What is the treatment for oxcarbazepine (Trileptal) poisoning?

Treatment of Oxcarbazepine Poisoning

Oxcarbazepine overdose should be managed primarily with supportive care, including airway protection, benzodiazepines for seizures, and sodium bicarbonate for life-threatening cardiac toxicity with QRS prolongation. 1

Initial Management and Supportive Care

The cornerstone of oxcarbazepine poisoning treatment is aggressive supportive care:

• Establish and maintain airway patency with bag-mask ventilation or endotracheal intubation as needed for patients with CNS depression and loss of protective airway reflexes 1
• Provide supplemental oxygen and support breathing as required 2
• Establish intravenous access and administer IV fluids for volume resuscitation 2
• Monitor vital signs continuously, including cardiac monitoring for dysrhythmias 2
• Contact poison control (1-800-222-1222 in the US) for expert guidance on specific case management 1

Specific Interventions Based on Clinical Presentation

Cardiovascular Toxicity

Oxcarbazepine is structurally related to carbamazepine and can cause sodium channel blockade, leading to cardiac toxicity:

• For QRS prolongation or wide-complex dysrhythmias: Administer sodium bicarbonate 1-2 mEq/kg IV bolus (hypertonic solution: 1000 mEq/L in adults, 500 mEq/L in children) 1, 2
• For hypotension unresponsive to IV fluids: Administer vasopressors such as dopamine or vasopressin 2
• Monitor ECG closely for intraventricular conduction delay and terminal rightward axis deviation in lead aVR, which typically precede ventricular dysrhythmias 1

Neurological Complications

• For seizures or severe agitation: Administer benzodiazepines (diazepam first-line or midazolam) 1, 2
• For coma or altered mental status: Maintain airway protection and provide supportive care 3

Electrolyte Monitoring

• Monitor serum sodium levels closely, as hyponatremia can develop or worsen in overdose, particularly in patients already on oxcarbazepine therapy 4, 5
• Relevant hyponatremia (<125 mmol/l) may occur and require specific management 5

Clinical Context and Prognosis

The severity of oxcarbazepine overdose is generally dose-dependent but outcomes are typically favorable:

• Most common clinical effects include drowsiness (25%), vomiting (8%), tachycardia (3%), and agitation (1.8%) 3
• Severe outcomes are infrequent (<1% of cases), with major effects occurring primarily in intentional exposures 3
• Unlike other anticonvulsants, oxcarbazepine does not appear to be proconvulsant in overdose 3
• Pediatric exposures typically result in mild symptoms, and observation at home may be appropriate for the majority of cases without significant ingestion 3
• Adult intentional exposures require hospital evaluation due to higher risk of cardiovascular and neurological complications 3

Important Caveats

• Avoid neuromuscular blockers metabolized by cholinesterase (succinylcholine, mivacurium) in patients with potential anticholinergic effects 1, 2
• Consider co-ingestions, as mixed overdoses are common and may complicate management 1
• No specific antidote exists for oxcarbazepine; treatment remains entirely supportive 3
• Hemodialysis is not typically indicated as oxcarbazepine and its active metabolite undergo primarily renal excretion and glucuronidation 6