What supportive treatments and antidotes are recommended for severe ivermectin poisoning?

1. Clinical context and why the absence of a consensual antidote matters

Ivermectin toxicity typically produces gastrointestinal symptoms at lower overdoses and central‑nervous‑system depression, ataxia, visual disturbance, and in severe cases coma or death at high doses or with veterinary formulations — exposures that increased during COVID‑19 misinformation campaigns — so immediate, pragmatic supportive strategies rather than a single “antidote” drive clinical care ^{[1] [6] [7]}. Multiple poison‑control and toxicology sources explicitly state there is no specific antidotal therapy for ivermectin overdose and emphasize that most patients recover with supportive care ^{[1] [2] [8]}.

2. First‑line actions: decontamination and early toxin removal

In cases of recent large oral ingestion, gastrointestinal decontamination with activated charcoal is commonly recommended when the patient is alert and within an appropriate time window; repeated doses may be considered because ivermectin undergoes enterohepatic circulation ^{[1] [4]}. Older toxicology summaries also describe emesis induction (historically with syrup of ipecac) in significant ingestions as part of initial measures, although modern practice favors charcoal and expert poison‑control consultation ^[2].

3. Supportive critical‑care measures that save lives

Supportive care focuses on airway protection, hemodynamic monitoring and support, seizure management, temperature control, and treating secondary complications such as aspiration or skin reactions; case reports describe intensive monitoring of vital signs and neurologic status over days with favorable outcomes ^{[9] [2] [6]}. Symptomatic treatments recommended include analgesics and antihistamines for adverse effects, and standard critical‑care interventions when respiratory depression, hypotension, or reduced consciousness occur ^{[2] [1]}.

4. Seizures and neurotoxicity: pharmacologic choices and caveats

When seizures or significant CNS depression occur, clinicians use standard anticonvulsant and supportive protocols but must weigh drug interactions: some agents that reverse GABAergic effects have been studied experimentally ^[5]. Animal research tested antigabaergic convulsants (picrotoxin, PTZ, beta‑CCM) in chickens with mixed or limited benefit and no clear human translation; benzodiazepines and other routine anticonvulsants may be used for seizure control despite theoretical interactions ^{[5] [10]}.

5. Experimental and case‑report antidotes: lipid emulsion, flumazenil, hemoperfusion — limited evidence only

Intravenous lipid emulsion therapy has been reported in veterinary cases and small human case reports as a rescue measure for lipophilic drug toxidromes, including isolated ivermectin cases, but the evidence base is sparse and mainly anecdotal ^[4]. Flumazenil shortened recovery time in some animal studies and has been proposed in experimental work, but it is not an established antidote for ivermectin in humans and carries risks if benzodiazepine dependence is present ^[3]. Hemoperfusion or extracorporeal elimination appears to have limited utility for ivermectin because of its pharmacokinetics and has not been proven effective ^[11].

6. Practical takeaways and system‑level steps

All suspected overdoses should prompt immediate contact with poison control and consideration for hospital monitoring because many reported severe cases — especially those involving veterinary products or very high doses — required hospitalization and supportive care ^{[6] [7]}. Public‑health messaging and clinician guidance consistently emphasize that prevention (avoiding inappropriate use of veterinary formulations, adhering to approved dosing) and rapid supportive management are the practical cornerstones, given the lack of a validated antidote ^{[7] [1] [8]}.