What Medications Can Cause Malignant Hyperthermia?
Volatile Inhalation Anesthetics
This is the most common group of medications that gives rise to malignant hyperthermia (MH). Volatile inhalation medications include:
Halothane: Malignant hyperthermia is triggered faster with halothane compared to the other volatile inhalation medications. Median is 20 minutes and it can range between 5 to 45 minutes.
Isoflurane: The median time malignant hyperthermia was triggered was 30 minutes and it can range from 5 to 210 minutes. So, after halothane isoflurane is the medication that has a less median time to trigger malignant hyperthermia.
Sevoflurane: The median time malignant hyperthermia was triggered was 60 minutes and it can range from 10 to 210 minutes.
Enflurane: The median time malignant hyperthermia was triggered was 55 minutes and it can range from 20 to 480 minutes.
Methoxyflurane: Studies have shown methoxyflurane also triggers malignant hyperthermia
Desflurane: Studies have shown desflurane medication also triggers malignant hyperthermia
From the above information you see that isoflurane, enflurane and sevoflurane medications have a delayed anesthesia trigger of malignant hyperthermia compared to halothane. But do keep in mind any of these drugs can trigger malignant hyperthermia very quickly within minutes after induction of anesthesia.
Ether And Ether Derivatives: It is a flammable and explosive agent and needs special precautions when it is used as an anesthetic agent therefore, not commonly used now.
An article published in British Journal of Anesthesia shows in UK; in the past 40 year’s halothane triggered malignant hyperthermia in most cases, but with serious hepatotoxicity it causes, it is not commonly used in UK now. Isoflurane and sevoflurane were the common volatile anesthetic medications used over the past 3 years; therefore many cases of reported malignant hyperthermia are triggered by these two agents. The study also suggests that malignant hyperthermia trigger by drugs can be dose dependent, but the minimum dose that can trigger malignant hyperthermia in each medication is unknown.
Succinylcholine medication is depolarizing muscle relaxant that is given intravenously. This is used with general anesthesia as an adjunct to help tracheal intubation and to relax the muscles during surgery. One study has shown that when a potent volatile anesthetic agent is combined with succinylcholine the serum creatinine kinase (it’s a product released from damaged skeletal muscles) levels were six to ten times higher than when only an anesthetic agent is the trigger of malignant hyperthermia. Another showed when halothane and succinylcholine combination enhanced the malignant hyperthermia trigger. Some studies show that succinylcholine medication alone also trigger malignant hyperthermia and some shows succinylcholine alone does not trigger malignant hyperthermia. Therefore, the matter remains controversial but most believed that inhalation anesthetic agent and succinylcholine together can rapidly trigger malignant hyperthermia. So, the combination should be always avoided.
Some studies say the combination of anticholinergic medications with volatile inhalation anesthetic medications cause malignant hyperthermia. The matter remains controversial.
Drugs That Are Safe To Use In Malignant Hyperthermia
- All local anesthetics
- Inhaled non-volatile general anesthetics – nitrous oxide
- Non-depolarizing muscle relaxants
- Barbiturates / Intravenous Anesthetics
Volatile inhalation anesthetic medications such as halothane, isoflurane, sevoflurane, enflurane, methoxyflurane, desflurane, and ether triggers malignant hyperthermia. Out of this halothane trigger malignant hyperthermia quickly compared to the other anesthetic agents (median 20 minutes). But malignant hyperthermia can be triggered within minutes to few hours after the induction of inhalation general anesthesia with these agents. Succinylcholine also trigger malignant hyperthermia when combined with volatile inhalation anesthetic medications, the development of malignant hyperthermia is enhanced with the combination. Although this matter remains controversial some studies also show that anticholinergic drugs when combined with volatile inhalation anesthetic drugs trigger malignant hyperthermia.
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