Systemic toxicity from subcutaneous brimonidine injection successfully treated with naloxone

• Published in: The American journal of emergency medicine Vol. 59; pp. 218.e5 - 218.e6
• Main Authors: Tobarran, Natasha, Kershner, Emily, Chambers, Andrew, Cumpston, Kirk L., Wills, Brandon K.
• Format: Journal Article
• Language: English
• Published: Philadelphia Elsevier Inc 01.09.2022; Elsevier Limited
• Subjects: Alpha-adrenergic agonist; Antihypertensives; Blood pressure; Bradycardia; Brimonidine; Cardiac arrhythmia; Case report; Case reports; Central nervous system; Drowsiness; Drug overdose; Emergency medical care; Emergency medical services; Glaucoma; Hypertension; Hypotension; Injection; Intravenous administration; Naloxone; Opioids; Overdose; Pacemakers; Patients; Pediatrics; Subcutaneous injection; Sympathomimetics; Toxicity; Bradycardia; Case report; Naloxone; Brimonidine; Alpha-adrenergic agonist; Subcutaneous injection; Hypotension
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2022.07.007

Brimonidine is a topical ophthalmic alpha-2 adrenergic agonist solution used to treat glaucoma. The toxidrome includes drowsiness, lethargy, hypotension, bradycardia, and respiratory depression when ingested in infants. We report a case of intentional subcutaneous injection of brimonidine in an elderly patient resulting in hypotension and CNS depression that responded to naloxone. A 73-year-old female with a past medical history significant for glaucoma, hypertension, and indwelling pacemaker presented to the emergency department after injecting her brimonidine tartrate ophthalmic solution subcutaneously (SQ). The patient was not taking any antihypertensive medications or opioids. Initial presentation consisted of lethargy, a paced rhythm of 60 bpm, and blood pressure of 91/24 mmHg with a MAP of 46. Due to central nervous system depression, 3 mg of intranasal naloxone was administered. The patient was treated with intravenous fluids and escalating doses of naloxone and required a continuous infusion. Mental status and vital signs subsequently improved. The patient was admitted to the ICU and naloxone was subsequently weaned over 12 h. Systemic central alpha-2 adrenergic agonist toxicity resulted from SQ brimonidine injection. Central alpha-2 adrenergic agonist overdoses present as sympatholytic effects including CNS depression, bradycardia, hypotension, and may mimic the opioid toxidrome. Brimonidine SQ injection has not previously been reported and this case has similar findings to other central alpha-2 adrenergic agonist poisonings. Naloxone has previously shown variable reversal of CNS depression in central alpha-2 overdose. In this case, high-dose naloxone was useful for reversing CNS depression and hemodynamic instability.