Utilization of hydroxocobalmin in nitroprusside induced cyanotoxicity

[tongiecc]

Hey guys, had a patient on nipride for several days when I came in this weekend, and concern was raised over possible cyanotoxicity; I suggested changing agents or giving sodium thiosulfate, with the former being the most viable option (pt was eventually changed to cardene). The question I have for all of you (Z, praziquantel, etc. feel free to chime in), is whether you have ever used/seen the use of hydroxocobalmin in instances of either the occurrence of cyanotoxicity d/t extended nipride use or to prevent/curb the risk of such events. From the literature it appears to have reduced side fx/risk of toxic metabolite buildup. Just curious if anyone has experience with this.

J

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[Praziquantel86]

I've never seen hydroxocobalamin used for nitroprusside toxicity, but I've heard of it being done. My thoughts are that the best way to prevent toxicity is to limit use of SNP to as brief a time period as possible, preferably less than 24 hours total. I can't think of very many situations where it wouldn't be possible to switch to a calcium channel blocker or nitroglycerin.

That being said, hydroxocobalamin would probably be a reasonable option in that "Oh ****, we left the SNP drip on for five days and now his lips are blue" situation. It's most likely cyanide toxicity, and hydroxocobalamin definitely works for that.

ETA: Forgot about thiosulfate. You can add thiosulfate to a bag of SNP to somewhat limit the toxicity, but it definitely isn't a cure-all. You're still better off using another agent if possible.

 

[njac]

Haven't seen it used with nipride; mostly because nitroprusside is never our "end point" drug - even if you have to escalate to using it (and as my comfort increases, my threshold decreases) your goal should always be to change to something else - it isn't intended for BP maintenance.

At $500/dose, I would reserve hydroxocobalamin for the "oh $#@#$" situations - such as an acute, profound drop in renal function, or coming in in the morning (or even a Monday morning) to find that the nurse cranked it up to 10mcg/kg/min for the night/weekend.

 

[tongiecc]

Thanks for the feedback guys; pretty much in line with my thought process on the issue, we did indeed get the MD to get them on another agent (as previously indicated), no idea why they had him on it so long w/o considering a change. Also thanks for the price info njac, I was curious about that, also is there any other available source/dosage form of it other than the 'cyanokit'?

Thanks again prazi and njac

J