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Table 4 Indications and recommended availability times for the main antidotes

From: Management of pharmaceutical and recreational drug poisoning

Antidote Toxin Indications Availability Evidence level
Folinic acid (l-folinic acid) Methotrexate SID–1000 mg/m2 (taking serum methotrexate levels into account)
Kidney failure
2 h Expert opinion
Digoxin antibodies [248] Digoxin Semimolar neutralization: bradycardia ≤ 50 bpm refractory to 1 mg of atropine i.v.; atrioventricular block (regardless of degree); serum potassium ≥ 4.5 mmol/L
Molar neutralization: ventricular arrhythmias (ventricular fibrillation or ventricular tachycardia); severe bradycardia ≤ 40 bpm refractory to 1 mg of atropine i.v.; serum potassium ≥ 5.5 mmol/L; mesenteric infarction; cardiogenic shock
Expert centre Expert opinion
Methylene blue (methylthioninium chloride, Proveblue®) Sulphones
Lidocaine, prilocaine
Methaemoglobinaemia ≥ 20% or signs of tissue hypoxia Immediate Expert opinion
Carbopeptidase G2 (Voraxase®) Methotrexate Serum methotrexate ≥ 1 µmol/L at H48 with kidney failure Expert centre Expert opinion
Iron SID ≥ 150 mg/kg and/or
Signs of poisoning
Serum iron at H2–H4 ≥ 500 µg/dL
Metabolic acidosis
 > 2 h Expert opinion
Diazepam [249] Chloroquine In the presence of a single risk factor for poor prognosis: SID ≥ 4 g or systolic blood pressure ≤ 100 mmHg, or QRS ≥ 100 ms
In combination with intubation and adrenaline
Immediate Expert opinion
Flumazenil [250] Benzodiazepines Coma and/or acute respiratory failure requiring intubation Immediate Grade 2
Dabigatran Severe haemorrhage
Surgical emergency
< 2 h Grade 2
l-Carnitine Valproic acid Severe poisoning with hyperammonaemia or hyperlactataemia
Plasma concentration ≥ 850 mg/L
< 2 h Expert opinion
N-Acetylcysteine Acetaminophen Serum acetaminophen greater than 150 mg/L at H4 (Rumack and Matthew's nomogram)
Unknown time of intake or impaired level of consciousness (continue if serum acetaminophen remains detectable or elevation of ALAT)
Susceptibility factor (chronic liver disease, nutritional deficiency; continue if serum acetaminophen remains detectable or elevation of ALAT)
Delayed admission more than H24 post-exposure with elevated ALAT
Repeated use of supratherapeutic doses of acetaminophen (continue if elevation of ALAT)
2 h Grade 1+
Expert opinion
Naloxone [251] Opioids Coma and/or respiratory depression requiring intubation Immediate Grade 1+
Neostigmine Non-depolarizing muscle relaxants
Respiratory distress (TOF > 0/4)
Severe anticholinergic syndrome
Immediate Expert opinion
Octreotide [252] Sulphonylureas Symptomatic hypoglycaemia Immediate Grade 2
PPSB Vitamin K antagonist anticoagulants
Direct oral anticoagulant
Severe or potentially severe haemorrhage
Urgent surgery
In combination with vitamin K
Immediate Expert opinion
Sugammadex Rocuronium
Respiratory distress Operating room Grade 2
Protamine sulphate Unfractioned heparin and low-molecular weight heparins (less effective) Severe haemorrhage
Surgical emergency
< 2 h Expert opinion
Vitamin B6 Isoniazid SID > 2 g with seizures < 2 h Expert opinion
Vitamin K1 Vitamin K antagonist anticoagulants INR ≥ 6
And/or severe haemorrhage
And/or urgent surgery
In combination with PCC
Immediate Expert opinion
  1. ALAT alanine aminotransferase, SID supposed ingested dose, INR international normalized ratio, i.v. intravenous, PCC prothrombin complex concentrate, TOF train-of-four (stimulations)