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Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK.
Clin Toxicol (Phila). 2021 Nov; 59(11):992-1001.CT

Abstract

BACKGROUND

Bites by the European adder (Vipera berus) in the UK are uncommon but potentially life threatening, and can be associated with marked limb swelling and disability. Following an interruption in Zagreb Imunološki zavod antivenom supply around 2012, the UK changed its national choice of antivenom for Vipera berus to ViperaTAb, an ovine Fab monospecific antivenom. In the absence of randomised controlled trials, we established an audit to review its use in clinical practice.

METHODS

A prospective audit of ViperaTAb use was conducted from March 2016 until November 2020 by the UK National Poison Information Service (NPIS). Users of the NPIS online toxicology database, TOXBASE, considering the use of antivenom for V. berus envenoming were invited to discuss the case with the on-call clinical toxicology consultant. Information was collected prospectively on indications, administration, adverse reactions and outcome of patients administered ViperaTAb antivenom.

RESULTS

One hundred and seventy patients were administered ViperaTAb antivenom over five years. One hundred and thirty-two were adults and 38 children (median age and range: 38, 2-87 years). Bites occurred across the UK, but most commonly in coastal regions of Wales and of South-West and East England. Median time to presentation was 2.1 (IQR 1.5-4.0) h and to antivenom administration from presentation was 2.0 (IQR 0.9-3.6) h. A minority of patients presented to hospital more than 12 h after being bitten (n = 19, 11.2%) or received antivenom more than 12 h after presenting to hospital (n = 17, 10.0%). Features of systemic envenoming were present in 64/170 (37.6%) patients, including 23 (13.5%) with anaphylaxis and 26 (15.3%) with hypotension (nine with both). Clinician assessment considered the initial antivenom to have been effective in 122/169 (72.2%) patients. Repeated dosing was common, occurring in 55/169 (32.5%), predominantly due to persisting or worsening local effects (46/51, 90.2%). There were three cases of probable early adverse reaction. No deaths occurred during the study. Complications of envenoming were rare but included four patients that underwent surgery, three patients each with acute kidney injury, mild coagulopathy, or thrombocytopenia (one severe). The median duration of hospital stay was 43.7 (IQR 22.5-66.5) h, longer for children than adults (52.5 vs 41.3 h).

CONCLUSION

ViperaTAb antivenom appears to be effective and safe and should be administered as soon as possible for patients meeting clinical criteria. Patients require close observation following antivenom to detect adverse reactions and progression or recurrence of envenoming. Close collaboration with expert NPIS consultant advice can help optimise antivenom timing, ensure repeated dosing is given appropriately, and avoid unnecessary surgical intervention. All hospitals, particularly those located in areas of relatively high incidence, should stock sufficient antivenom available at short notice, 24 h a day.

Authors+Show Affiliations

National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK. Myanmar Oxford Clinical Research Unit, University of Oxford, Oxford, UK. Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK.Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.Liverpool School of Tropical Medicine, Liverpool, UK.National Poisons Information Service - Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.National Poisons Information Service - Newcastle, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.National Poisons Information Service - Newcastle, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.National Poisons Information Service - Cardiff, University Hospital Llandough, Cardiff, UK.National Poisons Information Service - Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK. Department of Pharmacology, Toxicology, Therapeutics, University/BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

