AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Carbamazepine (5H-dibenzazepine-5-carboxamide) is an iminostilbene derivative with a tricyclic structure. It is an antiepileptic drug widely used for treatment of simple and complex partial seizures, trigeminal neuralgia, and bipolar affective disorder.

Carbamazepine selectively inhibits high frequency epileptic foci while normal neuronal activity remains undisturbed. Carbamazepine is absorbed erratically after oral administration because of its lipophilic nature. It has a large volume of distribution; peak plasma levels occur 4-8 hours postingestion but may take up to 24 hours to peak. The primary site of metabolism is the liver; its metabolite also is active, which may increase duration of the symptoms of toxicity.

Pathophysiology

Carbamazepine reduces the propagation of abnormal impulses in the brain by blocking sodium channels, thereby inhibiting the generation of repetitive action potentials in the epileptic focus. Carbamazepine is absorbed slowly and distributed erratically following oral administration. It enters the brain rapidly because of its high lipid solubility.

Carbamazepine is metabolized primarily in the liver by oxidative enzymes, then is conjugated with glucuronic acid, and finally is excreted in the urine. Its metabolite, carbamazepine-10,11-epoxide, is active and may achieve up to 50% concentration of the parent compound.

The elimination of carbamazepine increases over the first few weeks because of autoinduction. Carbamazepine also enhances the metabolism of phenytoin, causing its levels to fall. Erythromycin, isoniazid, and propoxyphene inhibit the hepatic metabolism of carbamazepine; therefore, the dose of carbamazepine may need to be adjusted in patients taking multiple medications.

Carbamazepine induces the hepatic cytochrome P-450 system and its half-life decreases with chronic administration. The enhanced cytochrome P-450 system increases metabolism of other antiepileptic drugs.

Frequency

United States

According to the annual report of the American Association of Poison Control Centers' Toxic Exposure Surveillance System, an average of 6295 people were exposed to carbamazepine each year from 1993-1996. The total number of people exposed to carbamazepine during this period was 25,183; however, only 16,703 people (66.3%) sought treatment in a health care facility.

Mortality/Morbidity

Of the total US exposures reported to the American Association of Poison Control Centers from 1993-1996, 6359 (25.3%) resulted in no significant outcome and 1060 (4.2%) had a significant consequence. A total of 37 deaths (<1%) occurred following exposure to carbamazepine during the 4 years studied.

• Montgomery et al reports that severity at the time of initial contact with the poison control center correlates with outcome severity for children and adults.¹ However, the amount of time between ingestion and poison control center contact did not alter the correlation between initial severity and final severity.
• Far more exposures to the drug are unintentional (57.2%) than intentional (37.6%). A small number of people experienced the effects of toxicity secondary to adverse reactions rather than true poisonings (4.0%). Montgomery et al found that the reason for ingestion was correlated significantly with outcome. Carbamazepine levels greater than 85 mg/L were associated with severe toxicity.¹
• The new drug oxcarbazepine is metabolized to a product called 10-monohydrate derivate (MHD); this is the pharmacologically effective compound. van Optstal et al reported a case when a patient ingested more than 100 tablets of oxcarbazepine.² The serum level of the parent compound was 10-fold higher than the therapeutic dosage of 31.6 mg/L. However, the concentration of MHD was only 2-fold higher. MHD levels peaked 7 hours after intake. The patient survived without an adverse outcome. The authors concluded that since oxcarbazepine is a prodrug, formation of the active MHD metabolite is a rate-limiting process contributing to low overall toxicity of this drug.

Age

Roughly one third of carbamazepine exposures occur in children younger than 6 years. Pediatric patients with carbamazepine ingestion are at higher risk for dystonic reactions, coma, and apnea if serum levels exceed 28 mg/L. Children eliminate the drug more rapidly than adults.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Query about whether the patient has been taking carbamazepine on an acute or chronic basis, the time of ingestion, and the approximate dose ingested.

