UMEM Educational Pearls

Title: Co-ingestion of dihydropyridine with ARBs/ACEIs can cause more significant hypotension

Keywords: dihydropyridine, ARBs, ACEIs, co-ingestion, hypotension, toxicity (PubMed Search)

Posted: 10/15/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

Dihydropyridine (calcium channel blocker) overdose is one of the leading causes of death from cardiovascular drug poisoning. In contrast, angiotensin-II receptors blockers (ARBs) and angiotensin converting enzyme inhibitor (ACEIs) causes minimal toxicity in overdose. Frequently, these medications are co-ingested with dihydropridines.

Recently, a retrospective study was conducted to evaluate the hemodynamic impact of dihydropyridines with ARBs/ACEIs co-ingestion.

Results

Cohort

68 mixed overdoses of dihydropyridines with ARBs/ACEIs
21 single agent overdose (dihydropyridines)

Mixed overdose group had:

Lower median nadir mean arterial pressure: 62 vs. 75 mmHg (p<0.001)
Higher OR for hypotension: OR 4.5, (95% CI: 1.7 – 11.9)
Higher OR for bradycardia: OR 8.8 (95% CI: 1.1 – 70)
Lower minimum systolic blood pressure by 11.5 mmHg (95% CI: 4.9 – 18.1)

Higher proportion of the mixed overdose group received:

IV fluids: OR 5.7, (95% CI: 1.8-18.6)
Antidotes and/or vasopressor: OR 2.9 (95% CI: 1.004 – 8.6)

Conclusion

Combined overdose of dihydropyridines with ARBs/ACEIs can result in more significant hypotension.

References

Huang J et al. Angiotensin axis antagonists increase the incidence of haemodynamic instability in dihydropyridine calcium channel blocker poisoning. Clint Toxicol (Phila) 2020. Epub. https://doi.org/10.1080/15563650.2020.1826504