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Experience with lower dose flumazenil at an academic medical center

Published:February 04, 2021DOI:https://doi.org/10.1016/j.ajem.2021.02.002
      Benzodiazepines (BZDs) are frequently used in self-poisonings [
      • Ngo A.S.
      • Anthony C.R.
      • Samuel M.
      • Wong E.
      • Ponampalam R.
      Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department?.
      ]. Flumazenil effects for BZD reversal are dose-dependent and higher doses are often used to achieve desired outcomes. However, higher doses are associated with increased risk of seizures, cardiac dysrhythmias, and other adverse drug effects (ADEs) [
      • Penninga E.I.
      • Graudal N.
      • Ladekarl M.B.
      • Jürgens G.
      Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication--a systematic review with meta-analyses of randomised trials.
      ,
      • Seger D.L.
      Flumazenil--treatment or toxin.
      ]. Multidrug intoxications involving tricyclic antidepressants (TCAs), stimulants, ethanol, anticonvulsants, propoxyphene, barbiturates, and other anxiolytics increase the frequency of significant ADEs from flumazenil [
      • Ngo A.S.
      • Anthony C.R.
      • Samuel M.
      • Wong E.
      • Ponampalam R.
      Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department?.
      ,
      • Penninga E.I.
      • Graudal N.
      • Ladekarl M.B.
      • Jürgens G.
      Adverse events associated with flumazenil treatment for the management of suspected benzodiazepine intoxication--a systematic review with meta-analyses of randomised trials.
      ,
      • Seger D.L.
      Flumazenil--treatment or toxin.
      ,
      • Winkler E.
      • Almog S.
      • Kriger D.
      • Tirosh M.S.
      • Halkin H.
      • Ezra D.
      Use of flumazenil in the diagnosis and treatment of patients with coma of unknown etiology.
      ,
      • Marraffa J.M.
      • Cohen V.
      • Howland M.A.
      Antidotes for toxicological emergencies: a practical review.
      ,
      • Gueye P.N.
      • Hoffman J.R.
      • Taboulet P.
      • Vicaut E.
      • Baud F.J.
      Empiric use of flumazenil in comatose patients: limited applicability of criteria to define low risk.
      ]. In BZD overdose patients without evidence of underlying stimulation (e.g., neuromuscular excitation, tachycardia, hypertension) we often administer flumazenil 0.05–0.1 mg IV every 2–3 min to response. Patients receiving flumazenil for reversal of therapeutic BZD use are typically administered 0.2 mg [
      • Flumazenil. Lexi-Drugs. Lexicomp
      Wolters Kluwer Health, Inc. Hudson, OH.
      ]. Characterization of efficacy and safety of flumazenil in different populations and doses is necessary.
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