• Drowsiness
• Slurred speech
• Ataxia
• Hallucinations
• Nausea, vomiting
• Tremors
• Seizures
• Oliguria
• Blurred vision
• Bullous skin formations

Physical

• Ocular
• • Mydriasis
  • Nystagmus
  • Ophthalmoplegia
• Hypotension
• Neurologic
• • Ataxia
  • Slurred speech
  • Dystonia, myoclonic activity
  • Varying degrees of CNS depression progressing to coma
  • Seizures, headache, confusion, and athetosis
  • Increased or decreased deep tendon reflexes
• Respiratory depression, apnea
• Delayed gastric emptying, abdominal pain
• Oliguria, urinary retention
• Skin
• • Bullous skin eruptions: Toxic epidermal necrolysis (TEN) has been reported with use of this drug. Severe drug eruptions are rare, and life-threatening events occur in 4 per million persons a year. TEN can trigger a life-threatening systemic inflammatory reaction leading to respiratory failure.³
  • Rash, dermatitis: Drug rash with eosinophilia and systemic symptoms, also known as DRESS syndrome, reflects a serious hypersensitivity reaction to drugs. Clinically, a diffuse maculopapular rash, exfoliative dermatitis, facial edema, lymphadenopathy, fever, and multivisceral involvement may be observed. All of these symptoms are associated with a high mortality rate.⁴ A cross-reactivity between carbamazepine and phenytoin occurs, which may lead to or worsen DRESS syndrome. Discontinuation of the anticonvulsants and topical steroids should ameliorate the rash.
  • Stevens-Johnson syndrome
• Blood dyscrasias
• • Pancytopenia
  • Splenomegaly
  • Lymphadenopathy
  • Vasculitis
  • Aplastic anemia
  • Agranulocytosis

Causes

• Carbamazepine toxicity may result from acute overdose or chronic therapy.
• Therapeutic levels are 4-12 mg/L, but individual variation exists.
• Patients on multiple anticonvulsants may not tolerate high levels and can be maintained at 4-8 mg/L, while others can achieve levels of 8-12 mg/L without adverse effects.
• Ataxia and nystagmus may occur at levels greater than 10 mg/L.
• Cardiovascular effects are usually seen at levels greater than 12 mg/L. The drug interferes with action potentials in Purkinje fibers and the His bundle, which may lead to atrioventricular blocks and arrhythmias.
• Peak serum levels with controlled release formulations of carbamazepine can result in delayed presentations of toxicity. Levels may not peak for 96 hours from the time of ingestion. Continuing repeat dosing of activated charcoal and whole bowel irrigation is important. Hemoperfusion may be necessary if end-organ toxicity becomes evident.
• Drug-drug interactions are known to occur. Vander et al reported a case of carbamazepine toxicity that occurred after administration of oxybutynin and an increase in the dose of dantrolene.⁵ The combination of these drugs elevated the level of carbamazepine leading to toxicity.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Hypersensitivity reactions (eg, dermatitis, eosinophilia, lymphadenopathy, vasculitis, splenomegaly)
Pancytopenia (eg, aplastic anemia, leukopenia)
Drug-drug interactions

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Obtain a fingerstick glucose measurement for possible explanation of altered mental status.
• Measure carbamazepine plasma level to verify that carbamazepine toxicity is present.
• Perform liver function tests to ascertain if liver damage has occurred.
• Obtain a complete blood count with differential.
• Measure electrolyte levels; hyponatremia is not uncommon with chronic dosing but rarely is noted in acute overdose.
• Perform blood urea nitrogen and creatinine tests to ascertain if renal damage has occurred.
• Measure arterial blood gas if pulse oximetry reads less than 90-95% or if any respiratory compromise is evident.
• Obtain a pregnancy test in females of childbearing age.

Imaging Studies

• Obtain an abdominal radiograph because patients with rising serum levels may have a bezoar of undigested tablets that may be visualized radiographically.
• Obtain a chest x-ray if crackles or rales are heard on physical examination and pulmonary edema is suspected or to confirm endotracheal (ET) placement if respiratory depression occurs.

