›Propofol infusion if intubated
›1–4 mg/kg/hour; titrate to seizure suppression on EEG monitoring
›Avoid phenytoin — ineffective for toxin-induced seizures
›QTc prolongation management
›Discontinue all QTc-prolonging co-medications
›Avoid methadone, haloperidol, certain antibiotics
›Magnesium sulfate for QTc > 500 ms or torsades risk
›2 g IV over 10–15 minutes
›Repeat if torsades develops
›If torsades de pointes develops
›Overdrive pacing or isoproterenol to increase heart rate
›Cardiology consultation
›Hypertension and tachycardia management
›Benzodiazepines first-line for sympathomimetic-pattern hypertension
›Lorazepam 1–2 mg IV titrated
›Avoid beta-blockers alone (unopposed alpha)
›IV fluids for tachycardia from dehydration
›Normal saline 1–2 L over 1–2 hours initially
Serotonin syndrome management
›Serotonin syndrome treatment
›Cyproheptadine: serotonin antagonist for mild-moderate cases
›12 mg oral/NG loading dose, then 2 mg every 2 hours
›Maximum 32 mg/day
›Benzodiazepines for agitation and muscle rigidity
›Lorazepam 1–2 mg IV; titrate to effect
›Hyperthermia management if temperature > 41 C
›Active cooling measures
›Paralysis and intubation for refractory hyperthermia
Hepatotoxicity management
›Kratom-induced liver injury treatment
›Cessation of kratom — cornerstone of management
›Most cases resolve spontaneously after cessation
›Median time to recovery: weeks to months
›N-acetylcysteine (NAC)
›Consider empirically if acetaminophen co-ingestion cannot be excluded
›150 mg/kg IV over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours
›Supportive care
›Hydration, electrolyte management
›Avoid hepatotoxic medications and alcohol
›Hepatology consultation for acute liver failure
›Liver transplant evaluation if INR rising despite cessation
Withdrawal and dependence management
›Kratom withdrawal management
›Buprenorphine-naloxone (Suboxone) — first-line for kratom use disorder
›Home induction successfully reported via telehealth
›Initiate when COWS score >= 8–12
›Start 2–4 mg sublingual; titrate to 8–24 mg/day
›Evidence level: multiple case series and observational studies
›Clonidine — alternative for inpatient detoxification
›0.1 mg orally every 6–8 hours; titrate to autonomic symptoms
›Maximum 0.3 mg per dose; monitor for hypotension
›Supportive pharmacotherapy for withdrawal symptoms
›NSAIDs or acetaminophen (caution with liver injury) for myalgia
›Antiemetics for nausea and vomiting
›Loperamide for diarrhea
Drug interaction precautions
›CYP450 interaction management
›Kratom inhibits CYP3A4 (time-dependent) and CYP2D6
›Midazolam AUC increased ~1.4-fold even at 2 g kratom dose
›Methadone, certain antidepressants, antipsychotics at increased levels
›Avoid additional opioids, sedatives in acute setting
›Synergistic CNS and respiratory depression
›Avoid QTc-prolonging agents
›Haloperidol, certain antipsychotics, fluoroquinolones
›Naloxone prescription
›Provide to all patients continuing kratom use
›APA 2024 harm reduction guidelines
›Especially those co-using CNS depressants
›Nasal naloxone 4 mg/0.1 mL: educate patient and household contacts
›Addiction medicine referral
›All patients with identified kratom use disorder
›Buprenorphine-naloxone treatment program
›Co-occurring substance use disorder management