Amitriptyline toxicity death brings $1 million settlement

2008 Trial Lawyers Report

Medical malpractice settlement: Failure to check blood levels for amitriptyline toxicity results in 64 year old woman’s death

The plaintiff’s decedent was a 64 year-old woman who died on 6/12/04 from respiratory issues which the plaintiff claimed occurred as the result of a build up of Amitriptyline in the decedent’s body. The defendant conceded that the Amitriptyline level was elevated but argued that the Amitriptyline levels were not in a lethal range. The defendant further argued the elevated level was reversed three weeks prior to death suggesting the Amitriptyline was not the cause of death.

The plaintiff’s decedent had a past medical history significant for hypertension and depression. As of 9/24/01, she was taking medication to treat her high blood pressure, and 150 mg of Amitriptyline daily for her depression. At that time, she weighed 112.5 pounds.

In September 2001, following a gastrointestinal illness, she began experiencing intermittent episodes of lightheadedness and dizziness when she got up too fast. She continued to complain of these symptoms on several occasions between September 2001 and April 2002. She reported that she had these episodes for many years, approximately 3 times a year, and never had been given a diagnosis. Her PCP attributed symptoms to a variety of possible etiologies including an ear infection with labrynthitis, blood pressure medication changes, and metabolic abnormalities. By May 2002, after some blood pressure medication adjustments and a negative ENT evaluation, she was feeling well with no further episodes of dizziness.

Between May 2002 and June 2003, she had several visits to her PCP’s office with repeated complaints of anorexia and weight loss. There were no further documented episodes of dizziness. She underwent an extensive gastrointestinal work up and was diagnosed with Barrett’s esophagitis.

In June 2003, she again began to complain of dizziness, associated with taking her blood pressure medication. Her PCP changed her blood pressure medication, but her symptoms persisted. In July 2003, her PCP noted that she continued to have intermittent dizziness and anorexia. Her anorexia work up was negative, and she denied feeling depressed. Her PCP ordered a Holter monitor to rule out a cardiac etiology for her dizziness. The Holter monitor was negative.

On 12/10/03, she again complained of episodes of lightheadedness. At this visit, her blood pressure was 164/84 lying, 146/80 sitting, and 90/50 standing. The PCP noted that she had significant orthostasis and autonomic dysfunction. The PCP prescribed medication, Florinef, to treat her orthostasis as well as thigh high compression stockings, and noted that he would need to balance controlling her hypertension with her orthostasis issues. The PCP also obtained blood work but did not include an Amitriptyline level as part of his work up. The blood work was essentially normal.

On 4/9/04, she presented to her PCP with nausea and vomiting. She had significant orthostasis with blood pressure as low as 72/50, and was too weak to ambulate. The PCP admitted her to Baystate Medical Center. The admission orders indicate that she was still taking Amitriptyline at bedtime.

During her hospitalization from 4/9/04 to 4/16/04, she continued to have significant orthostasis with complaints of dizziness when standing. She was seen by a neurologist who ordered blood work, but did not include an Amitriptyline level. She was discharged from the hospital on 4/16/04 reportedly feeling better and able to ambulate with no dizziness.

After discharge from the hospital, she continued to see her PCP. At each visit, she continued to have significant orthostasis and dizziness. On 5/11/04, she presented to her PCP with complaints of increased anorexia, nausea, vomiting, and watery diarrhea and syncopal episodes. She had fallen several times and had bruises all over her body. She was again admitted to Baystate Medical Center.

On admission to the hospital, she was pale and cachectic, and her blood pressure dropped to 60/40 when standing upright. She was also noted to have tremors. She was diagnosed with profound orthostasis with syncope/autonomic dysfunction with a question of Shy-Drager Syndrome, a progressive central nervous system disorder which causes orthostatic hypotension. On 5/13/04 another neurologist examined her and his impression was that she had Multiple Systems Atrophy (MSA) with autonomic dysfunction (Shy-Drager), Parkinson’s, and dementia as well as spells suggestive of seizures. The neurologist did not obtain an Amitriptyline level.

Finally, a covering doctor thought to order blood work to check the Amitriptyline levels and they were found to be abnormally elevated. The Amitriptyline was discontinued, and the levels dropped back to the normal therapeutic range and then to zero. Nonetheless, she developed severe respiratory compromise with probable ARDS (adult respiratory distress syndrome and was transferred to intensive care. She died three weeks later from respiratory failure.

The defendant PCP contended that Amitriptyline toxicity is extraordinarily rare and is almost always associated with intentional overdoses, and thus the standard of care did not require the defendant to consider this as a potential cause of the decedent’s symptoms, especially given other readily explainable and logical diagnoses. As evidence, the defendant noted that other doctors including two neurologists had failed to consider the Amitriptyline as the cause.

The defendant also contended that there was evidence the decedent had not been taking her Amitriptyline as recommended, and had been taking too many pills at a time without telling her doctor.

The case settled prior to trial for $1,000,000.

Lubin & Meyer attorneys represented the plaintiff in this amitriptyline toxicity lawsuit.

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