The Canadian Journal of Hospital Pharmacy (CJHP) / Le Journal canadien de la pharmacie hospitalière (JCPH)

King, Garry

A Tribute

Authors, Various

Correction to Rappaport article in February issue

Meritorious Service Award Recipient

CSHP's New Address and Telephone Number

Brownlee, Thomas

Olson, Colleen

Deschamps, Michelle

English

Identifying Drug Interactions between Enzalutamide and Complementary Alternative Medications in a Patient with Metastatic Prostate Cancer: A Case Report

Bond (Pro), Christine M

Barry (Con), Arden R

Do the Benefits of Electronic Cigarettes Outweigh the Risks?

Dubé, Pierre-André

CJHP – Vol. 71, No. 1 – January–February 2018 JCPH – Vol. 71, no 1 – janvier–février 201848
RESEARCH LETTER
Path to the Canadian Antidote Registry
Antidotes play an essential role in the treatment of many 
poisonings and must be readily available for timely administration.
Although there is expert consensus concerning guidelines on stock-
ing of antidotes  (e.g., Dart and others1), studies have consistently
shown insufficient inventory of antidotes in Canadian emergency
care hospitals.2-5This letter describes some of the initiatives that have
emerged across Canada to ensure adequate stocking of antidotes,
which have ultimately led to development of the Canadian Antidote
Registry.
For many decades, the British Columbia Drug and Poison
Information Centre (DPIC) operated a clinical antidote program
for digoxin immune Fab (starting in 1986) and fomepizole 
(starting in 2002).6,7 Upon consultation, the DPIC would provide
free antidote replacement to the treating hospital. This approach
ensured that patients received the antidotes after consultation with
a toxicology expert, which minimized costs and allowed DPIC to
collect province-wide usage data. The program was discontinued
in April 2017. Now, BC hospitals must purchase their own stock
of antidotes, which makes it easier for each hospital to control its
inventory.
Between 2002 and 2004, the West Parry Sound Health 
Centre began to operate the Massasauga Rattlesnake Antivenom
Depot (https://www.wpshc.com/index.php/ontario-antivenom-
depot-117), which now manages antivenom supplies for depot
sites across Ontario (about 150–200 vials total). An advisory
group meets twice a year, and protocols are reviewed by the depot’s
medical director. The antivenom depot rotates stock across
provincial depot sites to avoid expiration of unused vials and to
reimburse hospitals that ask for clinical consultations. In the
Toronto region, hospital pharmacy directors have, since 2004,
signed an annual agreement for the Toronto and Area Hospital
Pharmacy Departments Antidote Sharing Strategy. This strategy
includes procedures and policies for sharing and borrowing 
antidotes. Following the death by poisoning of a 25-year-old
man,8 the Patient Safety Review Committee of the Office of the
Chief Coroner recommended in 2013 that “[h]ospitals should 
review the antidotes they stock on a regular basis, and at least 
annually. If a given antidote is not stocked by a hospital, a plan
should be in place and readily available to staff in order to ensure
that this antidote can be obtained rapidly from another institution
or source, on a 24/7 basis.”9
In May 2005, the IWK Regional Poison Centre introduced
the Nova Scotia Provincial Antidote Kit Program, through which
hospital administrators manage antidote purchases. All tertiary
care centres and regional hospital emergency departments stock
full kits, whereas community hospitals may stock full or modified
kits. Because the province has a small number of hospitals 
(n = 37), this initiative appears to be viable and provides usage
data. In 2016, overall hospital compliance was 89%.10
In 2012, the Institut national de santé publique du Québec
(the Quebec National Institute of Public Health) created the 
Quebec Antidote Registry to assist health care professionals.5This
registry is now hosted by the Portail Toxicologie Clinique (Clinical
Toxicology Portal; https://www.inspq.qc.ca/toxicologie-clinique/
registre-provincial-des-antidotes). It includes all available formu-
lations of antidotes, as selected by a group of experts, and hospital
participation is voluntary. An analysis of data from this registry
was undertaken recently as part of the background to the 
Canadian Antidote Registry. The analysis showed that from 2012
to 2016, an average of 85% (93/109) of hospitals providing 
emergency care services in the province participated in the registry.
Over the same period, for many antidotes the percentage of 
hospitals stocking the first dose or the minimum recommended
amount increased (Table 1), although a few antidotes remain 
unavailable. This small study is the first to report a substantial 
increase in hospitals’ adherence to the recommendations of the
Centre antipoison du Québec (Quebec Poison Centre) for 
antidote stockpiling in the province. 
In March 2012, the New Brunswick Drugs and Therapeutics
Committee adopted its Antidote Policy.11 All 19 NB hospitals
with an emergency department must stock and maintain a quota
of antidotes, with 8 of these hospitals being defined as depot sites.
The provincial Antidote Committee reviews the antidote list and
associated drug monographs every 12–18 months.
In 2014, Alberta Health Services Pharmacy Services developed
the Alberta Antidote Stocking Recommendations, which are 
reviewed every 1–2 years. Unlike typical poison centre recom-
mendations, these have been approved by the Provincial Drugs
and Therapeutics Committee, which makes them mandatory for
all hospitals in the province. However, no data are available on
hospitals’ compliance with the recommendations.
According to the successful model already in place in 
Quebec, a preliminary version of the Canadian Antidote Registry
was developed, following recommendations made by the experts
49CJHP – Vol. 71, No. 1 – January–February 2018 JCPH – Vol. 71, no 1 – janvier–février 2018
involved in the programs and initiatives described above. The 
application will be hosted on the Canadian Network for Public
Health Intelligence platform (https://www.cnphi-rcrsp.ca/cnphi/
