From the Guidelines
Norepinephrine is the preferred vasopressor for managing hypotension in beta blocker overdose, as it primarily acts on alpha-1 receptors to cause vasoconstriction, counteracting the vasodilation and hypotension caused by beta blockers. The recommended starting dose is 0.1-0.2 mcg/kg/min, titrated up as needed to maintain adequate blood pressure (typically systolic BP >90 mmHg) 1. This approach is supported by the most recent guidelines, which emphasize the importance of vasopressor therapy in managing severe beta blocker poisoning 1.
Key Considerations
- Norepinephrine's effectiveness in beta blocker overdose is due to its action on alpha-1 receptors, which are not affected by beta blockers 1.
- Other treatments that should be considered alongside norepinephrine include:
- High-dose insulin therapy (1 U/kg bolus followed by 1 U/kg/hr infusion with glucose supplementation) 1.
- Glucagon (5-10 mg IV bolus followed by 1-5 mg/hr infusion) 1.
- In severe cases, lipid emulsion therapy or extracorporeal membrane oxygenation may be necessary 1.
- Calcium gluconate or calcium chloride may also help improve cardiac contractility 1.
- Continuous cardiac monitoring is essential during treatment, and the norepinephrine infusion should be gradually weaned as the patient's condition improves and the beta blocker is metabolized and eliminated.
Evidence-Based Recommendations
The most recent and highest quality study, published in 2023, supports the use of norepinephrine as the preferred vasopressor in beta blocker overdose 1. This study, published in the journal Circulation, provides the most up-to-date guidance on the management of patients with cardiac arrest or life-threatening toxicity due to poisoning. While other studies, such as those published in 2020, provide additional insights into the management of cardiogenic shock and beta blocker toxicity 1, the 2023 study takes precedence due to its recency and prestige.
From the FDA Drug Label
OVERDOSAGE Overdosage with LEVOPHED may result in headache, severe hypertension, reflex bradycardia, marked increase in peripheral resistance, and decreased cardiac output. In case of accidental overdosage, as evidenced by excessive blood pressure elevation, discontinue LEVOPHED until the condition of the patient stabilizes. The role of norepinephrine in beta blocker overdose is not directly addressed in the provided drug label.
- The label discusses norepinephrine overdosage, not its use in beta blocker overdose.
- No information is provided on the use of norepinephrine as a treatment for beta blocker overdose 2.
From the Research
Role of Norepinephrine in Beta Blocker Overdose
- Norepinephrine is used as a treatment for beta blocker overdose, particularly in cases of hypotension and bradycardia 3, 4, 5
- It is a catecholamine that can help improve hemodynamics in patients with beta blocker overdose 4
- The use of norepinephrine in beta blocker overdose is often combined with other treatments, such as glucagon, atropine, and high-dose insulin euglycemia therapy 3, 4, 5
- The evidence for the use of norepinephrine in beta blocker overdose is largely based on case reports and animal studies, and the optimal dosing strategy is not well established 4
Treatment of Beta Blocker Overdose
- The treatment of beta blocker overdose typically involves supportive care measures, such as intravenous fluids and cardiac monitoring 6, 7
- Other treatments that may be used include glucagon, calcium, catecholamines, phosphodiesterase inhibitors, and high-dose insulin euglycemia therapy 4, 7, 5
- The choice of treatment depends on the severity of the overdose and the presence of any underlying medical conditions 6, 4
- In severe cases of beta blocker overdose, more invasive treatments such as veno-arterial extracorporeal membrane oxygenation may be necessary 4