Décès toxique à l'amlodipine et l'olmésartan : à propos d'un cas avec pharmacobézoard

Though calcium blocker intoxication gravity is well described, angiotensin II AT1 receptor blocker intoxication is poorly documented. We report the case of a self-induced intoxication of a 63-year-old woman involving amlodipin, olmesartan in association with psychotropes. Intensive unit cares included an extra-body circulation, hemofiltration, extrahepatic purification, catecholamines and specific treatments (glucagon, calcium chloride, intralipids and insulin). Amlodipin plasma concentration measured 2 hours after admission reached 373 μg/L. Toxicokinetics allowed to observe a first phase of decreasing concentrations followed by a second phase of increasing concentrations at H36 which motivated a gastric endoscopy revealing a massive pharmacobezoard. Despite its evacuation, the patient died 6 days after her intoxication with an amlodipin plasma concentration decreased to 55 μg/L and a relative clinical stabilization. The important signs of digestive ischemia and cutaneous necrosis could have been explained by the importance of the initial shock combined with the pharmacobezoard. Olmesartan concentrations were determined a posteriori: H2 concentration was 12.2 mg/L and gradually increased during five days, up to 228.4 mg/L at H90. This unusual evolution with accumulation may be due to the saturation of the metabolic and elimination pathways. This case describes, for the first time, the toxicokinetics of a combined intoxication with amlodipine and olmesartan and reiterates the primary importance to carry out a gastric endoscopy earlier in order to look for a pharmacobezoard.