To the Editor:
The article “Treatment of Hyperkalemia in a Patient with Unrecognized Digitalis Toxicity” (Van Deusen et al., Clinical Toxicology 2003;41:373–6) and the editorial that followed (Hoffman, R.S., Clinical Toxicology, 2003;41:377–9) both miss two very important points illustrated by the case presented.
First, a regional poison center should have been contacted before and not only after the correct diagnosis was finally made. Perhaps this would have shortened the time to diagnosis, especially if the general rule that medications taken by those in the household should have been asked about, not just the patient. This is more obvious for children with sibs and parents. The case illustrates that this principle is also important for the elderly.
The second point is that with modern day technology there is no reason that a digoxin level should need to be “sent out” as was done. The authors of the report or the editorial missed an important chance to discuss the lack of availability of quality therapeutic and toxic drug monitoring services. A good service would have had the result back within an hour and an excellent service might have even discovered the “housemate's” digoxin use. Either could have prevented some of the unnecessary treatments the patient received.
The risks of any treatment must be compared to the alternatives. The discussion of calcium toxicity was interesting but not exactly to the points that I feel are most clearly evidenced by this case.
Philip D. Walson, M.D.
Professor of Pediatrics
University of Cincinnati
Director, Clinical Pharmacology Division and Clinical Trials Office
Cincinnati Children's Hospital Medical Center
3333 Burnet Ave.
Cincinnati, OH 45229‐3039, USA
Phone 1‐513‐636‐3232
Fax 1‐513‐636‐3529