Toxic effect
Toxicity of Decongestant Drugs Sympathomimetic decongestants cause their toxic effects via excessive stimulation of the adrenergic
system and in effect produce signs and symptoms associated with the sympathomimetic toxidrome.
Excessive vasoconstriction can result in end-organ damage to the brain, retina, heart, and kidneys.
Imidazolines stimulate imidazoline receptors and produce a sympatholytic effect that in supratherapeutic
conditions results in marked bradycardia and hypotension.
Clinical Manifestations Sympathomimetics
Decongestants are divided into 2 categories, Following a decongestant overdose of this class, most patients present with a sympathomimetic
sympathomimetic amines and imidazolines. syndrome with CNS stimulation, hypertension, tachycardia, or reflex bradycardia in response to pure α1-
adrenergic agonist induced hypertension
Sympathomimetics The decongestants phenylephrine, pseudoephedrine,
ephedrine. reduce nasal congestion by stimulating the α-adrenergic receptor sites Imidazolines are potent central and peripheral α2-adrenergic and
on vascular smooth muscle. imidazoline receptor agonists. In overdose, they cause CNS depression, and initial brief hypertension
followed by hypotension, bradycardia, and respiratory depression .
Both α1- and α2-adrenergic receptor subtypes are linked to a Gq protein Acute respiratory distress syndrome from vasoconstriction of pulmonary vessels can also occur with
activating smooth muscle contraction via the IP3 signal transduction pathway both classes of decongestants. Reversible encephalopathy with bilateral posterior hemispheric
.This process constricts dilated arterioles and reduces blood flow to engorged edema.
nasal vascular beds.
. .
Prolonged topical administration produces rebound Management
congestion upon discontinuation; possible mechanisms
A cardiac monitor should be attached to the patient and observed for dysrhythmias.
Intravenous access should be established and airway protection ensured.
include desensitization of receptors and mucosal damage. This damage is
Gastrointestinal decontamination with AC is
caused by α2-adrenergic– mediated arteriolar constriction, resulting in
decreased blood supply to the mucosa. recommended in patients with large ingestions of
pseudoephedrine if no contraindications are present.
Phenylephrine is a direct α1-adrenergic receptor agonist with very little β- Specific Treatment
adrenergic agonist activity at therapeutic doses. Neurologic toxicity. Patients with extreme agitation, seizures, and psychosis should
initially be treated with administration
Pseudoephedrine and ephedrine are mixed-acting direct and indirect of oxygen and IV benzodiazepines,
nonspecific α1,2-adrenergic and β1,2- adrenergic receptor agonists.
Pseudoephedrine is the d- isomer of ephedrine and has only up to 25% of the Respiratory toxicity. Children presenting with respiratory depression from imidazoline
adrenergic receptor activity of ephedrine decongestants have responded to naloxone.
Imidazolines The decongestant effects of the imidazoline class of xenobiotics results Cardiovascular toxicity. Tachycardia, palpitations, and
from their vasoconstrictive action as α-adrenergic agonists, with binding to α2-
adrenergic receptors on blood vessels. hypertension that occur in mild sympathomimetic poisonings usually respond to
benzodiazepines. For a patient who remains hypertensive or is believed to have
The imidazoline (I) category of direct sympathomimetic receptor agonists is generally chest pain of ischemic origin treatment with phentolamine, an α-adrenergic
reserved for topical application The more common medications include antagonist, or nicardipine is recommended.
oxymetazoline, tetrahydrozoline, and naphazoline . Labetalol has been proposed and used in some reported cases; however, because
of its different affinity for α- and β- adrenergic receptors depending on the route of
The α1-adrenergic–mediated vasoconstriction is complemented by an additive administration.
effect of preferential binding to α2- adrenergic receptors located on resistance vessels
regulating blood flow . Patients with ventricular dysrhythmias from sympathomimetic decongestants
should be treated with standard doses of lidocaine or sodium bicarbonate (if the
QRS complex is prolonged).
