Antidotes and chelators
Drug Safety Update
June 2020: Direct-acting oral anticoagulants (DOACs): reminder of bleeding risk, including availability of reversal agents
Royal College of Emergency Medicine and National Poisons Information Service
Guideline on Antidote Availability for Emergency Departments (Version 7, September 2023)
Please consider all the drugs in the above link as on formulary.
NICE Guidance
TA697: Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban
| CATEGORY A – Immediately Available in ED The following drugs should be immediately available in the ED or any area where poisoned patients are initially treated. These drugs should be held in a designated storage facility that is clearly marked for antidote storage only [antidotes requiring refrigeration should be segregated from other medicines in the medication fridge and clearly identified as antidotes]. |
|
| Drug | Indication |
| Acetylcysteine | Paracetamol |
| Activated charcoal | Many oral poisons |
| Atropine | Organophosphorus or carbamate insecticides |
| Bradycardia | |
| Calcium chloride | Calcium channel blockers Systemic effects of hydrofluoric acid |
|
Calcium gluconate Calcium gluconate gel |
Local infiltration for hydrofluoric acid Hydrofluoric acid |
|
Cyanide antidotes
|
Cyanide: the choice of antidote depends on the severity of poisoning, cause of poisoning and source of cyanide – generally sodium thiosulfate is recommended for mild-moderate cyanide poisoning and hydroxocobalamin for moderate-severe cyanide poisoning but clinicians are advised to consult TOXBASE and/or call NPIS for advice on the management of patients with cyanide poisoning |
| Digoxin specific antibody fragments (DIGIFab®) |
Digoxin and related glycosides |
| Flumazenil | Reversal of iatrogenic over-sedation with benzodiazepines. Should not be used as a “diagnostic” agent. Use with caution in patients with benzodiazepine poisoning, particularly in mixed drug overdoses; contraindicated in mixed tricyclic antidepressant / benzodiazepine overdoses and in those with a history of epilepsy. |
| Glucagon | Beta-adrenoreceptor blockers. Other indications e.g. calcium channel blockers, seek NPIS advice |
| Intralipid 20% | Severe systemic local anaesthetic toxicity. Always seek NPIS advice before giving intralipid for other poisonings. |
| Methylthioninium chloride (methylene blue) | Methaemoglobinaemia |
| Naloxone | Opioids |
| Procyclidine injection | Dystonic reactions |
| Sodium bicarbonate 8.4% and 1.26% or 1.4% |
TCAs & class Ia & Ic antiarrhythmic drugs Urinary alkalinisation |
| ViperaTAb® or Viperfav® * | European adder (Vipera berus) |
* ViperaTAb/Viperfav do not need to be held in hospitals in Northern Ireland
| CATEGORY B – Available within 1 hour The following drugs should be available within 1 hour (i.e. usually# within the hospital) |
|
| Drug | Indication |
| Andexanet alfa | Reversal of anticoagulation from apixaban or rivaroxaban in adults with life threatening or uncontrolled gastrointestinal bleeding (use according to local and national guidelines – discuss with local haematologists and NPIS). |
| Cyproheptadine | Serotonin syndrome |
| Dantrolene | Neuroleptic malignant syndrome (NMS) |
| Other drug-related hyperpyrexia seek NPIS advice | |
| Desferrioxamine | Iron |
| Folinic Acid (either calcium folinate or disodium folinate) |
Methotrexate |
| Methanol, formic acid | |
| Fomepizole (or Ethanol). Fomepizole is the antidote of choice. Ethanol should only be held if fomepizole is not available. |
Ethylene glycol, diethylene glycol, methanol |
| Idarucizumab | Dabigatran etexilate related active, life-threatening bleeding (use according to local and national guidelines – discuss with local haematologists and NPIS) |
| L-Carnitine (levocarnitine) | Severe sodium valproate toxicity |
| Macrogol ‘3350’ based bowel cleansing preparation (polyethylene glycol -3350) [Klean-Prep®, Moviprep®, Plenvu® or other equivalent preparation] |
Whole bowel irrigation for agents not bound by activated charcoal e.g. iron, lithium, also for bodypackers and for slow release preparations |
| Mesna (in hospitals commonly using cyclophosphamide) |
Cyclophosphamide |
| Octreotide | Sulfonylureas |
| Phytomenadione (Vitamin K1) | Vitamin K dependent anticoagulants |
| Protamine sulfate | Heparin |
| Pyridoxine, high dose injection | Isoniazid |
# Shared arrangements between local hospitals may be appropriate provided the 1h target can be met
| CATEGORY C – Held Supra-Regionally These drugs are held in specialist sites for supply in England. Use of these antidotes should always be discussed with NPIS and/or a Clinical Toxicologist who will be able to provide contact details to arrange the supply of these antidotes. |
||
| Drug | Indication | Source |
| Prussian Blue (Berlin Blue) | Thallium | Category C Holding Centres** |
| Botulinum antitoxin | Botulism | Botulinum Antitoxin Holding Centres |
| Glucarpidase | Methotrexate | Oxford Pharmacy Store |
| Pralidoxime chloride | Organophosphorus insecticides | Pralidoxime Holding Centres*** |
| Sodium calcium edetate | Heavy metals (particularly lead) | Category C Holding Centres** |
| Succimer (DMSA) | Heavy metals (particularly lead and arsenic) | Category C Holding Centres** |
| Unithiol (DMPS) | Heavy metals (particularly mercury) | Category C Holding Centres** |
| Uridine Triacetate | 5-Fluorouracil or Capecitabine | Oxford Pharmacy Store |
**The eight Supra-Regional Category C Antidote Holding Centres are: Addenbrooke’s Hospital, Cambridge; St Thomas’ Hospital, London; Derriford Hospital, Plymouth; Salford Royal Hospital, Salford; St James’s University Hospital, Leeds; The Royal Victoria
Infirmary, Newcastle; The Royal Sussex County Hospital, Brighton; Sandwell General Hospital, West Bromwich.
***Tunbridge Wells Hospital (MTW) and Kent & Canterbury Hospital (EKHUFT) are holding centres for pralidoxime
- On Formulary Preferred
- On Formulary Second Line
- On Formulary Third Line
- Specialist Initiation
- Secondary Care Only
- Not Approved for Formulary