Q J Med 2002; 95: 275-283
© 2002 Association of Physicians
Oximes in acute organophosphorus pesticide poisoning: a systematic review of clinical trials
From the Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK, 1 Institute of Pharmacology and Toxicology, German Armed Forces Medical Academy, Munich, and 2 Walther-Straub-Institut für Pharmakologie und Toxikologie, Ludwig-Maximilians-Universitaet, Munich, Germany, and 3 Department of Clinical Pharmacology and Toxicology, The Canberra Hospital, Canberra, Australia
Received 19 September 2001 and in revised form 4 February 2002
Background: Acute organophosphorus (OP) pesticide poisoning is widespread in the developing world. Standard treatment involves the administration of intravenous atropine and an oxime to counter acetylcholinesterase inhibition at the synapse, but the usefulness of oximes is uncertain.
Aim: To assess the evidence on the use of oximes in OP poisoning.
Design: Systematic review.
Methods: We searched Medline, Embase, and Cochrane databases (last check 01/02/02) for ‘organophosphate’ or ‘oxime’ together with ‘poisoning’ or ‘overdose’. We cross-referenced from other articles, and contacted experts to identify unpublished studies. A Web search engine [www.google.com] was also used, with the keywords ‘organophosphate’, ‘oxime’, and ‘trial’ (last check 01/02/02).
Results: We found two randomized controlled trials (RCTs) involving 182 patients treated with pralidoxime. The RCTs found no benefit with pralidoxime, and have been used to argue that pralidoxime should not be used in OP poisoning.
Discussion: The RCT authors must be congratulated for attempting important studies in a difficult environment. However, their studies did not take into account recently clarified issues regarding outcome, and their methodology is unclear. A generalized statement that pralidoxime should not be used in OP poisoning is not supported by the published results. Oximes may well be irrelevant in the overwhelming self-poisoning typical of the tropics, but a large RCT comparing the current WHO-recommended pralidoxime regimen (>30 mg/kg bolus followed by >8 mg/kg/h infusion) with placebo is needed for a definitive answer. Such a study should be designed to identify any patient subgroups that might benefit from oximes.
Address correspondence to Dr M. Eddleston, Department of Clinical Medicine, Faculty of Medicine, University of Colombo, PO Box 271, 25 Kynsey Rd, Colombo-08, Sri Lanka. e-mail: eddlestonm{at}eureka.lk
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