Hemodiafiltration Practice in a Patient with Severe Amitriptyline Intoxication

Tricyclic antidepressants (TADs) are widely used drugs for different indications such as depression, neuropathic pain, nocturnal enuresis, obsessive-compulsive, panic and attention deficit hyperactivity disorders. These agents are the most prescribed drugs following selective serotonin reuptake inhibitors for depression (1). Taken in high doses either on purpose or accidentally they can result in serious morbidity and mortality. Data of 2008 from Turkey’s National Poison Consultation Center reveals that amitriptyline ranks 3rd, after paracetamol and combined upper respiratory tract infection treatment drugs, according to the classification made by reference active ingredient (2). Amitriptyline increases noradrenaline and serotonin levels by inhibiting their reuptake from the synaptic cleft (3). It also blocks adrenergic, histaminergic, central and peripheral cholinergic receptors. Toxicity symptoms are the results of the effects of amitriptyline in different systems. Dryness and metallic taste in the mouth, mydriasis, constipation, urinary retention, respiratory depression, and decreased cognitive functions and tachycardia occur due to the cholinergic receptor blockade. Weight gain, sedation and depression ABSTRACT Tricyclic antidepressants are widely used drugs for treatment of depression despite serious mortality and morbidity in higher doses. They can cause severe cardiac arrhythmias, hypotension and central nervous system depression. Some patients may remain unresponsive in spite of conventional therapies such as gastric lavage and activated charcoal administration, benzodiazepines, volume replacement, lidocaine and sodium bicarbonate infusion. In this paper we report a 20-year-old female patient who had severe amitriptyline intoxication with a Glasgow Coma Scale score 4 and severe cardiac arrhythmias and was treated with hemodiafiltration. Conventional therapy was inadequate and hemodiafiltration was applied to the patient for 36 hours. At the end of the 36-hours the patient was conscious and became stabilized in terms of hemodynamics. In case of serious intoxication that does not respond to conventional therapy, approaches like hemodialysis, plasmapheresis, hemoperfusion and hemodiafiltration can be a rescue therapy and they should be considered.