index.jsp) and will include a Web-based formulary to more 
effectively collect the data. Eventually, hospitals will be asked to
report their inventories of antidotes to the national registry, at least
twice a year and following any changes in their quotas. In the
coming months, one Provincial Antidote Registry (PAR) 
Coordinator will be appointed by each province or territory. Also,
within each jurisdiction, a Local Antidote Registry (LAR) 
Coordinator will be appointed for each hospital or health 
establishment that stocks antidotes. The experts working on the
national registry have agreed that all PAR and LAR Coordinators
should be hospital pharmacists. 
A pilot project will be conducted by March 31, 2018, in 
selected hospitals. Depending on the adjustments that need to be
carried out, the Canadian Antidote Registry should be operational
by fall 2018. Meanwhile, the “Canadian Antidote Guide in Acute
Care Toxicology” should be available online and on mobile apps
by summer 2018. This guide will complement the registry and
will help health care professionals in managing proper antidote
administration to their patients. It can be concluded that the 
expertise of hospital pharmacists will be required in the coming
months and years to improve the quality of care provided to 
patients who experience poisoning. 
References
1. Dart RC, Goldfrank LR, Erstad BL, Huang DT, Todd KH, Weitz J, et al.
Expert consensus guidelines for stocking of antidotes in hospitals that provide
emergency care. Ann Emerg Med. 2017. Available from: http://dx.doi.org/
10.1016/j.annemergmed.2017.05.021 [Epub ahead of print].
2. Bailey B, Bussières JF. Antidote availability in Quebec hospital pharmacies:
impact of N-acetylcysteine and naloxone consumption. Can J Clin Pharmacol.
2000;7(4):198-204.
3. Wiens MO, Zed PJ, Lepik KJ, Abu-Laban RB, Brubacher JR, Gorman SK,
et al. Adequacy of antidote stocking in British Columbia hospitals: the 2005
Antidote Stocking Study. CJEM. 2006;8(6):409-16.
4. Gorman SK, Zed PJ, Purssell RA, Brubacher J, Willis GA. Antidote stocking
in British Columbia hospitals. CJEM. 2003;5(1):12-7.
5. Dubé PA, Lord MC, Bussières JF, Courteau M. Conformité des établisse-
ments de santé du Québec aux recommandations de stockage des antidotes. 
Pharmactuel. 2013;46(3):221-7. Article in French, with English abstract.
6. Gair R, Kent DA, Purssell R, Copland M. Chronic digoxin toxicity in elderly
British Columbians. BC Med J. 2011;53(9):490-1.
7. Gair R. Antidote program in British Columbia [letter]. Am J Health Syst
Pharm. 2012;69(13):1108.
8. File no. 2012-7219 (PSRC-201 3-01) [case report of Patient Safety Review
Committee]. Toronto (ON): Office of the Chief Coroner for Ontario, Pa-
tient Safety Review Committee; 2013 [cited 2018 Jan 16]. Available from:
http://www.justiceforjosh.com/patientsafetya.PDF
9. Patient Safety Review Committee 2013-2014 annual report. Toronto (ON):
Office of the Chief Coroner Province of Ontario; 2015 Nov [cited 2016 Oct
12]. Available from: https://www.oha.com/Documents/2013-14%20PSRC
%20Annual%20Report%20-%20English.pdf
10. Murphy NG, Bona DR, Hurley TA. A system-wide solution to antidote
stocking in emergency departments: the Nova Scotia antidote program.
CJEM. 2017. doi: 10.1017/cem.2017.400. [Epub ahead of print].
11. Provincial Drugs and Therapeutics Committee. Antidotes policy. New
Brunswick Regional Health Authorities; 2015 Jun.
Pierre-André Dubé, MSc 
Chair, Steering Committee of the Canadian Antidote Registry
Pharmacist–Toxicologist, Institut national de santé publique du Québec
Québec, Quebec
e-mail: pierre-andre.dube@inspq.qc.ca
Competing interests: None declared.
Funding: The Canadian Antidote Registry has received financial, 
technical, and professional support from the Government of Canada,
through Defence Research and Development Canada, the Public Health
Agency of Canada, and Health Canada. The Government of Canada was
not involved in the design and conduct of this report; the collection, 
management, or interpretation of any data; or the preparation, review,
or approval of the manuscript.
Table 1. Stocking of Minimum Recommended Amount of First Dose of Selected Antidotes 
by Quebec Hospitals Providing Emergency Services (2016 versus 2012)
Antidote                                            No. (%) of Hospitals Stocking                 No. (%) of Hospitals Stocking
                                                     Minimum Recommended Amount*                            a First Dose
                                                         2012              2016          Increase†          2012              2016          Increase†
                                                       (n = 78)        (n = 100)                               (n = 78)        (n = 100)
Fomepizole                                      23 (29)          58 (58)              +29             30 (38)           92 (92)             +54
Digoxin immune Fab                        29 (37)           62 (62)              +25             67 (86)           93 (93)               +7
Hydroxocobalamin                           25 (32)           60 (60)              +28             54 (69)           89 (89)             +20
Pralidoxime                                      19 (24)           42 (42)              +18             44 (56)           69 (69)             +13
Pyridoxine                                        24 (31)           58 (58)              +27             68 (87)           91 (91)               +4
Black widow antivenom                    0   (0)             0   (0)               NA               0   (0)             0   (0)              NA
Rattlesnake antivenom                      0   (0)             0   (0)               NA               0   (0)             0   (0)              NA
Prussian blue                                      0   (0)             0   (0)               NA               0   (0)             0   (0)              NA
NA = not applicable.
*Amount necessary to treat a 70 kg patient for 24 h.
†Increases are presented in percentage points (obtained by subtraction).


