW - Beta-blockers
KW - ECLS
KW - Hemodialysis
KW - Hemoperfusion
KW - Intoxication
KW - Overdose
UR - http://www.scopus.com/inward/record.url?scp=85108043268&partnerID=8YFLogxK
U2 - 10.1186/s13054-021-03585-7
DO - 10.1186/s13054-021-03585-7
M3 - Article
C2 - 34112223
AN - SCOPUS:85108043268
SN - 1364-8535
VL - 25
JO - Critical Care
JF - Critical Care
IS - 1
M1 - 201
ER -