Tox in The Land: Ivermectin & Sodium Bicarbonate

Case Presentation

61-year-old female with no significant PMH presenting with generalized weakness, 80 lb weight loss over 8 months, feeling of impending doom. Endorsed taking Ivermectin to prevent COVID-19 prescribed by her primary care doctor. She endorsed diarrhea and vomiting daily which she treated with Baking Soda.

PMH: None

PSH: Denies

SH: Occasional EtOH, no other drugs, never smoker

Allergies: NKDA

Meds: Ivermectin, Baking soda for 8 months

Findings

Pt was found to have bowel pneumatosis and free air on CT abdomen and pelvis and was admitted to Acute Care Surgery. She underwent exploratory laparotomy, mesenteric lymph node biopsy, EGD, and dobhoff placement

Findings: mesenteric nodules along entire small bowel, large nodule at root of mesentery, hypertrophic pylorus unable to pass endoscope, viable stomach, small bowel, colon, otherwise normal EGD, no succus


Ivermectin

  • Anti-parasitic agent that is well tolerated and has a wide therapeutic safety profile

  • Also used in veterinary preparations in a variety of concentrations

  • MOA in antiparasitics is potentiation of GABA at chloride ion channels in the peripheral nervous system of parasites causing hyperpolarization of cells, paralysis and death

  • Humans have GABA only in their CNS and Ivermectin does not penetrate the blood brain barrier well

  • Typical dose is 0.15/mg/kg once or for several days to a week




Ivermectin and COVID-19

  • Proposed mechanism of action in COVID-19 relates to the inhibition of transport of the viral material into the nucleus by blocking importin.

  • Reported initially from an in-vitro study.

  • Proposed dosing to treat COVID was 0.2mg/ kg -0.3mg/kg once a day for five days (no toxicity should be expected in these doses)

Multiple Studies have demonstrated no clinical benefit in COVID-19

Summer 2021

 

it was the season of light

 

it was the season of darkness


Ivermectin Toxicity

  • Ivermectin is limited from crossing the blood brain barrier by the activity of the p glycoprotein pump.

  • At high levels of Ivermectin the pump can be overwhelmed

  • Toxicity when it does occur CNS effects predominate based on the potentiation of GABA at chloride ion channels

  • Factors that may increase toxicity

    • High concentrations

    • Presence of p glycoprotein medications (verapamil)

    • Conditions increasing BBB permeability (ie sepsis)

Presentation

  • CNS

    • Dizziness, ataxia

    • Decreased level of consciousness

    • Seizures

  • Cardiac

    • Hypotension, bradycardia

Treatment

  • Supportive

  • Seizures treated with benzodiazepine

  • Intubation if needed for CNS depression

  • No role for activated charcoal or other GI decontamination

*Typically well tolerated but most common are gastrointestinal upset with nausea, vomiting and diarrhea.


Patient prescription

  • 6 tablets 3.0 mg daily for 5 days x 5 days

  • Followed by 6 tablets per week

  • Per patient after extubation she began taking baking soda due to the stomach upset when she began the Ivermectin


Instructions for use as antacid

  • Baking soda misuse can result in serious acid/base and electrolyte imbalance

  • Adverse effects were also noted when the recommended doses were administered

  • Highest risk for electrolyte derangements include chronic use

 
 


Other Complications?

Case reports of spontaneous rupture of the stomach

Case Report Summary

FDA identified 21 cases of stomach rupture in the literature and directly reported to FDA using their reporting system which the amount of sodium bicarbonate was often not known and varied greatly. The symptoms described were acute onset severe abdominal pain shortly after ingestion Injuries that were specifically described are as follows

  • 52 year old following ingestion had an exploratory laparotomy that revealed a 6-cm tear in the stomach extending from the gastroesophageal junction down the lesser curvature of the stomach.

  • 31 year old male who ingested sodium bicarb to relieve indigestion had acute onset of abdominal pain and exploratory surgery revealed a 5-cm linear tear along the lesser curvature of the stomach.

  • 37 year old male who drank sodium bicarb and soda for indigestion was found to have a tear of the stomach just below the gastroesophageal juncture at laparotomy

  • 23 year old male who took sodium bicarb following a meal has exploratory laparotomy revealing 6-cm to 7-cm linear tear in the lesser curvature of the stomach.

There was a recorded case of patient with ingestion of baking soda who was subsequently diagnosed with a bowel perforation requiring surgical intervention from California Poison Control but the details of the case were not available

FDA Warning updated based on case reports

Conclusions

  • Ivermectin is a well tolerated medication that causes CNS toxicity in large doses its side effect profile includes gastrointestinal upset

  • There are no known indications for Ivermectin to treat or prevent COVID-19

  • Baking Soda has listed use for antacid

  • Sodium bicarbonate can cause metabolic alkalosis, hypernatremia, hypokalemia, hypocalcemia, hypochloremia

  • There having numerous case reports of gastric rupture following ingestion of sodium bicarbonate

POST BY: DR. ANNA WILLIAMS (R3)

FACULTY EDITING BY: DRS. RYAN MARINO & LAUREN PORTER

References

 
 
ToxLauren McCaffertytoxicology, tox, ivermectin, covid-19, covid, medical toxicology, medtox