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There are no documented cases of overdosage with BiDil (isosorbide dinitrate and hydralazine hcl) .The signs and symptoms of overdosage with BiDil (isosorbide dinitrate and hydralazine hcl) are expected to be those of excessive pharmaco-logic effect and those that may occur with overdosage of either isosorbide dini-trate or hydralazine hydrochloride administered alone.
Acute toxicity: No deaths due to acute poisoning have been reported.
Signs and Symptoms: The signs and symptoms of overdosage with BiDil (isosorbide dinitrate and hydralazine hcl) are expected to be those of excessive pharmacologic effect,i.e.,vasodilatation, reduced cardiac output and hypotension,and signs and symptoms include headache, confusion,tachycardia and generalized skin flushing. Complications can include myocardial ischemia and subsequent myocardial infarction,cardiac arrhythmia,and profound shock.Syncope,coma and death may ensue without appropriate treatment.
Treatment:There is no specific antidote.
Support of the cardiovascular system is of primary importance.Shock should be treated with plasma expanders,vasopressors,and positive inotropic agents.The gastric contents should be evacuated,taking adequate precautions to prevent aspiration. These manipulations have to be carried out after cardiovascular status has been stabilized,since they might precipitate cardiac arrhythmias or increase the depth of shock.
In patients with renal disease or congestive heart failure, therapy resulting in central volume expansion is not without hazard.Treatment of isosorbide dinitrate overdose in these patients may be difficult, and invasive monitoring may be required.
No data are available to suggest physiological maneuvers (e.g.,maneuvers to change the pH of the urine) that might accelerate elimination of the components of BiDil (isosorbide dinitrate and hydralazine hcl) . Dialysis is not effective in removing circulating isosorbide dinitrate.The dialyzability of hydralazine has not been determined.
Nitrate ions liberated during metabolism of isosorbide dinitrate can oxidize hemoglobin into methemoglobin.
There are case reports of significant methemoglobinemia in association with moderate overdoses of organic nitrates.
Methemoglobin levels are measurable by most clinical laboratories.
Methemoglobinemia could be serious in chronic heart failure patients because of already compromised vascular bed-tissue gas exchange dynamics. Classically, methemoglobinemic blood is described as chocolate brown,without color change on exposure to air.
When methemoglobinemia is diagnosed, the treatment of choice is methylene blue,1 to 2 mg/kg intravenously.
BiDil (isosorbide dinitrate and hydralazine hcl) is contraindicated in patients who are allergic to organic nitrates.
Last reviewed on RxList: 10/7/2008
This monograph has been modified to include the generic and brand name in many instances.
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