ANTIDOTE STOCKING

AND STORAGE
Nowell Benedict C. Catbagan, MD, DPCP
Fellow-in-Training, Clinical Toxicology
National Poison Management and Control Center
University of the Philippines – Philippine General Hospital

***Adapted from Dr. Erle Castillo’s lectures

 OBJECTIVES
• Discuss the common reasons for the inadequate
stocking of antidotes for acute poisoning cases
• Elaborate steps to ensure the adequate stocking of
antidotal drugs
• Enumerate the antidotal drugs for required stocking in
Hospitals accepting acute poisoning cases
• Define common storage terms for antidotal
medications
Inadequate Stocking of Antidotes and Drugs in
Poisonings
A. Death if NOT immediately available. TIME-
DEPENDENT Antidotes
Immediate administration required
1. Antivenoms
2. Pyridoxine
3. Ethanol
4. Cyanide kit (Hydroxocabalamine)
• Sodium Thiosulfate
Inadequate Stocking of Antidotes and Drugs in
Poisonings

B. Injury progresses to
the point of irreversible
damage, increased
morbidity, prolonged
recovery, prolonged
hospital stay.
Drugs Inadequately stocked
1. Digibind/DigiFab – Immune FAB
2. Polyvalent snake antivenom
3. Pyridoxine
4. Ethanol
5. Deferoxamine
Reasons for inadequate stocking
1.Cost – expensive drugs
2.Short half-life
– Atropine: 2 hrs
Reasons for inadequate stocking
3. Hospital characteristics
- Serving smaller population/patients
- Smaller bed capacity
- Non-teaching
- Lack of formal review process for antidote stocking
- Lack of personnel to monitor availability and
adequate amounts of antidote
- Lack of transportation to obtain antidote/s from
another hospital
Reasons for inadequate stocking
3. Other factors
– limited awareness
– infrequent use
– interruptions in supply
– allocation of limited hospital pharmacy
resources
Factors that promote adequate stocking
1. Higher annual ER department volume
2. Teaching hospital
3. Designation as trauma center
* Some antidotal meds stocked/used by other
departments in hospital
1. Naloxone
• Anesthesia
2. Glucagon
• GI
3. Atropine
• Cardio/ICU
4. Calcium
• ICU
ALGORITHM for Adequate Antidote Stocking
1. Identify antidotes to be included in hospital
formulary/NDF
2. Determine amount needed of antidote per patient (ER &
ICU & recovery)
3. Secure financial resources to purchase drug
4. Supply of hospital drugs/antidote must be monitored
4.1 proper storage 4.2 utilization/consumption 4.3 re-stocking

5. Establish STG or consensus guidelines for use of drugs

for poisoned patients
National Consensus Guidelines for Stocking of antidotes
needed in hospital accepting emergency patients.

ANTIDOTE Poisoning Recom- No. of Total stocking

indication mended Patients/ amount and
Stocking? Dose per per 24 hours
px (70 kg)

1. N-Acetylcys- Paracetamol Yes 2x19.6 g 39.2 g

teine
2. Antivenin Snake bite (Naja- Yes 1 x 10 10 vials
(Naja-Naja Naja vials
Mono-valent philipenensis
3. Atropine SO4 OP & Carba-mate Yes 2x 75 mg 150 mg
insecti-cides

4. Calcium Hydrogen Yes 2x100 200 mEq

gluconate & fluoride Calc. mEq
calcium channel blocker
chloride
ANTIDOTE Poisoning indication Recommen- No. of Total stocking
ded Patient/ Dose/ amount and per 24
Stocking? per px (70 kg) hours

