Acute Carbamazepine Poisoning: A Comprehensive Review of Clinical Manifestations, Toxicokinetics, Diagnosis, and Management (2020–2025)

Abstract

Background: Acute carbamazepine poisoning is among the most common anticonvulsant overdoses seen in emergency and toxicology settings, arising mainly from deliberate self-poisoning but also accidental paediatric ingestion, dosing errors, and drug–drug interactions. It produces a distinctive toxidrome of central nervous system depression, cerebellar/vestibular dysfunction, anticholinergic features, and cardiac conduction disturbance, reflecting use-dependent blockade of voltage-gated sodium channels compounded by its active epoxide metabolite. Toxicokinetics are complicated by high protein binding, erratic/delayed absorption from concretions or sustained-release formulations, hepatic autoinduction, and enterohepatic recirculation, producing a fluctuating, relapsing clinical course. Objective: To synthesize evidence from 2020–2025, alongside key earlier landmark studies, on the epidemiology, toxicokinetics/toxicodynamics, mechanisms, risk factors, clinical manifestations, diagnosis, concentration–severity relationship, and management of acute carbamazepine poisoning. Methods: This narrative (non-systematic) review searched terms including carbamazepine, poisoning, overdose, toxicokinetics, and extracorporeal treatment, focusing on 2020–2025 publications supplemented by hand-searched reference lists and landmark earlier studies. No systematic search protocol, study-selection flow diagram, or quality appraisal was applied, consistent with the narrative format. Content: Management is discussed systematically, covering airway/seizure management, single- and multiple-dose activated charcoal decontamination, supportive and cardiovascular care, extracorporeal treatments (haemodialysis, haemoperfusion, continuous renal replacement therapy), and the investigational role of intravenous lipid emulsion. Pediatric poisoning, pregnancy, prognosis, and persisting controversies — including the lack of a validated toxicity threshold, inconsistent decontamination practice, and low-quality extracorporeal treatment evidence — are addressed. Conclusion: Despite growing case-level evidence, high-quality comparative and prospective studies remain scarce; management continues to rely on supportive care, risk stratification, and individualized clinical judgment. Research priorities and pragmatic clinical recommendations are identified for emergency medicine, clinical pharmacology, toxicology, and critical care.