Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup

EXTRIP workgroup · 2021 · international

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Authors: Josée Bouchard, Greene Shepherd, Robert S. Hoffman et al.
Title: Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup
Journal: Critical Care, 2021
DOI: 10.1186/s13054-021-03585-7
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC8194226

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

General statements and indications for ECTR

In patients severely poisoned with propranolol, we recommend against performing ECTR in addition to standard care rather than standard care alonestrong recommendation, very low quality evidence
In patients severely poisoned with atenolol and kidney impairment*, we suggest performing ECTR in addition to standard care rather than standard care alone when refractory bradycardia and hypotension is presentweak recommendation, very low quality evidence
In patients severely poisoned with atenolol and normal kidney function, we make no recommendation for or against performing ECTR in addition to standard care rather than standard care aloneno recommendation, very low quality evidence
In patients severely poisoned with sotalol and kidney impairment*, we suggest performing ECTR in addition to standard care rather than standard care alone when refractory bradycardia and hypotension and/or recurrent torsade de pointes is presentweak recommendation, very low quality of evidence
In patients severely poisoned with sotalol with normal kidney function, we make no recommendation for or against performing ECTR in addition to standard care rather than standard care aloneno recommendation, very low quality evidence
In patients severely poisoned with sotalol, we suggest against performing ECTR solely based on the QT intervalweak recommendation, very low quality evidence

Abstract

Background: β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning.

Methods: We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods.

Results: A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations.

Conclusions: BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13054-021-03585-7.

Contents of the original publication

The section headings of the original.

Introduction
Clinical pharmacology and toxicokinetics
Overview of toxicity
Methods
Results
Summary of evidence
Discussion
Recommendations
Type of ECTR
Cessation of ECTR
Conclusion

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