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Evaluation and treatment of NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) overdose is based on experience with the individual components, dextromethorphan and quinidine. Metabolism of the dextromethorphan component of NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is inhibited by the quinidine component, such that adverse effects of overdose due to NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) might be more severe or more persistent compared to overdose of dextromethorphan alone.
During development of NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) , dose combinations of dextromethorphan/quinidine containing up to 6-times higher dextromethorphan dose and 12-times higher quinidine dose were studied. The most common adverse events were mild to moderate nausea, dizziness, and headache.
The most important adverse effects of acute quinidine overdose are ventricular arrhythmias and hypotension. Other signs and symptoms of overdose may include vomiting, diarrhea, tinnitus, high-frequency hearing loss, vertigo, blurred vision, diplopia, photophobia, headache, confusion, and delirium.
While therapeutic doses of quinidine for treatment of cardiac arrhythmia or malaria are generally 10-fold or more higher than the dose of quinidine in NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) , potentially fatal cardiac arrhythmia, including torsades de pointes, can occur at quinidine exposures that are possible from NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) overdose.
Adverse effects of dextromethorphan overdose include nausea, vomiting, stupor, coma, respiratory depression, seizures, tachycardia, hyperexcitability, and toxic psychosis. Other adverse effects include ataxia, nystagmus, dystonia, blurred vision, and changes in muscle reflexes. Dextromethorphan may cause serotonin syndrome, and this risk is increased by overdose, particularly if taken with other serotonergic agents, SSRIs or tricyclic antidepressants.
Treatment of Overdose
While serum quinidine levels can be measured, electrocardiographic monitoring of the QTc interval is a better predictor of quinidine-induced arrhythmia. Treatment of hemodynamically unstable polymorphic ventricular tachycardia (including torsades de pointes) is either immediate cardioversion or, if a cardiac pacemaker is in place or immediately available, immediate overdrive pacing. After pacing or cardioversion, further management must be guided by the length of the QTc interval. Factors contributing to QTc prolongation (especially hypokalemia and hypomagnesemia) should be sought out and (if possible) aggressively corrected. Prevention of recurrent torsades de pointes may require sustained overdrive pacing or the cautious administration of isoproterenol (30-150 ng/kg/min).
Because of the theoretical possibility of QT-prolonging effects that might be additive to those of quinidine, other antiarrhythmics with Class I (procainamide) or Class III activities should (if possible) be avoided.
If the post-cardioversion QTc interval is prolonged, then the pre-cardioversion polymorphic ventricular tachyarrhythmia was (by definition) torsades de pointes. In this case, class Ib antiarrhythmics like lidocaine are unlikely to be of value, and other Class I and Class III antiarrhythmics are likely to exacerbate the situation.
Quinidine-induced hypotension that is not due to an arrhythmia is likely to be a consequence of quinidine-related α-blockade and vasorelaxation. Treatment of hypotension should be directed at symptomatic and supportive measures. Repletion of central volume (Trendelenburg positioning, saline infusion) may be sufficient therapy; other interventions reported to have been beneficial in this setting are those that increase peripheral vascular resistance, including a-agonist catecholamines (norepinephrine).
Quinidine: Adequate studies of orally administered activated charcoal in human overdoses of quinidine have not been reported, but there are animal data showing significant enhancement of systemic elimination following this intervention, and there is at least one human case report in which the elimination half-life of quinidine in the serum was apparently shortened by repeated gastric lavage. Activated charcoal should be avoided if an ileus is present; the conventional dose is 1 gram/kg, administered every 2 to 6 hours as a slurry with 8 mL/kg of tap water. Although renal elimination of quinidine might theoretically be accelerated by maneuvers to acidify the urine, such maneuvers are potentially hazardous and of no demonstrated benefit. Quinidine is not usefully removed from the circulation by dialysis. Following quinidine overdose, drugs that delay elimination of quinidine (cimetidine, carbonic anhydrase inhibitors, thiazide diuretics) should be withdrawn unless absolutely required.
Dextromethorphan: Treatment of dextromethorphan overdosage should be directed at symptomatic and supportive measures.
Quinidine and related drugs
NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) contains quinidine, and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.
NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is contraindicated in patients with a history of NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) , quinine, mefloquine or quinidine-induced thrombocytopenia, hepatitis, bone marrow depression or lupus-like syndrome. NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is also contraindicated in patients with a known hypersensitivity to dextromethorphan (e.g. rash, hives) [see WARNINGS AND PRECAUTIONS].
NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs) or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI [see DRUG INTERACTIONS].
NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome or a history suggestive of torsades de pointes, and in patients with heart failure [see WARNINGS AND PRECAUTIONS].
NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is contraindicated in patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (e.g., thioridazine and pimozide), as effects on QT interval may be increased [see DRUG INTERACTIONS].
NUEDEXTA (dextromethorphan hydrobromide and quinidine sulfate capsules) is contraindicated in patients with complete atrioventricular (AV) block without implanted pacemakers, or in patients who are at high risk of complete AV block.
Last reviewed on RxList: 12/10/2010
This monograph has been modified to include the generic and brand name in many instances.
Additional Nuedexta Capsules Information
- Nuedexta Capsules Drug Interactions Center: dextromethorphan-quinidine oral
- Nuedexta Capsules Side Effects Center
- Nuedexta Capsules in detail including Side Effects and Drug Images
- Nuedexta Capsules Overview including Precautions
- Nuedexta Capsules FDA Approved Prescribing Information including Dosage
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