Abstract
PICO question
 In dogs with metaldehyde intoxication, are benzodiazepines (e.g. diazepam, midazolam) more effective than methocarbamol in relaxing muscles and reducing tremors?
 
 Clinical bottom line
 Category of research question
 Treatment
 The number and type of study designs reviewed
 Five papers were critically reviewed. There were five retrospective case series
 Strength of evidence
 Weak
 Outcomes reported
 Currently, five retrospective case series exist in the literature which discuss metaldehyde intoxication cases treated mainly with benzodiazepines, a few of which had methocarbamol. There is not really any study to compare directly benzodiazepines with methocarbamol. In addition to that, factors such as commercial (e.g. the low availability of methocarbamol in the UK market compared to the US market), administrational (e.g. multiple administration routes of benzodiazepines) and pharmacological (e.g. lack of anticonvulsant function of methocarbamol), have played an important role in the treatment choice. Several case reports exist as well
 Conclusion
 Currently, there is insufficient evidence to determine whether benzodiazepines are more effective than methocarbamol in relaxing muscles and reducing occurrence of muscle tremors
 
 How to apply this evidence in practice
 The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.
 Knowledge Summaries are a resource to help reinforce or inform decision-making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.
 
Highlights
There is not enough evidence to define whether benzodiazepines or methocarbamol is better for the control of muscle tremors during metaldehyde intoxication, the answer of the current PICO remains open
It is reported that the availability of methocarbamol is limited in the UK (Bates et al, 2012) and there are no prospective studies describing its efficacy on tremors, it is suggested that methocarbamol is very successful in reducing muscle tremors during this intoxication (Dolder, 2003)
Due to possible manifestation of epileptic seizures concurrently with the generalised muscle tremors and in the light of their anticonvulsant activity, their broader availability, their multiple administration routes and their rapid action when given IV, benzodiazepines are preferred for the initiation of the treatment in cases of metaldehyde intoxication by many vets; and they carry on with an antiepileptic drug or general anaesthesia (Firth, 1992; Yas-Natan et al, 2007; Zimmermann et al, 2010; Jull et al, 2011; and Bates et al, 2012)
Summary
Population: Dogs with snail bait poisoning (metaldehyde or methiocarb) and follow-up. Intervention details: 26/56 dogs were intoxicated by metaldehyde (30/56 dogs were intoxicated by methiocarb). Treatment was achieved with sedatives, general anaesthetics and/or muscle relaxants including: a. Methocarbamol was given only after performing GA with either one of the above mentioned GA protocols, but not as sole medication. Outcome studied: Different management protocols (including the use of premedication, general anaesthesia and post-general anaesthesia relaxants). The correlation between the treatment modality and patients’ response and outcome. Main findings: (relevant to PICO question): There was full recovery of 100% (24/24) metaldehyde intoxication cases using multimodal treatment, most of which included diazepam. There was no comparison between the usage of benzodiazepines and methocarbamol
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