Drugs Used to Treat Toxicoses

Chapter 23

Drugs Used to Treat Toxicoses

Paracelsus, who some consider the “Father of Toxicology,” declared in the sixteenth century, “All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy.” Given the large number of potential poisons (toxicants) in the world and the wide variety of clinical effects these toxicants have on biological systems, it is not surprising that a vast range of compounds have been used in attempting to treat the effects of these toxicants on the body.


In the broadest definition, any compound that is used to counteract the effects of a toxicant is an antidote. The compound can interfere with the absorption, distribution, metabolism, or elimination of a toxicant; reduce or eliminate the adverse effects of that toxicant; or perform any combination of these biological effects. As our understanding of the mechanisms of action of various compounds increases, so does our ability to choose the most appropriate drugs to counter the adverse effects of toxicoses. This knowledge puts to rest the legend of the “universal antidote,” that mythical compound that can counter the effects of any poison. Table 23-1 lists drugs commonly used in the management of toxicoses.

Table 23-1

Drugs Used in Toxicology*

Drug Indication
Acepromazine Sedation for agitation caused by psychotropic drugs (e.g., amphetamines, phenylpropanolamine, pseudoephedrine)
N-acetylcysteine (Mucomyst, Acetadote) Management of acetaminophen toxicosis
Activated charcoal Adsorption of ingested toxicants (poor adsorption of many metals and minerals, small molecules [e.g., alcohols])
Multidose protocols: monitor for hypernatremia
Aluminum hydroxide Antacid; use for ingestion of corrosives or ulcerogenic drugs (e.g., NSAIDs)
Anti-digoxin Fab fragments, ovine origin (Digibind, DigiFab) Management of cardiac glycoside toxicosis (drugs, plants, toads) in which life-threatening arrhythmias have not resolved with symptomatic therapy or serum potassium levels > 5 mmol/L
Antitoxin, botulinum, equine origin Management of clinical signs of botulism
Antitoxin, tetanus, equine origin Management of clinical signs of tetanus
Antivenin Crotalidae polyvalent, equine origin Polyvalent, immune Fab, ovine origin (Cro Fab) Management of North American crotalid envenomation (rattlesnake, copperhead, water moccasin)
Antivenin Micrurus (Wyeth) Management of North American elapid envenomation (coral snake)
Antivenin Latrodectus (Merck) Management of envenomation by black widow spider
Antivenom, Centruroides immune F(ab′)2, equine origin (Anascorp) Treatment of clinical signs of North American scorpion envenomation
Apomorphine Induction of emesis; may not be effective in cats because they have few dopaminergic receptors in their CNS emetic center
Ascorbic acid Antioxidant
Urinary acidifier
Atipamezole hydrochloride (Antisedan) Reversal of bradycardia, hypotension, and sedation from α-agonists (e.g., amitraz, xylazine, imidazole decongestants)
Atropine Test dose for suspected organophosphorus (OP) or carbamate toxicosis
Management of bradycardia or excessive bronchial secretions from OP or carbamate toxicosis
Treatment of bradycardia from cardiac depressant drugs (e.g., digoxin)
Bicarbonate, sodium Management of acidosis (e.g., ethylene glycol)
Blood, whole Replacement therapy for anemia (e.g., anticoagulant rodenticides)
Buprenorphine Management of pain
Calcitonin, salmon Treatment of hypercalcemia (e.g., vitamin D or analogs)
Calcium EDTA Heavy metal chelator (lead)
Calcium gluconate, calcium chloride Management of fluoride or calcium channel blocker toxicosis
Management of hypocalcemia
Cholestyramine resin polystyrene Ion-binding resin; may help remove agents that undergo extensive enterohepatic recirculation
Hepatotoxic mushroom ingestion
Chlorpromazine Antiemetic
Sedation for agitation caused by psychotropic drugs (e.g., amphetamines, pseudoephedrine)
Cyproheptadine Assist in management of serotonin syndrome and serotonergic effects of psychotropic drugs (e.g., SSRI)
Dantrolene Management of Latrodectus (black widow spider) bites; management of malignant hyperthermia from hops
Dapsone Management of dermal necrosis from Loxosceles (recluse spider) bites
Deferoxamine mesylate (Desferal, Novartis) Heavy metal chelator (iron)
Dextrose Treatment of hypoglycemia due to xylitol, α-lipoic acid, or antidiabetic drug (e.g., sulfonylurea) toxicosis
Diazepam Sedation for CNS stimulation or seizures; use with caution with sympathomimetic (e.g., amphetamine) intoxication because paradoxical excitation may occur
Dimercaprol (BAL) Heavy metal chelator (arsenic, lead, mercury)
Diphenhydramine Management of acute allergic reactions; antiemetic
Epinephrine Systemic treatment of acute anaphylaxis
Esmolol Management of ventricular arrhythmias; ultra–short acting β-blocker
Ethanol Prevent formation of toxic metabolites in ethylene glycol toxicosis
Etidronate Treatment of hypercalcemia (e.g., vitamin D or analogs)
