Pediatric Amatoxin Toxicity Medication

  • Author: Douglas S Lee, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Mar 30, 2012
 

Medication Summary

Given the delay between ingestion and the development of clinical symptoms, the role of gastric decontamination may be more limited than with other intoxications. However, multidose activated charcoal may still have a role in interrupting enterohepatic circulation of amatoxin. Clear benefit has not been established.

No US Food and Drug Administration (FDA)-approved specific antidote for cyclopeptide poisoning exists. Intravenous silymarin (derived from the Mediterranean milk thistle plant) is the treatment of choice in Europe, but the antidote is not available in the United States. Milk thistle, or Silybum marianum, is hypothesized to provide hepatoprotective effects via interruption of the enterohepatic circulation of amanitin and inhibition of penetration into liver cells. Other therapies that have been suggested include benzylpenicillin (penicillin G), N -acetylcysteine, thioctic acid, cimetidine, cytochrome C, and hyperbaric oxygen.

Given the rarity of toxic mushroom ingestion and the difficulties in designing prospective trials, evidence is limited to animal studies and retrospective analysis in humans. Because these suggested therapies are unapproved, consult with a medical toxicologist from the nearest regional poison control center before undertaking a course of therapy.

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Gastrointestinal decontaminations

Class Summary

Activated charcoal may reduce the amount of toxin absorbed.

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Activated charcoal (Liqui-Char)

 

Used for emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.

For maximum effect, administer within 30 min of ingesting poison.

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Potentially beneficial medications

Class Summary

The literature is fraught with case studies and trials. Decreases in mortality are likely due to improved supportive care.[6]

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Penicillin G (Pfizerpen)

 

May displace amanitin from plasma proteins, thus increasing the renal excretion. May inhibit amanitin from entering hepatocytes. May bind to acid amanitin.

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Silibinin (Legalon)

 

A flavolignone isolated from the milk thistle Silybum marianum. Also known as silymarin or silidianin. May interrupt the enterohepatic circulation of the toxin or inhibit the penetration of amanitin into hepatocytes. Available in Europe but not available in the United States.

Thioctic acid (Thiocid, Alpha Lipoic Acid)

 

It is a coenzyme in cellular metabolism, a free radical scavenger, and an antioxidant used for diabetic neuropathies and various metabolic disorders. No controlled trials are known. Clinical efficacy has not been proven.

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Contributor Information and Disclosures
Author

Douglas S Lee, MD  Attending Physician, Department of Emergency Medicine, Naples Community Hospital

Douglas S Lee, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Suzanne Bentley, MD  Clinical Instructor, Department of Emergency Medicine, Elmhurst Hospital, Mount Sinai School of Medicine

Suzanne Bentley, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Medical Women's Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Theodore Bania, MD  Program Director, Assistant Director of Research, Department of Emergency Medicine, Division of Toxicology, Assistant Professor, St Luke's-Roosevelt Hospital Center, Columbia University

Theodore Bania, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, New Mexico Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Matthew R Denny, MD, MPH  Staff Physician, Department of Emergency Medicine, Santa Clara Valley Medical Center; Clinical Instructor, Department of Emergency Medicine, Stanford University School of Medicine

Matthew R Denny, MD, MPH is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael E Mullins, MD  Assistant Professor, Division of Emergency Medicine, Washington University in St Louis School of Medicine; Attending Physician, Emergency Department, Barnes-Jewish Hospital

Michael E Mullins, MD is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Emergency Physicians

Disclosure: Johnson & Johnson stock ownership None; Savient Pharmaceuticals stock ownership None

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

Paul D Petry, DO, FACOP, FAAP  Consulting Staff, Freeman Pediatric Care, Freeman Health System

Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

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Amanita phalloides.
 
 
 
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