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Therapeutic Interventions in Organophosphate Poisoning: An Umbrella Review of Systematic Reviews
Vivek Chauhan1, Divyam Goyal2, Suman Thakur3
1Indira Gandhi Medical College Shimla, Department of Medicine, Himachal Pradesh, India.
Introduction:
Organophosphate (OP) poisoning is a significant global health issue, particularly in tropical regions. Despite established treatments such as atropine and oximes, the effectiveness of other interventions remains uncertain. This umbrella review is a critical synthesis of evidence from systematic reviews and meta-analyses on OP self-poisoning.
Methods:
Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we conducted a review of systematic reviews and meta-analyses published up to January 2025. Databases searched included PubMed, Epistemonikos, and the Cochrane Library. We performed quality assessment using A Measurement Tool to Assess Systematic Reviews, version 2 (AMSTAR-2), and applied the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to evaluate evidence certainty.
Results:
Of 416 potential papers identified we assessed 27 for eligibility, of which 19 were included in the review. The papers evaluated 11 different interventions as an adjuvant to atropine. Oximes, although commonly used, showed neither benefit nor harm. The systematic reviews and meta-analyses on gastric lavage, plasma exchange with hemoperfusion, lipid emulsions, magnesium sulfate, penehyclidine, rhubarb, and xuebijing have reported significant reductions in mortality, but the evidence comes from very low-quality studies. Alkalinization was not found to be effective for OP poisoning. Evidence was limited by small sample size, inconsistent protocols, and geographical bias, with many studies originating from China.
Conclusion:
After careful scrutiny of evidence pooled by various systematic reviews and meta-analyses, we found that atropine remains the mainstay of treatment for OP self-poisoning. It may be supplemented with oximes, as recommended by the World Health Organization. Gastric lavage has doubtful efficacy and may even be harmful. Additionally, we recommend against the routine use of penehyclidine, rhubarb, xuebijing, hemofiltration, plasma exchange with hemoperfusion, lipid emulsions, magnesium sulfate, and alkalinization in the management of OP self-poisoning.
Insights
Organophosphate poisoning treatment primarily relies on atropine, with oximes as a potential supplement. Other interventions like gastric lavage show doubtful efficacy and are not recommended for organophosphate self-poisoning.
Area of Science:
- Toxicology
- Clinical Medicine
- Evidence Synthesis
Background:
- Organophosphate (OP) poisoning is a critical global health concern, especially in tropical regions.
- Established treatments like atropine and oximes exist, but the efficacy of additional interventions requires clarification.
- This umbrella review synthesizes evidence from systematic reviews and meta-analyses on OP self-poisoning management.
Purpose of the Study:
- To critically evaluate the evidence for various interventions used as adjuncts to atropine in organophosphate self-poisoning.
- To assess the quality of existing systematic reviews and meta-analyses on this topic.
- To provide evidence-based recommendations for the management of organophosphate poisoning.
Main Methods:
- Umbrella review methodology adhering to PRISMA guidelines.
- Searched PubMed, Epistemonikos, and Cochrane Library for systematic reviews and meta-analyses up to January 2025.
- Assessed study quality using AMSTAR-2 and evidence certainty with GRADE.
Main Results:
- Nineteen systematic reviews and meta-analyses were included, evaluating 11 adjuvant interventions.
- Oximes demonstrated neither benefit nor harm. Interventions like gastric lavage, lipid emulsions, and magnesium sulfate showed potential mortality reduction but were based on very low-quality evidence.
- Alkalinization was ineffective; evidence was limited by small sample sizes, inconsistent protocols, and geographical bias.
Conclusions:
- Atropine remains the cornerstone treatment for organophosphate self-poisoning.
- Oximes may be used as a supplement, aligning with WHO recommendations.
- Routine use of other interventions including gastric lavage, penehyclidine, rhubarb, xuebijing, hemofiltration, plasma exchange, lipid emulsions, magnesium sulfate, and alkalinization is not recommended due to insufficient or unfavorable evidence.
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