Other Tests

• Obtain a 12-lead electrocardiogram (ECG) to determine any conduction abnormalities or interval prolongations.
• • QRS widening
  • Sinus tachycardia
  • Varying degrees of atrioventricular block
  • QT prolongation

Procedures

• Repeat doses of activated charcoal and whole bowel irrigation

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Intravenous heplock, cardiac monitor
• Intravenous fluids if patient is hypotensive

Emergency Department Care

For carbamazepine toxicity, the following ED care may be indicated:

• Place patient on a monitor.
• Administer IV fluids as needed for hypotension.
• Administer IV diazepam (5-10 mg, repeat q10-15min prn) or other suitable benzodiazepine to control seizures.
• Gastric lavage may be helpful if performed within 1 hour of ingestion.
• Protect airway by placing the patient in left lateral decubitus position or by intubating.
• Induction of emesis is not recommended because of the risk of CNS depression and seizures.
• Administer 3-4 doses of activated charcoal (1 g/kg) to enhance total body clearance and elimination.
• A saline cathartic or sorbitol may be given with the first dose of charcoal, although evidence for their effectiveness is lacking.
• Do not repeat activated charcoal administration if an ileus is present.

Consultations

• Consult a medical toxicologist or a certified poison control center.
• Nephrology consultation is indicated if considering charcoal hemoperfusion. Hemodialysis and peritoneal dialysis are not useful.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Unfortunately, no regimen is reported to be highly effective in slowing or reversing motor or cognitive symptoms of this disease. Medications for Parkinson disease, including anticholinergics, levodopa, and dopamine agonists, can reduce the rigidity to a minor extent in some patients and usually are tried at some point in the course of the disease.

Drug Category: Dopaminergic medications

Stimulate dopamine receptors.

Pergolide was withdrawn from the US market March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. It is important not to abruptly stop pergolide. Health care professionals should assess patients' need for dopamine agonist (DA) therapy and consider alternative treatment. If continued treatment with a DA is needed, another DA should be substituted for pergolide. For more information, see FDA MedWatch Product Safety Alert and Medscape Alerts: Pergolide Withdrawn From US Market.

Drug Category: Neuroprotective agents

No studies demonstrate that therapy with neuroprotective drugs slows the course of CBGD. However, such therapy does affect the course of other neurodegenerative dementias; therefore, neuroprotective agents are generally offered empirically.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDS)

Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions.

Drug Category: Steroid hormones

Have hemodynamic effects.

Drug Category: Benzodiazepines

By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Drug Category: Toxins

Botulinum toxin can inhibit transmission of impulses in neuromuscular tissue.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Monitor carbamazepine plasma levels to make sure that they are decreasing and correlating with the clinical picture.

Transfer

• Transfer the patient if appropriate monitoring facilities or critical care areas are not available.

Deterrence/Prevention

• Education and communication between the primary care physician and the patient is important for prevention of carbamazepine overdose.

Complications

• Coma
• Stevens-Johnson syndrome
• Syndrome of inappropriate antidiuretic hormone (SIADH)
• Elevated liver function tests
• Pulmonary edema
• Pancytopenia
• Anuria

Prognosis

• The patient may experience altered levels of consciousness for several days following acute overdose.
• The patient's clinical examinations should improve as the plasma levels of the drug fall.

