Abstract
Carbamazepine overdose is a common, toxic ingestion, manifesting as central nervous system (CNS) and respiratory depression. Carbamazepine is highly protein bound with a large volume of distribution and, therefore, inefficiently removed by conventional hemodialysis. We describe the successful use of continuous venovenous hemodialysis (CVVHD) with 5 % albumin enhanced dialysate in a 31-year-old female who developed CNS depression, hypotension and respiratory failure, requiring mechanical ventilation, after an intentional ingestion of approximately 10 g of extended release carbamazepine, Tegretol CR®. The peak drug level was 26 mcg/ml, therapeutic range 8–12 mcg/ml, with toxicity often developing a level above 15 mcg/ml. Normal half-life of drug elimination is 35–60 h in carbamazepine naïve patients. In contrast, with albumin-enhanced dialysis, we observed a drug half-life of 18 h. She was extubated on day two and was transferred to inpatient psychiatry by day 3 without significant neurologic sequelae. In vitro studies have been done with bovine blood demonstrating significant carbamazepine removal using CVVHD with albumin-enhanced dialysate. There has been very limited experience using albumin-enhanced CVVHD in an adult patient with carbamazepine toxicity.
Similar content being viewed by others
References
Vree TB, Janssen TJ, Hekster YA. Clinical pharmacokinetics of carbamazepine and its epoxy and hydroxy metabolites in humans after an overdose. Therap Drug Monit. 1986;8:297–304.
Lurie Y, Bentur Y, Levy Y, Baum E, Krivoy N. Limited efficacy of gastrointestinal decontamination in severe slow-release carbamazepine overdose. Ann Pharmacother. 2007;41:1539–43.
Vree TB, van Dalen R, Geerts Y. Clinical pharmacokinetics of a massive overdose of carbamazepine and acute renal failure. Clin Drug Invest. 1997;14:66–75.
Cameron RJ, Hungerford P, Dawson AH. Efficacy of charcoal hemoperfusion in massive carbamazepine poisoning. J Toxicol Clin Toxicol. 2002;40:507–12.
Nilsson C, Sterner G, Idvall J. Charcoal hemoperfusion for treatment of serious carbamazepine poisoning. Acta Med Scand. 1984;216:137–40.
Graudins A, Peden G, Dowsett RP. Massive overdose with controlled-release carbamazepine resulting in delayed peak serum concentrations and life-threatening toxicity. Emergency Med (Fremantle). 2002;14:89–94.
Kale PB, Thomson PA, Provenzano R, Higgins MJ. Evaluation of plasmapheresis in the treatment of an acute overdose of carbamazepine. Ann Pharmacother. 1993;27:866–70.
Duzova A, Baskin E, Usta Y, Osten S. Carbamazepine poisoning: treatment with plasma exchange. Hum Exp Toxicol. 2001;20:175–7.
Schuerer DJ, Brophy PD, Maxvold NJ, Kudelka T, Bunchman TE. High-efficiency dialysis for carbamazepine overdose. J Toxicol Clin Toxicol. 2000;38:321–3.
Bek K, Kocak S, Ozkaya O, Yilmaz Y, Aydin OF, Tasdoven CS. Carbamazepine poisoning managed with haemodialysis and haemoperfusion in three adolescents. Nephrology (Carlton). 2007;12:33–5.
Kołacński Z, Winnicka R, Lopaciński B, Kołacińska M. Carbamazepine, “CR”–clinical picture of intoxication: the kinetics of extracorporeal elimination. Przegl Lek. 2005;62:482–5.
Winchester JF, Boldur A, Oleru C, Kitiyakara C. Use of dialysis and hemoperfusion in treatment of poisoning. In: Daugiridas JT, Blake PG, Ing TS, editors. Handbook of dialysis. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2007. pp. 300–319.
Churchwell MD, Pasko DA, Smoyer WE, Mueller BA. Enhanced clearance of highly protein-bound drugs by albumin-supplemented dialysate during modeled continuous hemodialysis. Nephrol Dial Transplant. 2009;24:231–8.
Askenazi DJ, Goldstein SL, Chang IF, Elenberg E, Feig DI. Management of a severe carbamazepine overdose using albumin-enhanced continuous venovenous hemodialysis. Pediatrics. 2004;113:406–9.
Package insert. Tegretol (carbamazepine) USP chewable tablets of 100 mg, tablets 200 mg, suspension 100 mg/5 ml, Tegretol-XR, carbamazepine extended-release tablets 100 mg, 200 mg, 400 mg. East Hanover: Novartis Pharmaceutical Corp. 2008.
Conflict of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding authors
Rights and permissions
About this article
Cite this article
Narayan, R., Rizzo, M. & Cole, M. Successful treatment of severe carbamazepine toxicity with 5 % albumin-enhanced continuous venovenous hemodialysis. J Artif Organs 17, 206–209 (2014). https://doi.org/10.1007/s10047-014-0754-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10047-014-0754-4