Unintentional ingestion of brimonidine antiglaucoma drops: a case report and review of the literature

Brimonidine tartrate ophthalmic solution 0.025% for redness relief: an overview of safety and efficacy

INTRODUCTION

Ocular redness, or conjunctival hyperemia, is a common ophthalmic sign associated with reduced quality of life. For redness without apparent underlying pathology, topical ophthalmic decongestants have been widely used.

AREAS COVERED

Brimonidine tartrate was approved in 2017 as a topical vasoconstrictor at a 0.025% concentration for relief of ocular redness. Since then, investigators have reported on efficacy and safety findings from studies evaluating low-dose brimonidine for reducing ocular redness.

EXPERT OPINION

Brimonidine is highly selective for α₂-adrenergic receptors. Clinical trials have so far shown that the drug in low doses significantly reduces ocular redness in comparison to vehicle for up to 8 hours. Brimonidine-treated eyes did not present side effects of other vasoconstrictors, such as hypotension, cardiac arrhythmia or drowsiness. Ocular adverse events such as allergic reactions and redness rebound were also minimal. In this review, we examine in detail published literature on the mechanism of brimonidine tartrate and its efficacy and safety in relieving conjunctival hyperemia.

Brimonidine Eye Drops Causing Encephalopathy in a Patient With Advanced Chronic Kidney Disease

Brimonidine eye drops are frequently prescribed for the treatment of glaucoma and ocular hypertension in adults. Systemic toxicities including neurological side effects have been reported with its use, especially in the paediatric population. In this report, we present a case of encephalopathy secondary to the use of brimonidine eye drops in a patient with underlying advanced chronic kidney disease, who recovered promptly after drug cessation. Herein, we also review the pharmacokinetics of eye drops leading to their systemic side effects, especially in the context of renal impairment. We also explore the possibility of extracorporeal treatment, such as by haemodialysis, for the treatment of these manifestations. This case demonstrates the need to clarify a patient’s drug history and stop offending medications early on in a patient with delirium, while treatments such as antidotes or extracorporeal treatment are being considered.

Adverse effects of brimonidine eye drop in children: A case series

WHAT IS KNOWN AND OBJECTIVE

Brimonidine is increasingly used in the treatment of intraocular hypertension.

CASE SUMMARY

We report on five paediatric patients suffering from brimonidine eye drop intoxication. The most frequent signs of the intoxication were a lowered level of consciousness and hypotonia. Other complications were apnea, bradycardia, hypotension and seizure. One of the patients needed cardiopulmonary resuscitation. Apnea in one of the cases was resistant to naloxone. Pupils were unremarkable in two cases.

WHAT IS NEW AND CONCLUSION

Brimonidine is potentially lethal for young infants. The absence of miosis and absence of response to naloxone is not a reason to rule out brimonidine poisoning.

A review of neuropsychiatric adverse events from topical ophthalmic brimonidine

Brimonidine is a first-line topical medication for increased intraocular pressure and glaucoma which may be used alone or in conjunction with other topical therapies. Its structural and pharmacological comparabilities to clonidine give way to the hypothesis that it may cause neuropsychiatric side effects. The majority of case reports citing brimonidine toxicity, either for topical or peripheral exposure, include pediatric age groups but especially infants. Among the latter, a dose-response phenomenon is evident. Dose-response correlates have also been shown among adults. Case series and prospective double-blind treatment studies also give evidence for the occurrence of several central nervous system adverse reactions. Topical ophthalmic brimonidine use should be followed for the occurrence of neuropsychiatric disturbances generally, and enhanced vigilance should be maintained for at-risk populations.

Respiratuvar depression after accidental nasal ingestion of brimonidine eye drops in infant

OBJECTIVES

Brimonidine tartrate is an alpha-2 agonist used for glaucoma treatment. It can lead to serious poisoning symptoms when misused by children.

CASE REPORT

In this case report, 3 months-old male patient with severe central nervous system depression and respiratory arrest as a result of accidentally nasal instillation of 1 cc brimonidine tartrate that benefited from mechanic ventilation and naloxone treatment was presented.

CONCLUSION

This case report suggested, that misuse of nasal brimonidine eye drop could result in serious respiratory distress and central nervous system depression. Mechanical ventilation and naloxone administration can be useful for these patients.

Cardiotoxicodynamics: Toxicity of Cardiovascular Xenobiotics

Maintaining adequate tissue perfusion depends on a variety of factors, all of which can be influenced by xenobiotics (substances foreign to the body, including pharmaceuticals, chemicals, and natural compounds). Volume status, systemic vascular resistance, myocardial contractility, and cardiac rhythm all play a significant role in ensuring hemodynamic stability and proper cardiovascular function. Direct effects on the nervous system, the vasculature, or the heart itself as well as indirect metabolic effects may play a significant role in the development of cardiotoxicity. This article is dedicated to discussion of the disruption of cardiovascular physiology by xenobiotics.

Brimonidine tartrate poisoning in children: frequency, trends, and use of naloxone as an antidote

BACKGROUND

Brimonidine tartrate, a centrally acting selective alpha-2 adrenergic agonist with a toxicity that is often compared with that of clonidine, is used as eye drops to lower intraocular pressure in glaucoma. We investigated characteristics of childhood exposures to brimonidine-containing products.

METHODS

All brimonidine exposures in children 0 to 5 years of age between 1997 and 2005 were retrieved from the American Association of Poison Control Centers' Toxic Exposure Surveillance System database and the US Food and Drug Administration's Medwatch Adverse Events Reporting System. The design of the study was retrospective, and the main outcome measures were frequency of exposures over time, reason, symptoms/signs of toxicity, dose, management site, treatment, and outcome.

RESULTS

There were 413 brimonidine reports in the Toxic Exposure Surveillance System and 340 in the Adverse Events Reporting System during the 9 years under study, of which 185 Toxic Exposure Surveillance System reports involved children < or =5 years of age versus 15 cases in the Adverse Events Reporting System. There were no deaths. The peak age of poisoning in the Toxic Exposure Surveillance System pediatric cases was 2 years of age, and circumstances were unintentional poisoning in 176 cases, usually by ingestion (84.3%). Common symptoms in 176 children included drowsiness (40.9%), ataxia (4.5%), pallor (4.5%), irritability (4.0%), hypotension (4.0%), bradycardia (4.0%), miosis (3.4%), and respiratory depression (3.4%). Of the 176 unintentional pediatric poisonings, 73 children were observed at home and 103 were seen at a health care facility; 28 were hospitalized and 11 received naloxone. Of the 15 pediatric cases in the Adverse Events Reporting System data set, all were hospitalized, and 13 had ocular exposures only.

CONCLUSIONS

All children < or =5 years of age with confirmed brimonidine ingestions should be medically evaluated and monitored for an extended period. Indications for the use of naloxone in brimonidine poisoning remain uncertain.