Acute chloroquine poisoning: A comprehensive experimental toxicology
assessment of the role of diazepam
Abstract
Background and Purpose: Resurgence in the use of chloroquine as a
putative treatment for COVID-19 has seen recent cases of fatal toxicity
due to unintentional overdoses. Protocols for the management of
poisoning recommend diazepam, although there are uncertainties in its
pharmacology and efficacy in this context. The aim was to assess the
effects of diazepam in experimental models of chloroquine
cardiotoxicity. Experimental Approach: In vitro experiments involved
cardiac tissues isolated from rats and incubated with chloroquine,
alone, or in combination with diazepam. In vivo models of toxicity
involved chloroquine administered intravenously to
pentobarbitone-anaesthetised rats and rabbits. Randomised, controlled
interventional studies in rats assessed diazepam, clonazepam and
Ro5-4864 administered: (i) prior, (ii) during, and (iii) after
chloroquine; and the effects of diazepam: (iv) at high dose, (v) in
urethane-anaesthetised rats, and (vi) co-administered with adrenaline.
Key Results: Chloroquine decreased the developed tension of left atria,
prolonged the effective refractory period of atria, ventricular tissue
and right papillary muscles, and caused dose-dependent impairment of
haemodynamic and electrocardiographic parameters. Cardiac arrhythmias
indicated impairment of atrioventricular conduction. Studies (i), (ii)
and (v) showed no differences between interventions and control.
Diazepam increased heart rate in study (iv) and, as with clonazepam,
also prolonged the QTc interval in study (iii). Combined administration
of diazepam and adrenaline in study (vi) improved cardiac contractility
but caused hypokalaemia. Conclusion and Implications: Neither diazepam,
nor other ligands for benzodiazepine binding sites, protect against or
attenuate chloroquine cardiotoxicity. However, diazepam may augment the
effects of positive inotropes in reducing chloroquine cardiotoxicity.