In Reply to "Hydroxychloroquine Overdose: What Are the Exact Roles of Diazepam and Potassium Infusion?"
In Reply to "Hydroxychloroquine Overdose: What Are the Exact Roles of Diazepam and Potassium Infusion?"
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回复“羟氯喹过量：地西泮和钾输注的确切作用是什么？”
DOI：
10.1007/s13181-020-00812-5
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发表时间：
2021
期刊：
影响因子：
--
通讯作者：
Erickson,TB
中科院分区：
文献类型：
--
作者：
Chai,PR;Ferro,EG;Kirshenbaum,JM;Hayes,BD;Culbreth,SE;Boyer,EW;Erickson,TB
We thank Drs. Megarbane and Schicchi for their thoughtful comments and highlights regarding recent animal models suggesting the importance of mechanical ventilation and vasopressor support in the setting of acute hydroxychloroquine poisoning [1, 2]. We agree that although the literature on hydroxychloroquine poisoning is scarce, it is reasonable to infer treatment strategies from clinical experience with chloroquine ingestions. Drs. Megarbane and Schicchi make valid points on the consideration of initiation of intravenous diazepam compared with epinephrine infusions in moderately and severely poisoned patients. The writers point to in vitro and in vivo data suggesting that the use of diazepam does not impact cardiac performance nor do its attributable cardioprotective effects contribute to significant recovery of cardiac function in poisoned rats [1, 3]. These investigations do suggest that diazepam may have some effect in augmenting the inotropy imparted through concomitant administration of vasopressors. It does, however, highlight the challenge in developing data-driven treatment algorithms for acutely poisoned patients given the lack of ethical mechanisms through which to conduct adequately powered human clinical trials. Clinically, one confounding factor frequently encountered is the unknown dose of hydroxychloroquine taken and the time of ingestion, as well as coingestants. While hydroxychloroquine (HCQ) levels might suggest the severity of ingestion, if we extrapolate from data surrounding chloroquine, these concentrations do not result in real time and are rarely clinically relevant once obtained. We therefore think that in some cases, diazepam may still be of value, especially in critically ill individuals who are mechanically ventilated, supported hemodynamically with vasopressors, and continue to manifest signs of HCQ toxicity. Unlike animal studies that have defined doses and controlled times to intervention, the condition of human intentional and unintentional ingestion is widely variable, often associated with chronic toxicity, coingestants, and underlying disease states, thereby requiring elasticity around direct extrapolation of animal data. In individuals who have moderate HQC toxicity (acute doses of 2–4 g), diazepam may be less effective, assuming that the dose ingested is known [2].We also thank Drs. Megarbane and Schicchi for reminding us that correcting hydroxychloroquine-induced hypokalemia should be a careful intervention as aggressive over-correction can result in hyperkalemia. Depending of the degree of cardiac conduction abnormalities seen after acute hydroxychloroquine overdose, infusion of potassium may help eliminate the confounding factor of hypokalemia contributing to dysrhythmias. As medical and clinical toxicologists, we frequently manage the effects of druginduced hypokalemia due to intracellular sequestration of potassium ions. Ensuring correction of this electrolyte abnormality and
