A Dual Beta Blocker and Calcium Channel Blocker Overdose in a Patient with Substance Abuse

Abstract

Aim: Nearly 25% of hospital admissions have related adverse drug events with 6-7% of these related to beta blockers (BB) or calcium channel blockers (CCB). Introduction: In some cases, patients do not report their noncompliance at home as well as their illicit substance use leading to worsened outcomes. We present a case of BB and CCB toxicity with concomitant substance abuse, its treatment and general outcome. Case: A 49-year-old woman with history of diabetes mellitus, stroke, and hypertension presented with flu-like symptoms including fever, nausea, vomiting, diarrhea and dysuria. She was admitted for treatment of urinary tract infection and possible left lower lobar pneumonia with guideline-directed antibiotic and IV fluids for acute kidney injury. She was elusive about her substance use history and endorsed compliance with her cardiac and other medications. Unfortunately, after administration of her morning medications, she had cardiac decline including hypotension and bradycardia with a subsequent hypoglycemia and left sided deficits leading to further investigation into her medication adherence and substance use history. History evolved that she was noncompliant with her high dose cardiac medications and a urine drug screen was positive for amphetamines, barbiturates, and nonprescription benzodiazepines. Treatment: The patient’s shock was treated with resuscitative fluids, glucagon, and calcium infusion as well as a short round of vasopressor. She was transferred to a higher acuity center for large vessel occlusion at the distal portion of the left vertebral artery as seen on stroke imaging. Her blood and urine cultures ultimately grew extended spectrum beta lactamase bacteria, meanwhile her shock was deemed medication-induced hypovolemic shock with a depressed heart rate response given a normal transthoracic echocardiogram and quick resolution after reversal agent. Despite the severity and progression of the hospitalization the patient elected to leave against medical advice (AMA) prior to neurosurgical evaluation and completion of antibiotics. She has since been seen well in follow up by her outpatient provider. Discussion: Cardiac medications are associated with adverse cardiac effects and should be prescribed carefully in patients with substance abuse. Further elucidation of substance abuse led to improved treatment outcomes in this patient with polysubstance and alcohol abuse.