Management of Oxcarbazepine (Trileptal) Overdose
There is no specific antidote for oxcarbazepine overdose. Treatment should focus on supportive care, including gastric lavage and/or activated charcoal administration to reduce absorption. 1
Clinical Presentation of Oxcarbazepine Overdose
- Overdose symptoms include nausea, vomiting, somnolence, aggression, agitation, hypotension, and tremor 1
- Additional manifestations may include coma, confusion, seizures, dyscoordination, decreased consciousness, diplopia, dizziness, dyskinesia, dyspnea, QT prolongation, headache, miosis, nystagmus, and decreased urine output 1
- Serious toxicity is generally less severe compared to other anticonvulsants, likely because oxcarbazepine is a prodrug with rate-limited conversion to its active metabolite (10-monohydroxy derivative or MHD) 2
Management Algorithm
Immediate Interventions
- Secure airway, breathing, and circulation following standard resuscitation protocols 3
- Administer activated charcoal if presentation is within 1-2 hours of ingestion 1
- Consider multiple doses of activated charcoal for the first 24-48 hours in severe cases 4
Supportive Care
- Monitor vital signs, cardiac rhythm, and neurological status 3
- Provide respiratory support as needed, including intubation for patients with decreased consciousness 5
- Treat seizures with benzodiazepines if they occur 4
- Monitor serum sodium levels, as hyponatremia is a potential complication of oxcarbazepine therapy and may be exacerbated in overdose 6
Enhanced Elimination
- Standard hemodialysis may be considered in severe cases, although evidence for its efficacy in accelerating oxcarbazepine elimination is limited 5
- The decision to implement extracorporeal removal should be based on clinical severity rather than drug levels alone 5
Special Considerations
- Unlike benzodiazepine overdose, which may respond to flumazenil, or opioid overdose, which responds to naloxone, there is no specific reversal agent for oxcarbazepine 3, 1
- Oxcarbazepine overdose appears to have lower toxicity compared to other anticonvulsants like carbamazepine, likely due to its prodrug nature 2
- Patients typically recover with appropriate supportive care 1, 2
Monitoring and Follow-up
- Monitor serum electrolytes, particularly sodium levels 6
- Continue cardiac monitoring until symptoms resolve 3
- Observe for at least 24 hours in symptomatic patients 2
Common Pitfalls to Avoid
- Failing to consider co-ingestions, which may require specific antidotes (e.g., naloxone for opioids) 3
- Overlooking the need to monitor for hyponatremia, which can develop gradually 6
- Assuming that flumazenil would be beneficial - it has no role in oxcarbazepine overdose 3, 1
In contrast to some other medication overdoses where specific antidotes exist (such as naloxone for opioids or flumazenil for benzodiazepines), management of oxcarbazepine overdose relies primarily on supportive care and gastrointestinal decontamination measures 3, 1.