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Poison Centre

Methylphenidate intoxications in children and adults: exposure circumstances and evidence-based dose threshold for pre-hospital triage

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Pages 168-177 | Received 05 Sep 2014, Accepted 02 Jan 2015, Published online: 04 Feb 2015
 

Abstract

Context. Methylphenidate intoxications mostly have a relatively mild course, although serious complications can occur. Objective. We aimed to characterize methylphenidate exposures and reassess our current dose threshold for hospital referral (2 mg/kg). Methods. In a prospective follow-up study, we analysed 364 consecutive methylphenidate exposures that were reported to the Dutch Poisons Information Center. Patients and/or physicians were surveyed by telephone using standardized questionnaires. Three physicians independently scored the observed severity of the intoxication of each patient as ‘no/mild’ (observation at home) or ‘moderate/severe’ (hospital referral necessary). Results. Unintentional exposures (40%) mostly occurred at home involving the patients’ own medication or those from a family member. Compared to unintentionally exposed patients, intentionally exposed patients were exposed to relatively high methylphenidate doses (3.1 vs 1.6 mg/kg), more often used immediate release methylphenidate formulations (62 vs 34%) and more frequently had concomitant exposures (71 vs 17%). Severe symptoms like convulsions or coma were reported only in patients with concomitant exposures. Following exposure to methylphenidate only (i.e. no concomitant exposures), the most commonly reported symptoms were dry mucosa, headache, agitation, sleepiness and tachycardia. Our results show that the reported methylphenidate dose is predictive of the observed severity of the intoxication and can therefore aid in pre-hospital triage. Conclusion. We increased our current dose threshold for hospital referral from 2 to 3 mg/kg. In addition, we will refer patients at lower doses when clinical symptoms indicate the need for hospital referral. Application of this new dose threshold optimizes triage, thereby reducing unnecessary hospital referral and thus costs, without jeopardising patient safety.

Acknowledgements

We gratefully acknowledge M. Leenders (MD) and D. de Lange (MD, PhD) for their effort in rating the severity of the intoxications.

Declaration of interest

Apart from Dr. Pereira, none of the authors have a potential conflict of interest. Those from Dr. Pereira are as follows: chairman of the Dutch ADHD network, payment for educational presentations (for psychologists at Cure and Care (Arnhem, the Netherlands), up to 2011 also for pharmaceutical companies like Lilly, Janssen, Eurocept and Shire) and royalties of his book ‘ADHD, en nu?’ (ADHD, what now?, ISBN 9021550407).

Congress presentations

Parts of this study have been presented at the annual congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT XXXIII 2013 Copenhagen, and XXXIV 2014 Brussels).

Hondebrink L, Rietjens SJ, Kelleci N, Yasar G, de Vries I, Meulenbelt J. Prospective follow-up study on potential toxic methylphenidate exposures (Abstract EAPCCT XXXIII International Congress). Clin Toxicol (Phila) 2013;51(4):298.

Rietjens SJ, Hondebrink L, Hunault CC, Pereira R, Kellici N, Yasar G, Ghebreslasie A, Lo-A-Foe C, de Vries I, Meulenbelt J. Clinical outcomes of methylphenidate intoxications in children and adults: A prospective follow-up study (Abstract EAPCCT XXXIV International Congress). Clin Toxicol (Phila) 2014;52(4):328.

Supplementary material available online

Supplementary data for detailed questionnaires and Supplementary Tables 1–3.

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