33720783

Citation

Lamb, Thomas, et al. "Moderate-to-severe Vipera Berus Envenoming Requiring ViperaTAb Antivenom Therapy in the UK." Clinical Toxicology (Philadelphia, Pa.), vol. 59, no. 11, 2021, pp. 992-1001.
Lamb T, Stewart D, Warrell DA, et al. Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK. Clin Toxicol (Phila). 2021;59(11):992-1001.
Lamb, T., Stewart, D., Warrell, D. A., Lalloo, D. G., Jagpal, P., Jones, D., Thanacoody, R., Gray, L. A., & Eddleston, M. (2021). Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK. Clinical Toxicology (Philadelphia, Pa.), 59(11), 992-1001. https://doi.org/10.1080/15563650.2021.1891245
Lamb T, et al. Moderate-to-severe Vipera Berus Envenoming Requiring ViperaTAb Antivenom Therapy in the UK. Clin Toxicol (Phila). 2021;59(11):992-1001. PubMed PMID: 33720783.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Moderate-to-severe Vipera berus envenoming requiring ViperaTAb antivenom therapy in the UK. AU - Lamb,Thomas, AU - Stewart,David, AU - Warrell,David A, AU - Lalloo,David G, AU - Jagpal,Pardeep, AU - Jones,Dacia, AU - Thanacoody,Ruben, AU - Gray,Laurence A, AU - Eddleston,Michael, Y1 - 2021/03/15/ PY - 2021/3/16/pubmed PY - 2021/11/9/medline PY - 2021/3/15/entrez KW - Vipera KW - ViperaTAb KW - antivenins KW - snakebite KW - snakes SP - 992 EP - 1001 JF - Clinical toxicology (Philadelphia, Pa.) JO - Clin Toxicol (Phila) VL - 59 IS - 11 N2 - BACKGROUND: Bites by the European adder (Vipera berus) in the UK are uncommon but potentially life threatening, and can be associated with marked limb swelling and disability. Following an interruption in Zagreb Imunološki zavod antivenom supply around 2012, the UK changed its national choice of antivenom for Vipera berus to ViperaTAb, an ovine Fab monospecific antivenom. In the absence of randomised controlled trials, we established an audit to review its use in clinical practice. METHODS: A prospective audit of ViperaTAb use was conducted from March 2016 until November 2020 by the UK National Poison Information Service (NPIS). Users of the NPIS online toxicology database, TOXBASE, considering the use of antivenom for V. berus envenoming were invited to discuss the case with the on-call clinical toxicology consultant. Information was collected prospectively on indications, administration, adverse reactions and outcome of patients administered ViperaTAb antivenom. RESULTS: One hundred and seventy patients were administered ViperaTAb antivenom over five years. One hundred and thirty-two were adults and 38 children (median age and range: 38, 2-87 years). Bites occurred across the UK, but most commonly in coastal regions of Wales and of South-West and East England. Median time to presentation was 2.1 (IQR 1.5-4.0) h and to antivenom administration from presentation was 2.0 (IQR 0.9-3.6) h. A minority of patients presented to hospital more than 12 h after being bitten (n = 19, 11.2%) or received antivenom more than 12 h after presenting to hospital (n = 17, 10.0%). Features of systemic envenoming were present in 64/170 (37.6%) patients, including 23 (13.5%) with anaphylaxis and 26 (15.3%) with hypotension (nine with both). Clinician assessment considered the initial antivenom to have been effective in 122/169 (72.2%) patients. Repeated dosing was common, occurring in 55/169 (32.5%), predominantly due to persisting or worsening local effects (46/51, 90.2%). There were three cases of probable early adverse reaction. No deaths occurred during the study. Complications of envenoming were rare but included four patients that underwent surgery, three patients each with acute kidney injury, mild coagulopathy, or thrombocytopenia (one severe). The median duration of hospital stay was 43.7 (IQR 22.5-66.5) h, longer for children than adults (52.5 vs 41.3 h). CONCLUSION: ViperaTAb antivenom appears to be effective and safe and should be administered as soon as possible for patients meeting clinical criteria. Patients require close observation following antivenom to detect adverse reactions and progression or recurrence of envenoming. Close collaboration with expert NPIS consultant advice can help optimise antivenom timing, ensure repeated dosing is given appropriately, and avoid unnecessary surgical intervention. All hospitals, particularly those located in areas of relatively high incidence, should stock sufficient antivenom available at short notice, 24 h a day. SN - 1556-9519 UR - https://www.unboundmedicine.com/medline/citation/33720783/Moderate_to_severe_Vipera_berus_envenoming_requiring_ViperaTAb_antivenom_therapy_in_the_UK_ L2 - https://www.tandfonline.com/doi/full/10.1080/15563650.2021.1891245 DB - PRIME DP - Unbound Medicine ER -