Flumazenil Benzodiazepine antagonist used to aid in severe benzodiazepine overdose
Fomepizole (Antizol-Vet) Prevent formation of toxic metabolites in ethylene glycol toxicosis
Furosemide Diuretic for use in management of pulmonary edema secondary to inhaled toxicants
Enhance calcium excretion in hypercalcemia (e.g., cholecalciferol toxicosis)
Glucagon Manage hypotension (e.g., β-adrenergic blocker, calcium channel blocker, tricyclic antidepressant toxicosis); manage hypoglycemia (e.g., antidiabetic drug toxicosis)
H2-blockers (cimetidine, famotidine, nizatidine, ranitidine) Reduce gastric acid production
Prevention and healing of gastrointestinal ulcers (e.g., NSAIDs)
Hemoglobin glutamer-200, bovine (Oxyglobin) Replacement therapy for anemia (e.g., anticoagulant rodenticides); does NOT provide clotting factors
Improved perfusion of tissues with pressure hypoperfusion (e.g., snakebite swelling)
Hydroxocobalamin (Cyanokit) Management of cyanide toxicosis
Hydrogen peroxide USP, 3% Induction of emesis; CAUTION: overuse can result in esophagitis or gastritis
Intravenous lipid solution, intravenous fat emulsion (20%; Liposyn, Intralipid) Management of intoxication by highly lipid-soluble compounds (e.g., avermectins, baclofen, calcium channel blockers); emerging modality that some consider experimental; should be reserved for severe cases that are poorly responsive to other therapy
Kaolin-pectin Demulcent and putative adsorbent; CAUTION: many formulations now contain salicylates
Lactulose Laxative and reduces blood ammonia levels
Management of liver insufficiency (e.g., Cycas toxicosis)
Leucovorin calcium Management of folate antagonist (methotrexate, trimetrexate) overdoses
Lidocaine Management of ventricular arrhythmias
Magnesium hydroxide Antacid; use for ingestion of corrosives or ulcerogenic drugs (e.g., NSAIDs)
Magnesium sulfate Cathartic
Mannitol Management of oliguric renal failure
Treatment of cerebral edema
Maropitant (Cerenia) Antiemetic
Methocarbamol Management of muscle tremors, rigidity, convulsive activity (e.g., permethrin toxicosis, metaldehyde toxicosis)
Methylene blue Treatment of methemoglobinemia; use with extreme caution, especially in cats (many clinicians no longer recommend); DO NOT USE new methylene blue from staining kits
Metoprolol Management of tachycardia
Milk Diluent
May reduce pain from exposure to insoluble calcium oxalate–containing plants
Misoprostol (Cytotec) Synthetic prostaglandin; prevention and healing of gastrointestinal ulcers (e.g., NSAIDs)
Naloxone Opiate antagonist; management of opioid toxicosis
Neostigmine, physostigmine, pyridostigmine Management of toxicosis from non-depolarizing neuromuscular blocking agents, botulism, atropine, coral snake envenomation, and anticholinergics
Nitroprusside Treatment of hypertension
Norepinephrine Treatment of hypotension
Ondansetron (Zofran) Antiemetic
Pamidronate (Aredia) Treatment of hypercalcemia (e.g., vitamin D or analogs)
D-Penicillamine Heavy metal chelator (arsenic, copper, lead)
Pentobarbital Management of seizures
Phenobarbital Management of seizures
Plasma, frozen plasma, fresh frozen Management of coagulopathy from anticoagulant rodenticides; provide clotting factors
Pralidoxime chloride (Protopam) Treatment of nicotinic signs of OP insecticide intoxication
Prednisone Adjunct therapy in hypercalcemia (e.g., cholecalciferol)
Propofol Management of seizures
Propranolol Management of tachycardia or other cardiac arrhythmias; management of hypokalemia in albuterol toxicosis
Protamine sulfate Management of heparin overdoses
Proton pump inhibitors (e.g., omeprazole, lansoprazole, pantoprazole) Reduce gastric acid production
Prevention and healing of gastrointestinal ulcers (e.g., NSAIDs)
Prussian blue Management of thallium toxicosis
Pyridoxine (vitamin B6) Management of seizures from penicillamine, Gyromitra mushroom, isoniazid, and hydrazines; adjunct therapy for ethylene glycol toxicosis
SAMe Hepatoprotectant
Silymarin Hepatoprotectant
Sodium sulfate Cathartic
Sorbitol Cathartic
Succimer (Chemet, Lundbeck) Heavy metal chelator (arsenic, lead, mercury)
Sucralfate Management and prevention of esophageal (slurries) and gastrointestinal ulceration
Trientine (Syprine) Heavy metal chelator (copper)
Vitamin K1 (phytonadione) Treatment of anticoagulant rodenticide coagulopathy
Xylazine Emetic, especially for cats
Yohimbine Reversal of bradycardia, hypotension, and sedation from α-agonists (e.g., amitraz, xylazine, imidazole decongestants)

CNS, Central nervous system; EDTA, ethylenediaminetetraacetic acid; NSAIDs, nonsteroidal antiinflammatory drugs; SAMe, s-adenosyl methionine; SSRI, selective serotonin reuptake inhibitor; USP, United States Pharmacopeia.

*See Appendix for dosages.

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Jul 18, 2016 | Posted by in PHARMACOLOGY, TOXICOLOGY & THERAPEUTICS | Comments Off on Drugs Used to Treat Toxicoses

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