Isoniazid toxicity
Reviewed and revised 8 April 2014
OVERVIEW
- isoniazid toxicity, like other hydrazines, primarily cause life-threatening seizures and lactic acidosis through depletion of vitamin B6
- the antidote is pyridoxine
BASIC TOXICOLOGY
Toxicodynamics
- hydrazines like isoniazid decreased pyridoxal 5-phosphate levels (by inhibiting formation, binding and inactivating free P5P and increasing rate of P5P elimination)
- P5P is vitamin B6
- P5P is a cofactor in >100 enzyme reactions, including conversion of glutamate to GABA
- thus hydrazines cause GABA depletion resulting CNS excitation and seizures
- lactic acidosis results from seizures and from impaired conversion of lactate to pyruvate
Toxicokinetics
- rapid and complete oral absorption
- peak levels at 1-2 hours
- hepatic metabolism via acetylation or cytochrome P450 mediated hydrolysis
- half life varies from 1-4 hours depending on whether the patient is a ‘fast’ or ‘slow’ acetylator
RISK ASSESSMENT
Toxicity is rapid (30 min to 2 hours) and predictable
- >1.5g (20mg/kg) – symptoms may develop
- >3g (40mg/kg) – seizures, metabolic acidosis, coma
- >10g (130 mg/kg) – always lethal without treatment
CLINICAL FEATURES
- dizziness, blurred vision, photophobia, nausea and vomiting
- tachycardia, mydriasis, dysarthria, ataxia and hyperreflexia
- rapid confusion, coma, seizures, lactic acidosis in large overdoses
- seizures are usually generalised tonic-clonic in nature, and may resolve spontaneously then recur rapidly
- complications of prolonged seizures
INVESTIGATIONS
- screening ECG and paracetamol
- lactate and HAGMA on ABD
- isoniazid levels are rarely available, and only have a potential role in retrospectively confirming the diagnosis
MANAGEMENT
Resuscitation
- attend to ABCs
- treat seizures with benzodiazepines (high doses may be needed), escalate to barbiturates and give pyridoxine as soon as available (See below)
- prepare for and perform intubation in the event of prolonged seizures
Supportive care and monitoring
Decontamination
- only give activated charcoal after securing the airway by intubation
Enhanced elimination
- hemodialysis is not indicated even though it removes isoniazid because it is too slow
Antidote
- pyridoxine is indicated for isoniazid-induced seizures
- give 1g pyridoxine for each gram of isonizid ingested up to a maximum of 5g (70mg/kg in children) – give 5g IV if isonizid dose is unknown
- give as slow infusion of 0.5g/min until seizures stop
- also used for toxicity from other hydrazines e.g. Gyromitra mushrooms, rocket fuel (give 25mg/kg slow IV bolus initially); and as an adjunct in ethylene glycol toxicity (give 50mg IV q6h)
- 50% oral bioavailability and VD of 0.6L/kg, undergoes rapid extra-hepatic metabolism
- peripheral neuropathy from high chronic oral dosing of pyridoxine does not occur from acute treatment of an overdose
- only comes in 50mg vials!
- role of prophylactic isoniazid in asymptomatic overdoses is controversial
Disposition
- observe asymptomatic overdoses for 6 hours, then discharge if remain well and no treatment required
- symptomatic patients required HDU/ ICU admission
References and Links
CCC Toxicology Series
General
Approach to acute poisoning, ECGs in Tox, Evidenced-based Tox, Toxicology literature summaries, Does anti-venom work?
Toxins / Overdose
Amphetamines, Barbituates, Benzylpiperazine, Beta Blockers, Calcium Channel Blocker, Carbamazepine, Carbon Monoxide, Ciguatera, Citrate, Clenbuterol, Cocaine, Corrosive ingestion, Cyanide, Digoxin, Ethanol, Ethylene Glycol, Iron, Isoniazid, Lithium, Local anaesthetic, Methanol, Monoamine oxidase inhibitor (MAOI), Mushrooms (non-hallucinogenic), Opioids, Organophosphate, Paracetamol, Paraquat, Plants, Polonium, Salicylate, Scombroid, Sodium channel blockers, Sodium valproate, Theophylline, Toxic alcohols, Tricyclic antidepressants (TCA)
Envenomation
Marine, Snakebite, Spider, Tick paralysis
Syndromes
Alcohol withdrawal, Anticholinergic syndrome, Cholinergic syndrome, Drug withdrawals in ICU, Hyperthermia associated toxidromes, Malignant hyperthermia (MH), Neuroleptic malignant syndrome (NMS), Opioid withdrawal, Propofol Infusion Syndrome (PrIS) Sedative toxidrome, Serotonin syndrome, Sympatholytic toxidrome, Sympathomimetic toxidrome
Decontamination
Activated Charcoal, Gastric lavage, GI Decontamination
Enhanced Elimination
Enhanced elimination, Hyperbaric therapy for CO
Antidotes
Antidote summary, Digibind, Glucagon, Flumazenil, HIET – High dose euglycaemic therapy, Intralipid, Methylene Blue, N-Acetylcysteine (NAC), Naloxone
Miscellaneous
Cocaine chest pain, Digoxin and stone heart theory, Hyperbaric oxygen, Hypoxaemia in tox, Liver failure in tox, Liver transplant for paracetamol, Methaemoglobinaemia, Urine drug screen
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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