5. Cyanide kit Cyanide Yes 2x1 kit 2 kits

(amylnitrite 300
mg Sod. Nitrite
12.4 g Sod.
Thiosulfate)
6. Deferoxamine Iron Yes 1x8.4 g 8.4 g
mesylate
7. Digoxin Digoxin Digitoxin Yes 1 x 15 15 vials -
Immune FAB natural products vials $8,350.00
(plants toad)
8. Ethanol Methanol Ethylene Yes 2 x 90.7 181.4 mL
Solution for Glycol mL absolute
Injection alcohol
9. Alcohol Same as # 8 Yes 2 x 1.05 g 2.1 g
dehydrogenase
blocking drug
(Fomepizole) (4
methyl pyrazole)
ANTIDOTE Poisoning indication Recommen- No. of Total stocking
ded Patients/ amount and per 24
Stocking? dose per px hours
(70 kg)
10. Flumazenil Benzodiazepines Yes 1 x 4 mg 4 mg
11. Glucagon Beta Adrenergic Yes 1 x 50 mg 50 mg
antagonist or calc.
channel blocker
12. Methylene Methemoglobi- Yes 2 x 140 mg 280 mg
blue nemia
13.Naloxone Acute Opioid Yes 2 x 15 mg 30 mg
hydrochloride poisoning
14. Pyridoxine Isoniazid Yes 3 x 30 g 90 g

15. Sodium Tricyclics Cocaine Yes 10 x 500 5,000 mEq

bicarbonate Methamphetamine mEq
Salicylates
16. DMPS Metals, Inorganic Yes Oral
(Dimercapto mercury, arsenic, tablets 100
propane sulfonic chromium, cobalt, mg
acid copper, lead
ANTIDOTE Poisoning indication Recommen- No. of Patients/ Total stocking
ded Dose per px (70 amount and per
Stocking? kg) 24 hours

17. Succimer Metals, Lead, Yes Oral capsule 1,900

(DMSA) (100 mg/cap) capsules
Mercury, Arsenic
5 x 20
capsules (19
days therapy)
18. Ascorbic acid Methemoglobi- Yes 500 mg/vial 1 4 vials
nemia x 4 vials

19. Phytomena- Warfarin-induced Yes 3 x 10 30 mg/day (3

dione (Vit K1) anticoagulation mg/ampule ampule) x 5
hypoprothrombi- (for 5 days) days
nemia 2o to toxin –
Salicylates, 15 ampules
sulfonamides,
quinidine
paracetamol OP &
OC insecticides)

20. Activated For orally absorbed Yes 10 x 100 1,000 g/day

charcoal powder poison and those g/sachet (10 sachet)
with enterohepatic
recirculation (except
iron, cyanide etc.
STORAGE TEMPERATURE FOR DRUGS
• Freezer – a place in which the temperature is maintained
thermostatically between -200 and -100C ( -40 & 14F)

• Cold- any temperature not exceeding 80 (460F)

STORAGE TEMPERATURE FOR DRUGS
• Refrigerator – a cold place in which the temperature is
maintained thermostatically between 20 and 80 (360-460F)
• DigiFAB – reconstituted form stored under refrigeration at 2° to 8°C (36°
to 46°F) for up to 4 hours
• N-Acetylcysteine - opened undiluted vials for up to 4 days

• Cool – any temperature between 80 and 150 (46 and 590F). An

article for which storage in a cool place is directed may
alternatively, be stored in a refrigerator.
STORAGE TEMPERATURE FOR DRUGS
• Room temperature – temperature prevailing in a working
area.

• Controlled Room Temperature – temperature maintained

thermostatically that encompasses the usual and customary
working environment of 20 to 250 (68 to 770F). An article for which
storage at controlled room temperature is directed may,
alternatively be stored in a cool place, unless otherwise specified
on the label.
• Activated Charcoal
• Cobra antivenom
STORAGE TEMPERATURE FOR DRUGS

• Warm – any temperature between 300 and 400 (860 and 1040F)
• Excessive heat – any temperature above 400 (1040F)
• Protection from freezing – where, in addition to risk of
breakage of the container, freezing subjects an article to loss of
strength or potency or to destructive alteration of its
characteristics as stated in label.
THANK YOU!