Neither therapeutic plasma exchange nor high-flux hemodialysisenhances the removal of Chlorprothixene in case of intoxication despite adrop in plasma levels: a case report

We present the case of a 19-year-old female who ingested 5 g of chlorprothixene in attempted suicide. Upon admission to the intensive care unit (ICU), she was mildly hypothermic but awake, responsive, and oriented. Initial management included 50 g of activated charcoal via nasogastric tube. As doses of >2 g chlorprothixene can cause severe intoxication and death, attempts to enhance secondary drug elimination by extracorporeal therapy were undertaken. First therapeutic plasma exchange (TPE), initiated approximately three hours after admission, exchanging 5096 mL of plasma against an albumin solution and fresh frozen plasma (FFP) with a treatment time of 3 h 10 min. This was followed by a 10 h 10 min prolonged intermittent kidney replacement therapy (PIKRT). Serial sampling of serum, apheresis fluid, and dialysate was conducted to assess the quantitative impact of TPE and dialysis on chlorprothixene plasma levels. Both procedures were well tolerated without adverse effects. The patient remained clinically stable and was transferred to a psychiatric facility 24 hours post-admission. Although there was a drop in chlorprothixene plasma levels, the total amount of the drug removed seems to be inconsequential and would be qualified by the EXTRIP as “not dialyzable”. Given the limited clinical evidence and the pharmacokinetic properties of chlorprothixene, TPE cannot be recommended for the management of chlorprothixene overdose and should not be regarded as a standard treatment option.To the best of our knowledge, this is the first description of chlorprothixene intoxication managed with both therapeutic plasma exchange and high-flux hemodialysis, highlighting the limited extracorporeal removal of this drug.