Royal College of Emergency Medicine and National Poisons Information Service Guideline on Antidote Availability for Emergency Departments, 2021 Update

Please see below the updated 2021 Royal College of Emergency Medicine (RCEM) and National Poisons Information Service (NPIS) guideline for the stocking of antidotes by Emergency Departments in the UK which replaces the 2017 guideline. These guidelines are also available on TOXBASE and the RCEM Clinical Guidelines website.

The main changes since the 2017 guideline are:

1. Formal arrangements are now in place for the supply of Category C Antidotes.

• Prussian Blue, Sodium Calcium Edetate, Succimer (DMSA) and Unithiol (DMPS) are held in eight holding centres as shown in the map overleaf
• Botulinum Antitoxin and Pralidoxime are available from separate holding centres overseen by the Health Security Agency (HSA)
• Glucarpidase and Uridine Triacetate are supplied by WEP Clinical
• Use of Category C antidotes should always be discussed with NPIS and/or a Consultant Clinical Toxicologist who will be able to provide contact details to arrange the supply of these antidotes

2. Cyanide antidotes: removal of Sodium Nitrite and Dicobalt Edetate; the recommended cyanide antidotes are Sodium Thiosulphate and Hydroxocobalamin
3. Addition of Andexanet Alpha (Category B) for the reversal of anticoagulation from Apixaban or Rivaroxaban in adults with life-threatening or uncontrolled gastrointestinal bleeding
4. Addition of Disodium Folinate (Category B) as an alternative to Calcium Folinate for administration of Folinic Acid in Methotrexate or Methanol poisoning
5. Addition of L-Carnitine (Category B) for severe Sodium Valproate toxicity
6. Addition of Viperfav (Category B) for European Adder (Vipera berus) as an alternative to ViperaTAB
7. Addition of Uridine Triacetate (Category C) for severe 5-Fluorouracil or Capecitabine toxicity

Antidotes form an important component of the management of the poisoned patient and it is important that they are available in a timely fashion to ensure optimum care of these patients. A 2018/19 audit of UK antidote stocks showed that less than half of hospitals are fully compliant with stocking recommendations for Category A and B antidotes. We would urge you to work with your pharmacy department to ensure that you implement this guideline focusing particularly on stocking of Category A and B antidotes.

See related documentation below:

RCEM NPIS Antidote Letter | RCEM NPIS Antidote Guideline List | RCEM NPIS Antidote Guideline Appendix 1 | See the Toxicology tab on the Clinical Guidelines page