Patient Education

• Carefully explain the proper method of taking anticonvulsants to avoid adverse reactions.
• Educate to keep all medications and poisons in a locked cabinet or on high shelves to prevent pediatric accidental ingestions.
• Instruct patients and parents to ensure that suspensions of Tegretol be agitated vigorously before administration. Otherwise, the drug settles in its container and early doses will contain less Tegretol and subsequent underdosing will occur; later doses may contain more drug and lead to toxicity.
• For excellent patient education resources, visit eMedicine's Drug Overdose Center and Poisoning - First Aid and Emergency Center. Also, see eMedicine's patient education articles Poisoning, Drug Overdose, Activated Charcoal, and Poison Proofing Your Home.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The physician should identify and diagnose carbamazepine toxicity to prevent increased morbidity and mortality of the patient.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. Montgomery VL, Richman BJ, Goldsmith LJ, Rodgers GC Jr. Severity and carbamazepine level at time of initial poison center contact correlate with outcome in carbamazepine poisoning. J Toxicol Clin Toxicol. 1995;33(4):311-23. [Medline].
2. van Opstal JM, Janknegt R, Cilissen J, et al. Severe overdosage with the antiepileptic drug oxcarbazepine. Br J Clin Pharmacol. Sep 2004;58(3):329-31. [Medline].
3. Fischer M, Hamm H, Wirbelauer J. [Severe drug-related skin reaction: toxic epidermal necrolysis caused by carbamazepine]. Klin Padiatr. Sep-Oct 2004;216(5):288-93. [Medline].
4. Allam JP, Paus T, Reichel C, et al. DRESS syndrome associated with carbamazepine and phenytoin. Eur J Dermatol. Sep-Oct 2004;14(5):339-42. [Medline].
5. Vander T, Odi H, Bluvstein V, Ronen J, Catz A. Carbamazepine toxicity following Oxybutynin and Dantrolene administration: a case report. Spinal Cord. Apr 2005;43(4):252-5. [Medline].
6. Apfelbaum JD, Caravati EM, Kerns WP, et al. Cardiovascular effects of carbamazepine toxicity. Ann Emerg Med. May 1995;25(5):631-5. [Medline].
7. Bass J, Miles MV, Tennison MB, et al. Effects of enteral tube feeding on the absorption and pharmacokinetic profile of carbamazepine suspension. Epilepsia. May-Jun 1989;30(3):364-9. [Medline].
8. Goldfrank L, Flomenbaum NE, Lewin NA. Carbamazepine. In: Goldfrank's Toxicologic Emergencies. Appleton & Lange; 1994:594-5.
9. Graudins A, Peden G, Dowsett RP. Massive overdose with controlled-release carbamazepine resulting in delayed peak serum concentrations and life-threatening toxicity. Emerg Med (Fremantle). Mar 2002;14(1):89-94. [Medline].
10. Klimaszyk D, Lukasik-GLebocka M. [Cardiac toxicity of carbamazepine]. Przegl Lek. 2002;59(4-5):384-5. [Medline].
11. Litovitz TL, Clark LR, Soloway RA. 1993 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1994;12(5):546-84. [Medline].
12. Litovitz TL, Felberg L, Soloway RA, et al. 1994 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1995;13(5):551-97. [Medline].
13. Litovitz TL, Felberg L, White S, Klein-Schwartz W. 1995 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1996;14(5):487-537. [Medline].
14. Litovitz TL, Smilkstein M, Felberg L, et al. 1996 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med. Sep 1997;15(5):447-500. [Medline].
15. Micromedex. Toxicologic Managements of Carbamazepine. Healthcare Series Micromedex;95.
16. Miles MV, Lawless ST, Tennison MB, et al. Rapid loading of critically ill patients with carbamazepine suspension. Pediatrics. Aug 1990;86(2):263-6. [Medline].
17. Riva R, Contin M, Albani F, et al. Free and total plasma concentrations of carbamazepine and carbamazepine-10,11-epoxide in epileptic patients: diurnal fluctuations and relationship with side effects. Ther Drug Monit. 1984;6(4):408-13. [Medline].
18. Romero Maldonado N, Sendra Tello J, Raboso Garcia-Baquero E, Harto Castano A. Anticonvulsant hypersensitivity syndrome with fatal outcome. Eur J Dermatol. Sep-Oct 2002;12(5):503-5. [Medline].
19. Stremski ES, Brady WB, Prasad K, Hennes HA. Pediatric carbamazepine intoxication. Ann Emerg Med. May 1995;25(5):624-30. [Medline].
20. Van Der Meyden CH, Kruger AJ, Muller FO, et al. Acute oral loading of carbamazepine-CR and phenytoin in a double-blind randomized study of patients at risk of seizures. Epilepsia. Jan-Feb 1994;35(1):189-94. [Medline].
21. Wada JA, Troupin AS, Friel P, et al. Pharmacokinetic comparison of tablet and suspension dosage forms of carbamazepine. Epilepsia. Jun 1978;19(3):251-5. [Medline].

Article Last Updated: Aug 14, 2008