- Michael Bodmer, MD, MSc
Michael Bodmer, MD, MSc
- Division of General Internal Medicine
- Bern University Hospital, Inselspital, Bern, Switzerland
- Pharmacoepidemiology Unit, Pharmaceutical Sciences
- University Hospital Basel, Switzerland
- Alessandro Ceschi, MD
Alessandro Ceschi, MD
- Head Division of Science
- Swiss Toxicological Information Centre, Associated Institute of the University of Zurich
- Department of Clinical Pharmacology and Toxicology
- University Hospital Zurich, Switzerland
- Section Editor
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Meprobamate is a sedative and anxiolytic medication that was marketed for decades in the United States and continues to be used in Europe. The first case of meprobamate poisoning was described in 1956 . Due to its substantial abuse potential, meprobamate is no longer recommended for treatment of insomnia and has been replaced by benzodiazepines and other agents. Although use of the drug is declining, significant meprobamate overdose remains a life-threatening emergency.
This topic will review the basic pharmacology, clinical presentation, and management of meprobamate poisoning. Discussions of the general approach to the management of poisoned patients and detailed management of other toxins are found elsewhere. (See "General approach to drug poisoning in adults" and "Initial management of the critically ill adult with an unknown overdose".)
Meprobamate poisoning is rare and most cases involve suicide attempts . In France, meprobamate has been used more widely and the drug was involved in approximately 7 percent of psychotropic poisonings in 2005 . Mortality in cases of overdose has ranged between 1.7 and 5 percent [4-6]. Meprobamate ingestion is associated with an increased risk of intensive care unit (ICU) admission (adjusted odds ratio [OR] = 2.71; 95% CI: 1.27-5.81) .
Meprobamate is a carbamate which acts primarily as a sedative by increasing GABAA-mediated neurotransmission in a manner similar to barbiturates [8,9]. Carisoprodol, prescribed as a centrally acting muscle relaxant, is mainly metabolized to meprobamate by cytochrome P450 2C19, shares properties with meprobamate, and also has significant potential for abuse [10-12].
PHARMACOKINETICS AND TOXICOKINETICS
After oral ingestion of a therapeutic dose, meprobamate is rapidly absorbed from the gastrointestinal tract and peak plasma concentrations are reached within one to three hours [13,14]. Protein binding is negligible (14 to 24 percent). The drug’s volume of distribution is reported to be 0.70 L/kg, and is not significantly altered in overdose. A standard single therapeutic dose for an adult ranges from 200 to 800 mg. Significant toxicity is likely with ingestions of 4 to 5 g or more [3,4].
- SHANE AM, HIRSCH S. Three cases of meprobamate poisoning. Can Med Assoc J 1956; 74:908.
- Lambert WE, De Leenheer AP, Van Bocxlaer JF, Piette M. Meprobamate intoxication: rare and difficult to find. J Toxicol Clin Toxicol 1992; 30:683.
- Charron C, Mekontso-Dessap A, Chergui K, et al. Incidence, causes and prognosis of hypotension related to meprobamate poisoning. Intensive Care Med 2005; 31:1582.
- Buire AC, Vitry F, Hoizey G, et al. Overdose of meprobamate: plasma concentration and Glasgow Coma Scale. Br J Clin Pharmacol 2009; 68:126.
- Gaultier M, Fournier E, Bismuth C, et al. [Acute poisoning by meprobamate. Apropos of 141 cases]. Bull Mem Soc Med Hop Paris 1968; 119:675.
- Mounier B, Pons B, Delavenne X, et al. [Severe meprobamate poisoning: description of 146 cases in a French department]. Therapie 2012; 67:183.
- Maignan M, Pommier P, Clot S, et al. Deliberate drug poisoning with slight symptoms on admission: are there predictive factors for intensive care unit referral? A three-year retrospective study. Basic Clin Pharmacol Toxicol 2014; 114:281.
- Rho JM, Donevan SD, Rogawski MA. Barbiturate-like actions of the propanediol dicarbamates felbamate and meprobamate. J Pharmacol Exp Ther 1997; 280:1383.
- Roache JD, Griffiths RR. Lorazepam and meprobamate dose effects in humans: behavioral effects and abuse liability. J Pharmacol Exp Ther 1987; 243:978.
- Heacock C, Bauer MS. Tolerance and dependence risk with the use of carisoprodol. Am Fam Physician 2004; 69:1622.
- Reeves RR, Carter OS, Pinkofsky HB, et al. Carisoprodol (soma): abuse potential and physician unawareness. J Addict Dis 1999; 18:51.
- Reeves RR, Pinkofsky HB, Carter OS. Carisoprodol: a drug of continuing abuse. J Am Osteopath Assoc 1997; 97:723.
- Verpooten GA, De Broe ME. Prediction of the efficacy of hemoperfusion and hemodialysis in severe poisoning. Arch Toxicol Suppl 1982; 5:304.
- Hoizey G, Gozalo C, Canas F, Fornes P, Binet L, Thomas A, Oget O, HerveMillart, Lamiable D. Distribution tissulaire post-mortem du meprobamate: à propos de 8 cas. Ann Toxicol Anal 2008; 20:47.
