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Toxicity, Ciguatera: Treatment & Medication
Updated: Aug 19, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- Treatment of ciguatera poisoning is largely supportive and symptom driven.
- GI decontamination with activated charcoal may be of value if performed within 3-4 hours of ingestion. Avoid syrup of ipecac because of its potential to worsen fluid losses. Orogastric lavage is not recommended; it is not of proven benefit for ciguatera poisoning, and risks of this procedure are likely to outweigh benefits.
- Antiemetics may control nausea and vomiting.
- Cool showers and antihistamines have been recommended to relieve pruritus.
- Manage hypotension with volume replacement. Pressor agents rarely are needed.
- Bradyarrhythmias respond well to atropine.
Medication
Medications used to treat ciguatera poisoning include (1) neurologic agents, (2) serotonin-norepinephrine reuptake inhibitors, (3) antihistamines, (4) analgesics, (5) antipyretics, and (6) anti-inflammatories.
Diuretics, osmotic
These agents are used empirically to treat neurologic symptoms associated with ciguatera poisoning.
Mannitol (Osmitrol, Resectisol)
Osmotic diuretic that has become mainstay of acute treatment in recent years.4 Mechanism of action unknown but has been reported to dramatically diminish or prevent neurologic symptoms associated with ciguatera poisoning. Most effective when given early in course of treatment, but somewhat effective even after several days of symptoms. Neurologic symptoms often decrease within minutes of treatment and may resolve completely within 2 days. At least one prospective, controlled study found no difference between mannitol and normal saline in the treatment of ciguatera poisoning.5
Adult
1 g/kg IV of 20% solution over 30 min; not to exceed 50 g
Pediatric
0.25-1 g/kg IV or 60 g/m2 IV administered over 2-6 h
None reported
Documented hypersensitivity; anuria; severe pulmonary congestion; progressive renal damage; severe dehydration; active intracranial bleeding; progressive heart failure
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Ensure adequate hydration status is attained prior to giving mannitol; monitor for fluid/electrolyte imbalance; solutions may crystallize if cooled
Serotonin/norepinephrine reuptake inhibitors
These agents have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Reported to relieve pruritus and dysesthesias; may act by blocking fast sodium channels that have been activated by ciguatoxin. Most effective for chronic neurologic symptoms that often follow ciguatera poisoning.
Adult
25-50 mg PO bid; start at 25 mg PO bid
Pediatric
1-5 mg/kg PO qd or divided bid
May cause cardiotoxicity (via sodium channel blockade) when used concurrently with type IA, IC, or III antiarrhythmics; phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; MAOIs in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, urinary retention
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiac disease, elderly patients, and renal or hepatic impairment
Analgesics
These agents are used symptomatically to provide pain relief.
Acetaminophen/paracetamol (Tylenol/Panadol)
Extremely useful in treatment of headaches.
Adult
325-500 mg PO q4-6h prn; not to exceed 4000 mg/d
Pediatric
10-15 mg/kg/dose PO q6h prn
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, or isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum
Indomethacin (Indocin)
Relieves myalgias and arthralgias.
Adult
75 mg PO qd
Pediatric
1.25-2.5 mg/kg/d PO divided tid/qid
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; may increase phenytoin levels
Documented hypersensitivity; active GI bleed; previous peptic ulcer disease is a relative contraindication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)
Antihistamines
These agents are used to reduce pruritus (itching).
Cyproheptadine (Periactin)
Antihistamine-antiserotonergic agent; reported to ameliorate pruritus.
Adult
4 mg PO bid/tid; not to exceed 0.5 mg/kg/d
Pediatric
<2 years: Not established
2-6 years: 2 mg PO bid/tid; not to exceed 0.25 mg/kg/d
7-14 years: 4 mg PO bid/tid; not to exceed 0.25 mg/kg/d
Potentiates effects of CNS depressants; MAOIs may prolong and intensify anticholinergic and sedative effects
Documented hypersensitivity; newborns or infants
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with predisposition to urinary retention, history of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease, or hypertension; may thicken bronchial secretions caused by anticholinergic properties and may inhibit expectoration and sinus drainage
Diphenhydramine (Benadryl, Benylin)
For relief of symptoms caused by release of histamine in pruritus.
Adult
25-50 mg PO/IV/IM q4-6h
Pediatric
5 mg/kg/d divided q4-6h
Potentiates effect of CNS depressants; because of alcohol content, do not give syrup form to patient taking medications that can cause disulfiramlike reactions
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Avoid in first trimester; unsafe when breastfeeding; may exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction
Hydroxyzine (Atarax, Vistaril)
Antagonizes H1 receptors in periphery. May suppress histamine activity in subcortical region of CNS. Has antipruritic effects.
Adult
0.5-1 mg/kg or 25-100 mg PO/IM qd/qid
Pediatric
Not recommended
Alcohol or other CNS depressants may cause CNS depression
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid when breastfeeding; associated with clinical exacerbations of porphyria (may not be safe for porphyric patients); ECG abnormalities (alterations in T waves) may occur; may cause drowsiness
More on Toxicity, Ciguatera |
| Overview: Toxicity, Ciguatera |
| Differential Diagnoses & Workup: Toxicity, Ciguatera |
 Treatment & Medication: Toxicity, Ciguatera |
| Follow-up: Toxicity, Ciguatera |
| References |
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References
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Further Reading
Keywords
ciguatera poisoning, ciguatoxin, Gambierdiscus toxicus, grouper, amberjack, red snapper, eel, sea bass, barracuda, Spanish mackerel, ciguatera toxicity, fish-borne poisoning, reef fish poisoning
