[toxvtc] FW: [EXTERNAL] RE: Chloroquine treatment

[Jeanna Marraffa]

To all that were on fellow rounds today, Rachel miraculously found this email string.

It is long but if you go all the way to bottom, you see Dr. Megarbane’s thoughts.

Jeanna

From: Schult, Rachel <Rachel_Schult at URMC.Rochester.edu>
Sent: Friday, August 19, 2022 2:46 PM
To: Jeanna Marraffa <MarraffJ at upstate.edu>
Subject: FW: [EXTERNAL] RE: Chloroquine treatment



From: Vincent Calleo <calleov at upstate.edu<mailto:calleov at upstate.edu>>
Sent: Thursday, March 26, 2020 10:44 PM
To: nicholasenacca at gmail.com<mailto:nicholasenacca at gmail.com>; Michael Hodgman <HodgmanM at upstate.edu<mailto:HodgmanM at upstate.edu>>; Jeanna Marraffa <MarraffJ at upstate.edu<mailto:MarraffJ at upstate.edu>>; Ross Sullivan <SullivaR at upstate.edu<mailto:SullivaR at upstate.edu>>; Wiegand, Timothy <Timothy_Wiegand at URMC.Rochester.edu<mailto:Timothy_Wiegand at URMC.Rochester.edu>>
Cc: alicia.lydecker at gmail.com<mailto:alicia.lydecker at gmail.com>; laurajfil at gmail.com<mailto:laurajfil at gmail.com>; boydm at mail.amc.edu<mailto:boydm at mail.amc.edu>; rowdena at mail.amc.edu<mailto:rowdena at mail.amc.edu>; Laura_Fil at teamhealth.com<mailto:Laura_Fil at teamhealth.com>; William Eggleston <EgglestW at upstate.edu<mailto:EgglestW at upstate.edu>>; Michael Holland <HollandM at upstate.edu<mailto:HollandM at upstate.edu>>; Heather Long <LongH at upstate.edu<mailto:LongH at upstate.edu>>; Nicholas Nacca <NaccaN at upstate.edu<mailto:NaccaN at upstate.edu>>; Christine Stork <STORKC at upstate.edu<mailto:STORKC at upstate.edu>>; Gorodetsky, Rachel <Rachel_Gorodetsky at URMC.Rochester.edu<mailto:Rachel_Gorodetsky at URMC.Rochester.edu>>; Schult, Rachel <Rachel_Schult at URMC.Rochester.edu<mailto:Rachel_Schult at URMC.Rochester.edu>>
Subject: Re: [EXTERNAL] RE: Chloroquine treatment

I feel like if diazepam is not available, using a midazolam drip for sedation would be my first go-to for an intubated pt. You'll get the sedation and possible benefit from it being a benzo? But good to know that intubation and epi are the main treatments.

Thanks for reaching out to him, Jeanna!


>>> "Wiegand, Timothy" <Timothy_Wiegand at URMC.Rochester.edu<mailto:Timothy_Wiegand at URMC.Rochester.edu>> 03/26/20 6:29 PM >>>
​We have really limited IV diazepam --oral available but not sure how much.  Diazepam is the BZD that is preferred due to effects Jeanna points out but as Ross and others did I would utilize high doses of alternative BZDs as available.

TW

Timothy J. Wiegand, MD
Director of Medical Toxicology and Toxicology Consult Service
Associate Clinical Professor of Emergency Medicine
URMC and Strong Memorial Hospital
Box 321 at URMC
601 Elmwood Avenue
Rochester, NY 14642

Office Phone #: 585-276-5710
Office Fax #: 585-2441677
Consult Cell Phone #: 585-278-8161
________________________________
From: Ross Sullivan <sullivar at upstate.edu<mailto:sullivar at upstate.edu>>
Sent: Thursday, March 26, 2020 6:02 PM
To: nicholasenacca at gmail.com<mailto:nicholasenacca at gmail.com>; Michael Hodgman; Jeanna Marraffa
Cc: alicia.lydecker at gmail.com<mailto:alicia.lydecker at gmail.com>; laurajfil at gmail.com<mailto:laurajfil at gmail.com>; boydm at mail.amc.edu<mailto:boydm at mail.amc.edu>; rowdena at mail.amc.edu<mailto:rowdena at mail.amc.edu>; Laura_Fil at teamhealth.com<mailto:Laura_Fil at teamhealth.com>; Vincent Calleo; William Eggleston; Michael Holland; Heather Long; Nicholas Nacca; Christine Stork; Gorodetsky, Rachel; Schult, Rachel; Wiegand, Timothy
Subject: RE: [EXTERNAL] RE: Chloroquine treatment

Yes we did give high dose midazolam (altho i cannot remember the infusion rate at this point).