- Bismuth C, Baud FJ, Galliot M, et al. [Liver metabolism of meprobamate: clinical estimation in acute intoxication]. J Toxicol Clin Exp 1985; 5:321.
- Micromedex Healthcare Series. Thomson Reuters, Greenwood Village, Colorado, 2010.
- Maddock RK Jr, Bloomer HA. Meprobamate overdosage. Evaluation of its severity and methods of treatment. JAMA 1967; 201:999.
- HOLLISTER LE, LEVY G. KINETICS OF MEPROBAMATE ELIMINATION IN HUMANS. Chemotherapia (Basel) 1964; 9:20.
- Jacobsen D, Wiik-Larsen E, Saltvedt E, Bredesen JE. Meprobamate kinetics during and after terminated hemoperfusion in acute intoxications. J Toxicol Clin Toxicol 1987; 25:317.
- Landier C, Lanotte R, Legras A, et al. [State of shock during acute meprobamate poisoning. 6 cases]. Ann Fr Anesth Reanim 1994; 13:407.
- Allen MD, Greenblatt DJ, Noel BJ. Meprobamate overdosage: a continuing problem. Clin Toxicol 1977; 11:501.
- Eeckhout E, Huyghens L, Loef B, et al. Meprobamate poisoning, hypotension and the Swan-Ganz catheter. Intensive Care Med 1988; 14:437.
- Lhoste F, Lemaire F, Rapin M. Treatment of hypotension in meprobamate poisoning. N Engl J Med 1977; 296:1004.
- Mellerio F. Clinical and EEG study of a case of acute poisoning, with cerebral electrical silence followed by recovery. Electroencephalogr Clin Neurophysiol 1971; 30:254.
- Mellerio F, Frejaville JP, Gluckman JC. [Apropos of acute poisoning with meprobamate. An unusual electroclinical case]. Presse Med 1968; 76:2227.
- Tirot P, Harry P, Bouachour G, et al. [Electroencephalographic silence after intoxication with a carbamate tranquilizer]. J Toxicol Clin Exp 1991; 11:417.
- Lobo PI, Spyker D, Surratt P, Westervelt FB Jr. Use of hemodialysis in meprobamate overdosage. Clin Nephrol 1977; 7:73.
- Axelson JA, Hagaman JF. Meprobamate poisoning and pulmonary edema. N Engl J Med 1977; 296:1481.
- Bertran F, de la Sayette V, Lacotte J, et al. [Acute rhabdomyolysis and meprobamate poisoning]. Therapie 1992; 47:444.
- Bourry J, Sainty JM, Roux JJ, Ressiot G. [Acute pancreatitis in the course of meprobamate poisoning. Possible role of pressor amine therapy]. Nouv Presse Med 1976; 5:1918.
- Fathallah N, Zamy M, Slim R, et al. Acute pancreatitis in the course of meprobamate poisoning. JOP 2011; 12:404.
- Schwartz HS. Acute meprobamate poisoning with gastrotomy and removal of a drug-containing mass. N Engl J Med 1976; 295:1177.
- Delavenne X, Gay-Montchamp JP, Basset T. HPLC MS/MS method for quantification of meprobamate in human plasma: application to 24/7 clinical toxicology. J Chromatogr B Analyt Technol Biomed Life Sci 2011; 879:215.
- Daval S, Richard D, Souweine B, et al. A one-step and sensitive GC-MS assay for meprobamate determination in emergency situations. J Anal Toxicol 2006; 30:302.
- Beveridge GW. Bullous lesions in poisoning. Br Med J 1971; 4:116.
- Dunn C, Held JL, Spitz J, et al. Coma blisters: report and review. Cutis 1990; 45:423.
- Hassan E. Treatment of meprobamate overdose with repeated oral doses of activated charcoal. Ann Emerg Med 1986; 15:73.
- Stack PE, Thomas E. Pharmacobezoar: an evolving new entity. Dig Dis 1995; 13:356.
- Meprobamate & bezoar formation. Ann Emerg Med 1987; 16:472.
- Crome P, Higgenbottom T, Elliott JA. Severe meprobamate poisoning: successful treatment with haemoperfusion. Postgrad Med J 1977; 53:698.
- Hoy WE, Rivero A, Marin MG, Rieders F. Resin hemoperfusion for treatment of a massive meprobamate overdose. Ann Intern Med 1980; 93:455.
- Lin JL, Lim PS, Lai BC, Lin WL. Continuous arteriovenous hemoperfusion in meprobamate poisoning. J Toxicol Clin Toxicol 1993; 31:645.
- Laroche B, Hoang The Dan P, Lapandry C, et al. [Acute meprobamate poisoning. Efficacy of peritoneal dialysis]. Cah Anesthesiol 1984; 32:677.
- PHARMACOKINETICS AND TOXICOKINETICS
- CLINICAL FEATURES OF OVERDOSE
- Clinical symptoms and signs
- - Overview
- - Cardiovascular
- - Neurologic
- - Respiratory
- - Other manifestations
- DIAGNOSTIC IMAGING
- LABORATORY EVALUATION
- Testing for meprobamate
- General evaluation
- DIFFERENTIAL DIAGNOSIS
- Initial stabilization
- Treatment of hypotension
- Gastrointestinal decontamination
- Enhanced elimination
- Ongoing treatment and disposition
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS