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Delayed Cardiotoxicity From a Massive Nortriptyline Overdose Requiring Prolonged Treatment
Pansy Elsamadisi1, Alyssa Sclafani2, Ifeoma Mary Eche1
1Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Journal of Pharmacy Practice
|April 16, 2019
Summary
Massive nortriptyline overdose can cause delayed arrhythmias, requiring prolonged sodium bicarbonate treatment. Standard pharmacokinetic models are unreliable in toxic ingestions, making urine screens useful for guiding therapy.
Area of Science:
- Emergency Medicine
- Clinical Toxicology
- Pharmacology
Background:
- Tricyclic antidepressants (TCAs) like nortriptyline are commonly prescribed but carry significant overdose risks.
- Managing massive TCA overdose requires understanding unique toxicokinetic challenges.
Observation:
- A 61-year-old male ingested up to 2500 mg of nortriptyline, presenting with QRS widening (240 ms).
- Despite initial sodium bicarbonate treatment, the patient experienced recurrent wide complex tachycardia.
- Prolonged sodium bicarbonate infusion was necessary until hospital day 14 due to persistent toxicity.
Findings:
- The patient's calculated nortriptyline elimination half-life was 184 hours, significantly longer than the typical 14-51 hours.
- Routine TCA pharmacokinetics proved unreliable in this massive overdose scenario.
- Urine tricyclic antidepressant (TCA) screens correlated with quantitative levels and guided therapy.
Implications:
- Clinical decisions in massive TCA overdose should not rely on standard pharmacokinetic data.
- Delayed absorption, enterohepatic recirculation, and saturable kinetics complicate overdose management.
- Urine TCA screens offer a practical alternative for monitoring and guiding treatment duration, alongside QRS duration.
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