Emerging treatments
Magnesium sulfate
Inhibits acetylcholine release and acts as an anticonvulsant. Small, poor-quality trials have reported mixed results; however, larger studies are under way.[35][36][37][38]
Sodium bicarbonate
Unknown mechanism of action; however, small poor-quality trials have reported lower mortality.[39] Better evidence is required before this treatment is recommended.[37]
Penehyclidine
An anticholinergic drug with both antimuscarinic and antinicotinic effects that was recently developed and is only currently available in China. One meta-analysis of non-randomised studies in China suggests it is used widely there and may have considerable benefit over atropine.[40] However, randomised controlled trial evidence is likely to be required before wider licensing and use will be possible.
Lipid emulsions
One meta-analysis of Chinese language randomised controlled trials reported benefit with lipid emulsion therapy.[41] Most of the included trials were small, and quality was difficult to evaluate. One further small trial reported no reduction in atropine requirement.[42] There are several theoretical concerns with recommending this treatment. The mechanism is unclear, and it may also interfere with other treatments.[37]
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