Pt absolutely had prolonged QTC and qrs of i remember correctly



Sent from my Verizon, Samsung Galaxy smartphone



-------- Original message --------
From: Jeanna Marraffa <MarraffJ at upstate.edu<mailto:MarraffJ at upstate.edu>>
Date: 3/26/20 9:33 AM (GMT-05:00)
To: Michael Hodgman <HodgmanM at upstate.edu<mailto:HodgmanM at upstate.edu>>, Nicholas Nacca <nicholasenacca at gmail.com<mailto:nicholasenacca at gmail.com>>
Cc: Vincent Calleo <CalleoV at upstate.edu<mailto:CalleoV at upstate.edu>>, William Eggleston <EgglestW at upstate.edu<mailto:EgglestW at upstate.edu>>, Nicholas Nacca <NaccaN at upstate.edu<mailto:NaccaN at upstate.edu>>, Michael Holland <HollandM at upstate.edu<mailto:HollandM at upstate.edu>>, Heather Long <LongH at upstate.edu<mailto:LongH at upstate.edu>>, Christine Stork <STORKC at upstate.edu<mailto:STORKC at upstate.edu>>, Ross Sullivan <SullivaR at upstate.edu<mailto:SullivaR at upstate.edu>>, Alicia Lydecker <alicia.lydecker at gmail.com<mailto:alicia.lydecker at gmail.com>>, laurajfil at gmail.com<mailto:laurajfil at gmail.com>, Molly Boyd <boydm at mail.amc.edu<mailto:boydm at mail.amc.edu>>, Adam Rowden <rowdena at mail.amc.edu<mailto:rowdena at mail.amc.edu>>, Laura Fil <Laura_Fil at teamhealth.com<mailto:Laura_Fil at teamhealth.com>>, "rachel_gorodetsky at urmc.rochester.edu<mailto:rachel_gorodetsky at urmc.rochester.edu>" <Rachel_Gorodetsky at URMC.Rochester.edu<mailto:Rachel_Gorodetsky at URMC.Rochester.edu>>, Rachel O'Geen Schult <Rachel_Schult at URMC.Rochester.edu<mailto:Rachel_Schult at URMC.Rochester.edu>>, Timothy Wiegand <Timothy_Wiegand at URMC.Rochester.edu<mailto:Timothy_Wiegand at URMC.Rochester.edu>>
Subject: Re: [EXTERNAL] RE: Chloroquine treatment


>>> "Jeanna Marraffa" 03/26/2020 09:33 >>>
There is at least some speculation/hypothesis that diazepam has specific effects on benzo receptors in the heart and interacts with TSPO...what that means, however, I do not know.
Anectodally, when we had a chloroquine case years ago (Ross your case), we used midazolam cont infusion and the patient had a good outcome.
I think I will start with diazepam and if the hospital doesn't have it, then give midazolam?



>>> Michael Hodgman <hodgmanm at upstate.edu<mailto:hodgmanm at upstate.edu>> 3/26/2020 9:25 AM >>>
Are all benzodiazepines created equal for this indication?  That is, IF diazepam does something, is there something unique with diazepam and peripheral benzo receptors that may or may not be true for other benzos at those peripheral receptors?

