Treatment of Oleander Poisoning
Administer digoxin-specific Fab antibody fragments (Digibind) immediately for severe oleander poisoning with life-threatening cardiac manifestations, as oleander contains cardiac glycosides that cause toxicity identical to digoxin poisoning. 1, 2
Understanding Oleander Toxicity
Oleander poisoning (both Nerium oleander and Thevetia peruviana/yellow oleander) causes cardiac glycoside toxicity through compounds including oleandrin, thevetin A and B, and neriifolin. 3 The clinical presentation mirrors digoxin toxicity with:
- Cardiac manifestations: Severe bradycardia, AV nodal blockade, ventricular arrhythmias, second-degree heart block type II, third-degree heart block, and potential cardiac standstill 1, 4
- Gastrointestinal symptoms: Nausea, vomiting, abdominal pain, diarrhea 3
- Metabolic derangements: Hyperkalemia in severe overdose 1, 3
Treatment Algorithm
Immediate Management
Administer digoxin-specific Fab antibody fragments (Digibind) as first-line definitive treatment for severe cardiac glycoside toxicity from oleander. 1, 2 The 2020 American Heart Association guidelines give this a Class I recommendation (strongest level) for severe cardiac glycoside toxicity. 1
Indications for Fab fragments include:
- Life-threatening ventricular arrhythmias 2, 5
- Severe bradycardia with hemodynamic compromise 2
- Second-degree heart block type II or third-degree heart block 4
- Hyperkalemia 1
- Cardiac arrest 1
Dosing: Initial dose of 5-10 vials (200-400 mg) of digoxin-specific Fab fragments, with clinical response typically occurring within 30 minutes to 4 hours. 5, 6
Supportive Cardiac Management
For bradydysrhythmias not immediately requiring Fab fragments:
- Atropine is reasonable as initial therapy for symptomatic bradycardia 2, 4
- Temporary cardiac pacing should be used for bradydysrhythmias not responding to atropine or medical therapy 2, 4
- Antiarrhythmic medications (lidocaine, phenytoin) may be reasonable for ventricular dysrhythmias until Fab fragments can be administered 2
In one Sri Lankan case series, 80 of 90 patients requiring treatment responded to atropine and/or isoprenaline alone, with only 10 requiring cardiac pacing. 4 However, this approach should be considered temporizing until Fab fragments are available for severe cases.
Gastrointestinal Decontamination
- Activated charcoal should be administered if presentation is within 1-2 hours of ingestion 3
Electrolyte Management
- Correct hypokalemia, hypomagnesemia as these potentiate cardiac glycoside toxicity 6
- Monitor for hyperkalemia in severe poisoning, which indicates massive toxicity 1, 3
Ineffective Treatments to Avoid
Do NOT use extracorporeal removal methods (hemodialysis, hemofiltration, hemoperfusion, or plasmapheresis) as these are ineffective for oleander poisoning. 2, 6 Cardiac glycosides have large volumes of distribution and are not effectively removed by dialysis.
Monitoring and Disposition
- Continuous cardiac monitoring for at least 24-48 hours after presentation 6
- Serial potassium levels to detect hyperkalemia 3
- Contact poison control (US: 1-800-222-1222) for expert guidance 2
Clinical Pearls
Digoxin immunoassays may cross-react with oleander glycosides, providing supportive diagnostic evidence but not reliably quantifying toxicity. 7, 3 The diagnosis relies on clinical presentation combined with exposure history.
Conservative management alone may be sufficient for mild cases without life-threatening arrhythmias, as demonstrated by case reports of recovery with supportive care only. 8 However, mortality occurs in delayed presentations before definitive treatment, emphasizing the importance of early Fab fragment administration in severe cases. 4
The key pitfall is delaying Fab fragment administration in patients with severe cardiac manifestations while attempting temporizing measures. The American Heart Association's Class I recommendation for Fab fragments in severe cardiac glycoside toxicity should guide aggressive early treatment. 1