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Try Naloxone for Severe ACE Inhibitor Poisoning

doi: 10.1097/01.EEM.0000581528.00557.a4
EMedHome's Clinical Pearl


ACE inhibitor toxicity can result in severe bradycardia and profound hypotension. (Am J Emerg Med. 2019;37[6]:1217; J Hum Hypertens. 1995;9[9]:711; Ann Emerg Med. 1991;20[10]:1125.)

Consider naloxone to treat ACEI poisoning, especially in cases of severe hypotension in which aggressive administration of IV fluids would be a concern. Using naloxone in this setting may also avoid the need to employ vasopressive support and pacing.

Several distinct families of endogenous opioids have been identified, with the most well-characterized being endorphins, enkephalins, and dynorphins. Enkephalins have direct effects on blood pressure, heart rate, and the baroreceptor reflex.

ACE inhibitors inhibit the metabolism of enkephalins, potentiating their opioid effect, which includes lowering blood pressure. Administering naloxone has been shown to increase blood pressure in ACE inhibitor overdoses. (Maryland Poison Center, toxtidbits. January 2012.

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Amal Mattu, MD, and Colleagues: Cardiogenic Pulmonary Edema, Syncope, and Hypotensive Heart Failure: Dr. Mattu is one of the premier speakers in emergency medicine, and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.

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James Ahn, MD: Finding the Subarachnoid in 2019: Dr. Ahn is an assistant professor of medicine and the associate program director and medical education fellowship director at the University of Chicago.

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