Multiple organ failure after an overdose of less than 0.4 mg/kg of colchicine: role of coingestants and drugs during intensive care management.

INTRODUCTION: Although the ingestion of a dose of colchicine lower than 0.5 mg/kg is usually complicated by a mortality rate less than 5%, severe complications may be associated with drug-drug interactions in case of overdose combining other drugs. CASE REPORT: A 33-year-old previously healthy woman was admitted after a drug overdose combining colchicine, atorvastatin, ibuprofen, diclofenac, and furosemide. The amount of colchicine ingested was exactly 20 mg, corresponding to 0.33 mg/kg. Despite this relatively low dose, she presented the clinical course that is usually seen with much larger colchicine ingestions. She developed acute renal and liver failure, acute lung injury, pancytopenia with sepsis, rhabdomyolysis, hypertriglyceridemia, and ultimately died on Day 14 from hyperammonemic encephalopathy, refractory hypoxemia, and cardiac arrhythmias. DISCUSSION: Serious drug-drug interactions may have complicated colchicine poisoning. In particular, atorvastatin, an inhibitor of P-glycoprotein and cytochrome P450 3A4, was likely responsible for an increased severity of rhabdomyolysis. In addition, propofol used for sedation during mechanical ventilation may have induced symptoms consistent with "propofol infusion syndrome," with further muscular injury and hypertriglyceridemia. The mechanism of death was unusual and similar to Reye's syndrome.

Diltiazem overdose: a role for high-dose insulin.

A 62-year-old man presented 6 h after a mixed intentional overdose of dilatizem (Adizem-SR), atorvastatin, aspirin and isosorbide mononitrate. He was symptomatic, with vomiting, blurred vision and unsteady gait. Despite initial fluid resuscitation and calcium chloride, glucagon, and high-dose ionotropic therapy, his hypotension remained refractory to treatment. A bolus of high-dose insulin (Actrapid) was administered, followed by a continuous infusion. Glucose was administered to maintain a state of euglycaemia. Over the following 24 h, the patient was given 1140 units of accumulative insulin. This resulted in a significant improvement in arterial blood pressure values and metabolic indices, allowing contiguous weaning off inotropes. This case supports the use of rescue hyperinsulinaemic euglycaemia in patients with an overdose of calcium channel blockers who remain hypotensive despite standard pharmacological measures.