ArticlesAnti-digoxin Fab fragments in cardiotoxicity induced by ingestion of yellow oleander: a randomised controlled trial
Introduction
Ingestion of sufficient quantities of any part of the common (Nerium oleander) or yellow (Thevetia peruviana) oleander can produce a syndrome similar to digoxin poisoning.1, 2 Accidental oleander poisoning occurs throughout the tropics and subtropics: 303 cases were reported in Texas during 19941 and oleander caused 27% of the paediatric plant poisonings in Australia during 1972–78.3 Fatal poisonings have been reported from across the world.4, 5, 6, 7, 8, 9, 10
Deliberate self-poisoning with yellow oleander is a recent phenomenon in Sri Lanka. The first cases occurred in Jaffna between 1981 and 1983, after publicity surrounding the suicide of two girls who ingested oleander seeds.11 In some areas, 40% of self-poisoning cases are now linked to oleander seeds, particularly in teenagers, with an annual incidence of more than 150 per 100 000.12, 13 This epidemic imposes a substantial burden on the Sri Lankan health services.
The most severely affected patients are transferred to the coronary-care unit (CCU) of the Cardiology Institute in Colombo for cardiac pacing.12 The transfer is long and hazardous, commonly taking more than 4 h. Patients die before and during transfer to the CCU; some die soon after arrival. Standard therapy in the CCU is to observe patients and then insert a pacemaker in those with marked arrhythmias.
There is a pressing need for a treatment that can be used in small peripheral hospitals. Polyclonal anti-digoxin Fab fragments are recommended for the treatment of life-threatening cardiac glycoside poisoning.14, 15 Although this recommendation for digoxin poisoning is based on a large open-label multicentre study,16 the use of these fragments in poisonings by other glycosides in based solely on case reports, commonly with poor results.17, 18, 19, 20, 21, 22 We assessed the efficacy and safety of anti-digoxin Fab fragments in patients with cardiac arrhythmias induced by yellow oleander.
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Patients
The study was designed in two parts: a dose-finding study to identify an effective dose of anti-digoxin Fab; and a randomised, double-blind, placebo-controlled trial of this dose in the treatment of oleander-induced cardiotoxicity. The trial was reviewed by the ethics review committee of Colombo University's Faculty of Medicine and done with the approval of the Sri Lankan Health Authorities.
Patients admitted to the Cardiology Institute with a history of yellow-oleander ingestion were included
Dose-finding study
Four groups of four consecutive patients fulfilling the entry crieria were recruited to the study. We expected the clinical severity and serum cardiac glycoside concentrations of the patients to vary substantially within these small groups. However, a dose-finding study was deemed essential as a basis for choosing an appropriate dose for the controlled trial and for identifying times at which to measure outcome.
There was a good clinical response in all patients who received 1200 mg of
Discussion
The oleanders are common causes of accidental poisoning worldwide. Their leaves and seeds are eaten intentionally in the USA, Germany, and Australia.1, 2 However, it is in Sri Lanka and south India that deliberate self-poisoning with yellow oleander has become an important problem, resulting in hundreds of deaths each year.12 In certain areas of Sri Lanka, ingestion of yellow oleander has become the method of choice for self-harm, particularly among women and children.
Currently, about 10% of
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