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Correspondence |

SilibininSilibinin for Amanita Poisoning: Where Is the Ethical Conundrum? FREE TO VIEW

Michael E. Mullins, MD; Evan S. Schwarz, MD; William H. Dribben, MD; S. Eliza Halcomb, MD; Anna M. Arroyo-Plasencia, MD
Author and Funding Information

From the Toxicology Section, Division of Emergency Medicine, Washington University School of Medicine in St. Louis.

CORRESPONDENCE TO: Michael E. Mullins, MD, Toxicology Section, Division of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8072, 660 S Euclid Ave, St. Louis, MO 63110; e-mail: mullinsm@wusm.wustl.edu


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Chest. 2015;147(3):e105. doi:10.1378/chest.14-2682
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To the Editor:

We read with great interest the recent article by Gores et al1 in CHEST (October 2014). While applauding the successful outcome of Amanita mushroom poisoning, it mystifies us that the authors perceived any ethical quandary concerning the use of silibinin. We would consider it more ethically questionable to deprive the patient an opportunity to receive silibinin.

Silibinin is the treatment best supported by available canine2,3 and human evidence.4-6 It has long been approved in Europe, where it is the drug of choice for amatoxin poisoning. While the market for silibinin in the United States is too small to justify efforts by the manufacturer to pursue US Food and Drug Administration approval, the drug is essentially available for compassionate use under the National Institutes of Health-registered study protocol referenced in the original case report.7

We recognize the rationale for IV N-acetylcysteine, IV penicillin G, and multidose-activated charcoal. All three have low risk and a modest role in treatment of amatoxin poisoning, but evidence of their efficacy is weak to nonexistent.

The authors seem concerned about the botanical origins of the drug. We point out that we have no anxiety about using other drugs derived from plants such as the willow and the poppy in our daily practice.

Most patients with amatoxin poisoning survive, and it is impossible to say whether this patient’s outcome would have been different without silibinin. Given the available evidence, we would want silibinin if we were inadvertently poisoned with amatoxin-containing mushrooms.

References

Gores KM, Hamieh TS, Schmidt GA. Survival following investigational treatment of amanita mushroom poisoning: thistle or shamrock? Chest. 2014;146(4):e126-e129. [CrossRef] [PubMed]
 
Vogel G, Tuchweber B, Trost W, Mengs U. Protection by silibinin againstAmanita phalloidesintoxication in beagles. Toxicol Appl Pharmacol. 1984;73(3):355-362. [CrossRef] [PubMed]
 
Floersheim GL, Eberhard M, Tschumi P, Duckert F. Effects of penicillin and silymarin on liver enzymes and blood clotting factors in dogs given a boiled preparation ofAmanita phalloidesToxicol Appl Pharmacol. 1978;46(2):455-462. [CrossRef] [PubMed]
 
Hruby K, Csomos G, Fuhrmann M, Thaler H. Chemotherapy ofAmanita phalloidespoisoning with intravenous silibinin. Hum Toxicol. 1983;2(2):183-195. [CrossRef] [PubMed]
 
Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol. 2002;40(6):715-757. [CrossRef] [PubMed]
 
Ganzert M, Felgenhauer N, Schuster T, Eyer F, Gourdin C, Zilker T. Amatoxin poisoning—comparison of silibinin with a combination of silibinin and penicillin [in German]. Dtsch Med Wochenschr. 2008;133(44):2261-2267. [CrossRef] [PubMed]
 
National Institutes of Health Clinical Center. Intravenous milk thistle (silibinin-legalon) for hepatic failure induced by amatoxin/amanita mushroom poisoning. NCT00915681. ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 2009. http://clinicaltrials.gov/ct2/show/NCT00915681. Updated September 15, 2014.
 

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References

Gores KM, Hamieh TS, Schmidt GA. Survival following investigational treatment of amanita mushroom poisoning: thistle or shamrock? Chest. 2014;146(4):e126-e129. [CrossRef] [PubMed]
 
Vogel G, Tuchweber B, Trost W, Mengs U. Protection by silibinin againstAmanita phalloidesintoxication in beagles. Toxicol Appl Pharmacol. 1984;73(3):355-362. [CrossRef] [PubMed]
 
Floersheim GL, Eberhard M, Tschumi P, Duckert F. Effects of penicillin and silymarin on liver enzymes and blood clotting factors in dogs given a boiled preparation ofAmanita phalloidesToxicol Appl Pharmacol. 1978;46(2):455-462. [CrossRef] [PubMed]
 
Hruby K, Csomos G, Fuhrmann M, Thaler H. Chemotherapy ofAmanita phalloidespoisoning with intravenous silibinin. Hum Toxicol. 1983;2(2):183-195. [CrossRef] [PubMed]
 
Enjalbert F, Rapior S, Nouguier-Soulé J, Guillon S, Amouroux N, Cabot C. Treatment of amatoxin poisoning: 20-year retrospective analysis. J Toxicol Clin Toxicol. 2002;40(6):715-757. [CrossRef] [PubMed]
 
Ganzert M, Felgenhauer N, Schuster T, Eyer F, Gourdin C, Zilker T. Amatoxin poisoning—comparison of silibinin with a combination of silibinin and penicillin [in German]. Dtsch Med Wochenschr. 2008;133(44):2261-2267. [CrossRef] [PubMed]
 
National Institutes of Health Clinical Center. Intravenous milk thistle (silibinin-legalon) for hepatic failure induced by amatoxin/amanita mushroom poisoning. NCT00915681. ClinicalTrials.gov. Bethesda, MD: National Institutes of Health; 2009. http://clinicaltrials.gov/ct2/show/NCT00915681. Updated September 15, 2014.
 
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