UMEM Educational Pearls

Category: Toxicology

Title: High dose insulin for calcium channel blockers: amlodipine vs. non-dihydropyridines

Keywords: amlodipine, non-dihydropyridines, high-dose insulin (PubMed Search)

Posted: 6/1/2023 by Hong Kim, MD, MPH (Updated: 4/24/2024)
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Calcium channel blocker (CCB) overdose can lead to severe shock/hypotension. A small study was conducted to compare the hemodynamic effects of high-dose insulin (HDI) for two classes of CCB (dihydropyridines vs. non-dihydropyridines) that work differently to manage hypertension.   

Study design:

  • Retrospective study from a single poison center (2019 – 2021)

Study sample:

  • Amlodipine poisoning cases: 18
  • Non-dihydropyridine (non-DHP) poisoning cases: 15

Result

Median number of maximum concomitant vasopressors (p=0.04)

  • Amlodipine: 3 (IQR: 2-5; range 0-6)
  • Non-DHP: 2 (IQR: 1-3; range 0-5)

Median difference in max concomitant vasopressors: 1 (95% CI: 0 – 2)

Median max epinephrine dosing

  • Amlodipine: 0.31 mcg/kg/min
  • Non-DHP: 0.09 mcg/kg/min

Use of rescue methylene blue (p=0.009)

  • Amlodipine: 7/18 (39%)
  • Non-DHP: 0

Conclusion:

  • Amlodipine poisoning on HDI required more vasopressors and higher doses of epinephrine compared to non-DHP (verapamil or diltiazem)
  • This may be due to vasodilatory effect of amlodipine compared to non-DHPs

References

Cole JB, Lee SC, Prekker ME, Kunzler NM, Considine KA, Driver BE, Puskarich MA, Olives TD. Vasodilation in patients with calcium channel blocker poisoning treated with high-dose insulin: a comparison of amlodipine versus non-dihydropyridines. Clin Toxicol (Phila). 2022 Nov;60(11):1205-1213. doi: 10.1080/15563650.2022.2131565. Epub 2022 Oct 25. PMID: 36282196.