What is the role of lipid emulsion therapy in the treatment of calcium channel blocker (CCB) toxicity?

Updated: Jan 04, 2021
  • Author: B Zane Horowitz, MD, FACMT; Chief Editor: Michael A Miller, MD  more...
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Answer

Lipid emulsion therapy (eg, Intralipid) has been studied in a few animal models of verapamil toxicity, demonstrating increased survival. [63, 66] Case reports have found either clinical improvement [61, 67] or significant drug sequestration. [68]

The therapeutic effect of lipid emulsion therapy is most commonly ascribed to the "lipid sink" theory, which posits that the lipid emulsion bolus sequesters lipophilic drugs from their target site, mitigating toxicity. Verapamil is quite lipophilic and thus is theoretically amenable to lipid emulsion therapy. [69] One case report demonstrated significant drug sequestration in a verapamil overdose, but uncertain clinical benefit. [68]

Lipid emulsion therapy can be considered as an antidotal therapy of last resort in calcium channel blocker overdose. Currently, the American College of Medical Toxicologists states that "in circumstances where there is serious hemodynamic, or other, instability from a xenobiotic with a high degree of lipid solubility, lipid resuscitation therapy is viewed as a reasonable consideration for therapy, even if the patient is not in cardiac arrest." [70]

For lipid emulsion therapy, a 20% lipid emulsion is administered initially as a 1.5-mL/kg bolus over 2-3 minutes, followed by an infusion of 0.25 mL/kg/min. The bolus may be repeated in patients who have recrudescent toxicity or cardiac arrest.


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