Lomotil toxicity

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 effects
Toxic dose is variable

Clinical Features

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

Differential Diagnosis

Sedative/hypnotic toxicity

Anticholinergic toxicity Causes

Medications[1]
- Atropine
  - Lomotil toxicity
- Antihistamines
- Antidepressants
  - Tricyclic antidepressant (TCA) toxicity
  - SSRIs
- Antipsychotics
- Muscle relaxants
- Anti-Parkinsonians
Plants
- Jimson weed (Devil's trumpet)
- Amanita mushroom

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)
Activated charcoal should be given promptly if available
No evidence for utility of physostigmine

Disposition

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

See Also

References

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

Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium – theory, evidence and practice. Br J Clin Pharmacol. 2015;81(3):516-24.

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