Lomotil toxicity

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Background

  • Mixture of diphenoxylate / atropine used to treat diarrhea
  • Children are especially sensitive to toxicity (death reported after ingestion of <5 tablets)

Mechanism of toxicity

  • Diphenoxylate
    • opioid analog of meperidine, which has opioid-like toxicity in overdose
  • Atropine
    • anticholinergic effect can contribute to lethargy, coma
  • Toxic dose is variable and difficult to predict

Clinical Features

  • Atropine effects
    • Lethargy, agitation, flushing, dry mucous membranes, mydriasis, ileus, tachycardia
  • Opioid effects
    • Miosis, coma, respiratory depression, respiratory arrest

Evaluation

  • Diagnosis is based on history and signs of toxicity

Management

  • Maintain airway and support ventilation, if needed
  • Naloxone 1-2mg IV for apnea, coma, or lethargy (may require repeat dosing)
  • No evidence for utility of physostigmine
  • Activated charcoal should be given promptly if available

Disposition

  • Pediatric patients should be observed in the ICU for 24 hours given risk of sudden respiratory arrest

References

  • Olson, K. Poisoning and Drug Overdose Clinical Manual. 2004
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