What are the recommended emergency treatments and antidote trials for severe ivermectin poisoning?

1. Clinical presentation and pathophysiologic priorities: what emergency teams must expect

Ivermectin toxicity at high doses typically produces an early gastrointestinal syndrome (nausea, vomiting, diarrhea) followed by central nervous system depression—drowsiness, ataxia, visual changes—and, in severe overdoses, profound CNS depression with respiratory failure or coma, so initial priorities are airway, breathing and circulation and neurologic monitoring ^{[1] [6] [7]}. Case reports demonstrate progression to cerebral edema and intracranial hypertension in fatal transdermal overdoses despite active measures, underscoring that rapid deterioration can occur and that supportive critical care resources are essential ^[5].

2. Immediate emergency treatments supported by poison-control practice

For acute oral overdoses, standard toxicologic practice includes early gastrointestinal decontamination when the patient presents within a window where benefit is plausible—activated charcoal to bind unabsorbed drug and consider gastric lavage in selected massive ingestions—while recognizing decisions must be individualized to airway status and timing ^{[1] [8]}. Because severe CNS depression and respiratory failure are the dominant life‑threatening manifestations, endotracheal intubation and mechanical ventilation, hemodynamic support with IV fluids and vasopressors as needed, continuous cardiac and neurologic monitoring, and critical-care level supportive measures are the mainstays of treatment ^{[1] [6]}.

3. Reported adjunctive and experimental antidote strategies—evidence and limits

There is no established, FDA‑approved antidote for ivermectin; interventions reported in the literature are anecdotal, experimental, or animal-based. Intravenous lipid emulsion has been used in veterinary cases (a cat) and is sometimes considered for highly lipophilic drug overdoses, but human evidence for ivermectin is lacking and the technique remains investigational in this setting ^[1]. Hemoperfusion and extracorporeal support were attempted in at least one fatal human transdermal‑overdose report without preventing death, indicating limited or unproven benefit in severe cases ^[5]. Preclinical studies have evaluated anti‑GABAergic convulsants (picrotoxin, pentylenetetrazol) in chickens with some mitigation of sedation and mydriasis, suggesting a mechanistic target via GABAergic pathways but with no direct human translation ^[3]. A recent animal paper explored flumazenil and vitamin C in rats as potential modulators of ivermectin effects, but authors emphasize the absence of established human standards and the need for further research ^[4]. In sum, candidate antidotes exist in the experimental literature, but none are proven or widely recommended for routine human use ^{[4] [3] [1]}.

4. Practical recommendations, reporting and research gaps

Clinicians should treat suspected severe ivermectin poisoning as a toxicologic emergency: stabilize airway/respiration, consider charcoal if within an appropriate window and airway protected, provide ICU-level support for neurologic and respiratory failure, and consult regional poison control and clinical toxicologists for case-specific guidance ^{[1] [2] [9]}. Public‑health reporting and poison‑center notification are important—CDC and state health departments documented large increases in exposures during the COVID‑19 era and advise against ivermectin for COVID‑19 outside trials, partly to reduce harm from misuse ^{[2] [10] [9]}. Research priorities are clear in the literature: randomized or systematic clinical evaluations of potential antidotes do not exist, and animal or small-case exploratory treatments (flumazenil, anti‑GABA agents, IV lipid emulsion, hemoperfusion, antioxidants) require rigorous human study before adoption ^{[4] [3] [5]}.