Michael Hodgman


Sent from my iPhone

> On Mar 26, 2020, at 09:17, Nicholas Nacca <nicholasenacca at gmail.com<mailto:nicholasenacca at gmail.com>> wrote:
>
> 
> Hey all,
>   My take on this is that the bzd were something we always discussed, but we pulled that literature during my fellowship and were not impressed.  We always said it with some degree of skepticism.
>   If given the opportunity to manage one of these patients I would reach for a high dose of a bzd (because I think it isn’t going to hurt an intubated patient), but the other interventions would take priority in my humble opinion.
>
> Nick
>
>> On Thu, Mar 26, 2020 at 9:07 AM Schult, Rachel <Rachel_Schult at urmc.rochester.edu<mailto:Rachel_Schult at urmc.rochester.edu>> wrote:
>> I would also appreciate thoughts.  I'm feeling very conflicted about the benzodiazepine recommendations.  Our institution does not stock diazepam due to cost.  I am comfortable being aggressive with epinephrine as suggested, but I really don't know what to do if diazepam is not available.
>>
>> If diazepam is not available, should we just be doing standard doses of another benzo?  If there is no benefit with another benzo, I could see it being potentially detrimental as well to give a huge dose.
>>
>> ‑‑‑‑‑Original Message‑‑‑‑‑
>> From: Jeanna Marraffa <MarraffJ at upstate.edu<mailto:MarraffJ at upstate.edu>>
>> Sent: Thursday, March 26, 2020 8:43 AM
>> To: Alicia Lydecker <alicia.lydecker at gmail.com<mailto:alicia.lydecker at gmail.com>>; Vincent Calleo <CalleoV at upstate.edu<mailto:CalleoV at upstate.edu>>
>> Cc: Laura Fil <laurajfil at gmail.com<mailto:laurajfil at gmail.com>>; Nicholas Nacca <nicholasenacca at gmail.com<mailto:nicholasenacca at gmail.com>>; Molly Boyd <boydm at mail.amc.edu<mailto:boydm at mail.amc.edu>>; Adam Rowden <rowdena at mail.amc.edu<mailto:rowdena at mail.amc.edu>>; Laura Fil <Laura_Fil at teamhealth.com<mailto:Laura_Fil at teamhealth.com>>; William Eggleston <EgglestW at upstate.edu<mailto:EgglestW at upstate.edu>>; Michael Hodgman <HodgmanM at upstate.edu<mailto:HodgmanM at upstate.edu>>; Michael Holland <HollandM at upstate.edu<mailto:HollandM at upstate.edu>>; Heather Long <LongH at upstate.edu<mailto:LongH at upstate.edu>>; Jeanna Marraffa <MarraffJ at upstate.edu<mailto:MarraffJ at upstate.edu>>; Nicholas Nacca <NaccaN at upstate.edu<mailto:NaccaN at upstate.edu>>; Christine Stork <STORKC at upstate.edu<mailto:STORKC at upstate.edu>>; Ross Sullivan <SullivaR at upstate.edu<mailto:SullivaR at upstate.edu>>; Gorodetsky, Rachel <Rachel_Gorodetsky at URMC.Rochester.edu<mailto:Rachel_Gorodetsky at URMC.Rochester.edu>>; Schult, Rachel <Rachel_Schult at URMC.Rochester.edu<mailto:Rachel_Schult at URMC.Rochester.edu>>; Wiegand, Timothy <Timothy_Wiegand at URMC.Rochester.edu<mailto:Timothy_Wiegand at URMC.Rochester.edu>>
>> Subject: Fwd: [EXTERNAL] RE: Chloroquine treatment
>>
>> I don't know about you but my mind was blown yesterday at Dr Megarbane's comments about epi...I ALWAYS thought it was the diazepam. This is his response below. I don't know what to do about this....and pray that I don't get one of these overdoses right now because I am just not sure what to do with any of this.
>> Any thoughts are appreciated
>> Jeanna
>>
>>
>> >>> MEGARBANE Bruno <bruno.megarbane at aphp.fr<mailto:bruno.megarbane at aphp.fr>> 3/25/2020 7:05 PM >>>
>> Hello Jeanna
>> Thanks for your message. I was very pleased to participate to this webinar. Just some thoughts
>>
>> I agree with what you stated. In our experience, the most important issues in chloroquine poisoning is to secure the respiratory airways and accelerate cardiac rhythm to be maintained at about 70 /min (to avoid ventricular arrhythmias, without accelerating too much to avoid the intensification of the membrane stabilizing effect). These supportive interventions should be performed based on prognosticators and before the onset of any life‑threatening complication if possible. So that, if any acute cardiac complication occurs ... you can focus your management on the heart without losing time with intubation.
>>
>> The "antidotal" effect of diazepam is really minor. There is a RCT diazepam versus placebo in moderate chloroquine poisoning that showed no significant cardiac/ECG effects of diazepam.
>> Do not use another BZD. It is probable that the protective effect is only related to a co‑ingestion of DZP/chloroquine and not to any post‑administration. The experimental evidence to support diazepam antidotal effects are weak.
>>
>> The recommended protocol is the following:
>> ‑ Intubation and mechanical ventilation
>> ‑ Epinephrine 0,25 µg/kg/min with increasing 0.25 µg/kg/min steps to obtain SBP ≥ 100 mmHg
>> ‑ Diazepam 2 mg/kg in 30 min followed with 2‑4 mg/kg/24h
>>
>> The cardiac toxicity of hydroxychloroquine is importantly lower than that of chloroquine, although we use the same criteria and management.
>> BW
>> Bruno
>>
>>
>>
>> ‑‑‑‑‑Message d'origine‑‑‑‑‑
>> De : Jeanna Marraffa <MarraffJ at upstate.edu<mailto:MarraffJ at upstate.edu>> Envoyé : mercredi 25 mars 2020 21:35 À : MEGARBANE Bruno <bruno.megarbane at aphp.fr<mailto:bruno.megarbane at aphp.fr>> Cc : Michael Hodgman <HodgmanM at upstate.edu<mailto:HodgmanM at upstate.edu>> Objet : Chloroquine treatment
>>
>> Hello Dr Megarbane
>> Thanks for a great talk today.....I have a question regarding treatment of chloroquine/hydroxychloroquine. You mentioned today that the two most important interventions for managing acute toxicity are intubation and epinephrine. I always thought that it was the diazepam that was the most important part and the epi was only given to manage the hemodynamic effects secondary to high doses of diazepam.
>>
>> I'd love to hear your thoughts on this and I want to be sure that I understood what you said.
>>
>> In a patient with acute overdose of either of the two agents, you would intubate early and start epi (and at what dose?) and what dose/which benzo would you use?
>>
>> Thank you so much for your time and any insight,
>>
>> Jeanna
>>
>> Jeanna M. Marraffa, Pharm.D., DABAT, FAACT Clinical Toxicologist Upstate Medical University, Upstate New York Poison Center Associate Professor, Department of Emergency Medicine
>> 315‑464‑7076
>>
>>
>> The information contained in this email is confidential intended only for the use of the party to whom it is addressed. If you are not the intended recipient, please be aware that you are strictly prohibited from sharing, distributing or copying this email. If you have received this email by mistake, please notify the sender. Thank you.
>>
>>
>>
> ‑‑
> Nicholas E. Nacca, MD
> Board Certified Emergency Medicine, Medical Toxicology & Addiction Medicine
>
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