This case report describes a nearly fatal case of amlodipine poisoning in an 11-month old infant. The infant received 6 doses of 15mg of amlodipine which was mistakenly dispensed instead of amoxicillin. Within hours, the infant developed vomiting, lethargy, bradycardia, respiratory distress, and hypotension. Laboratory tests showed hyperglycemia, electrolyte abnormalities, and elevated liver enzymes. The infant was treated with insulin, calcium gluconate, ionotropes, and peritoneal dialysis. The infant's condition gradually improved and was discharged after 10 days. The authors conclude that hyperinsulinemia therapy is beneficial in treating calcium channel blocker toxicity and

1. TOPIC: NEAR FATAL CASE OF
AMLODIPINE POISONING IN AN INFANT
INDIAN JOURNAL OF PEDIATRICS
JUNE 2013 volume 80 by Somashekar M. Nimbalkar ,Dipen
vasudev patel

2. INTRODUCTION
• Infants contribute about 5.25% of poisoning
exposure. Only one case of
amlodipine poisoning is reported in infants and
the child recovered after treatment.
• The authors report an 11 month old infant with
nearly fatal amlodipine poisoning.

3. CASE REPORT
• A 11 month old infant received 6 doses of 15mg of
amlodipine which was dispensed against
prescribed amoxicillin for lower respiratory tract
infection.
• He presented with vomitting and reduced activity.
• He worsened over few hours with increased
lethargy, bradychardia, respiratory distress and
progressive loss of consiousness , irregular heart
sounds, bilateral creptations over chest and
hepatomegaly.

4. • His blood sugar was 382mg/dl.
• On admission he had anemia.
• Blood pressure remained at 70/40 mm Hg
• He was progressed to hypotensive shock within
three hours of admission.

5. INVESTIGATION ADMISSION 24HOURS 48 HOURS 72 HOURS
s.Creatinine(mg/dl)
(0.6-1.5mg/dl)
0.59 0.81 0.49 0.34
s.Urea(8-25mg/dl) - 108 56 8
s.Sodium
(135-148mmol/l)
129 124 131 146
s.Potassium
(3.5-5.5 mmol/l)
5.8 5.7 3.6 21.9
s.Calcium(8-11mg/dl) 9.34 10.6 11.05 -

6. INVESTIGATION ADMISSION 24 HRS 48 HRS 72 HRS
Alanine transaminase
(u/l)
44 - - 124
Aspartate
transaminase(u/l)
112 - - 622
s.Total bilirubin(mg/dl) 0.24 - - 0.49
Haemoglobin(g/dl) 8.2 9.7 -
HCO3(22-29 meq/l) 17 19.3 23.6 -
PCO2(41-51mm hg) 33.4 34.6 34.6 -
PO2(30-40 mm hg) 267 356.1 398.6 -

7. • His blood sugar was found increased because
Calcium channel blockers bind to alpha unit of L-
type channel results in impaired secretion of
insulin results in hyperglycemia.
• CCB poisoning also results in insulin resistance.
• The maximum therapeutic dose of amlodipine is
0.6mg/kg per day. But the 6kg infant received 15
mg three times a day.
• Amlodipine three times a day for two days (about
12.5 times maximum dose of amlodipine).

8. TREATMENT
• He received mechanical ventilation.
• Fluid therapy with normal saline was given.
• His parameters only improved after giving insulin
0.5-1 unit/kg/hr was given for (15 hours) along with
calcium gluconate infusion for (72 hours).
• He was treated with adrenaline which is a powerful
cardiac stimulant .It acts on beta receptors and
increases heart rate, cardiac output.(as CCB in
higher dose causes decrease in heart rate,
decrease cardiac output)

9. • Calcium channel blockers usually causes negative
ionotropic effect ( weaken heart contraction and
slows the heart rate).
• So positive ionotropes such as dopamine,
epinephrine are given to change the force of heart
contractions and improves the heart rate.
• To manage renal failure , oliguria(decrease in urine
output), pulmonary edema, congestive cardiac
failure peritoneal dialysis was initiated at 24 hours
of admission and continued for 48 hours.

10.  Child improved hence insulin infusion was tapered
and stopped after 15 hours.
 Ionotropes was tapered after 48 hours.
 Calcium gluconate stopped after 72 hours.
 Liver enzymes increased after 72 hours of ingestion
without develpoment of jaundice.
 Patient was discharged after 10 days .

11. DISCUSSION
• Calcium channel blockers are a potential source of
risk for children due to the high dosage from
strength ,in relation to the body weight.
• A single dose of 10 mg nifedipine tablet was
associated with the death of an infant.
• Amlodipine has large volume of distribution and
half life is 35-45 hours and overdose causes
prolonged calcium channel blockers toxicity.

12. • Animal studies have shown insulin improves
myocardial infraction during shock induced by
calcium channel blockers toxicity.
• The author’s says that insulin therapy can be
recommended as first line therapy for calcium
channel blockers toxicity.

13. CONCLUSION
• It is said that hyperinsulinemia therapy is beneficial
in patients with calcium channel blockers induced
hypotension , hyperglyceamia and acidosis.
• High dose insulin therapy and other standard
therapies discussed above are used in
combination.
• The prescribers should avoid these kind of
medication errors in order to improve patient safety.

14. REFERENCES
• Bronstein Ac, Spyker DA , Cantilena Jr ,Green JL,
Rumack BH,2008.
• Annual report of American association of poison
control centres
• National poison data system (26 th annual report).
• Spiller HA, milliner BA amlodipine poisoning in an
infant by J.Med toxicol 2012 ;8; 179-182

15. THANK YOU