Path to the Canadian Antidote Registry

of Hospital Pharmacy, The Canadian Journal

CJHP – Vol. 71, No. 1 – January–February 2018 JCPH – Vol. 71, no 1 – janvier–février 201852
Tribute to the Reviewers of the 
Canadian Journal of Hospital Pharmacy
The Canadian Society of Hospital Pharmacy and the Canadian Journal of Hospital Pharmacy Editorial Board
would like to thank the following people for serving as peer reviewers for the CJHP in 2017. Their assistance
has helped us to maintain the high quality of articles published in the Journal.
Hani Abdelaziz
Margaret L Ackman
Teri Adamo
Ahmed Aljedai
Loyd Allen
Alison Alleyne
Enas Almanasreh
Wasem Alsabbagh
Zubin Austin
Arden R Barry
Bill Bartle
Marisa Battistella
Pierrick Bedouch
Emily Black
Anne Marie Bombassaro
Susan Bowles
Cynthia Brocklebank
Paula Brown
Shawn Bugden
Tammy J Bungard
Lisa D Burry
Roxane Carr
Stephen Carter
Betty Chaar
Doret Cheng
Judy Cheng
Kseniya Chernushkin
Cassyano Correr
Sue Corrigan
Dennis Cote
Celia L Culley
Claude Dagenais
Dawn Dalen
Bruce Dalton
Jane Day
Carlo De Angelis
Norman Dewhurst
Artemis Diamantouros
Carolyn Dittmar
George Dranitsaris
Linda Dresser
Andrea Edginton
David Edwards
Mary H H Ensom
Ema Ferreira
Marcus Ferrone
Patrick Fitch
Jean-Marc Forest
Marie-Andrée Fournier
Marjorie Friesen
Giselle Gallego
Rochelle M Gellatly
Daljit Ghag
Alfred Gin
Sean K Gorman
Margaret Gray
Julie Greenall
Henry Halapy
Ayesha Hassan
Michelle Hinch
Christine A Hughes
Marianne F Ivey
Lawrence Jackson
Ceridwen Jones
Tannis Jurgens
Zahra Kanji
Natalie Kennie-Kaulbach
Heather Kertland
Juno Kim
Angus Kinkade
Mark G Klang
Sandra Knowles
Debbie Kwan
Jaclyn M LeBlanc
Derek Lee
Tiffany Lee
Michael Legal
Elizabeth Leung
Sharon Leung
Stephanie Lovering
Vincent H Mabasa
Louise Mallet
Dan Martinusen
Sarah C Masson
Patrícia C Mastroianni
Karen McDermaid
Mark McIntyre
Mits Miyata
Janice Munroe
Tania Mysak
Jeff Nagge
David W Newton
Yee Ching Ng
Cesilia Nishi
Tejal Patel
Jon Penm
Marc M Perreault
Jerrold L Perrott
Linda Poloway
Colette Raymond
Deana Sabuda
Gregory Sacha
Cheryl A Sadowski
Teresa Salgado
Carl Schneider
Winnie Seto
Jacky T Siu
Sarah N Stabler
Paulina Stehlik
Maxime Thibault
Daniel Thirion
Dorothy Tscheng
Régis Vaillancourt
Philippe D Vincent
Sandra A Walker
Scott E Walker
Mary Wang
David R Williamson
Eric C Wong
William Wong
Rachel Worthington
Sharon Yamashita
Maria Zhang
The continuing support that these peer reviewers demonstrate for our publication is greatly appreciated, 
and we thank them for their time and effort on behalf of the CJHP.
If you are interested in becoming a reviewer for the CJHP, please register online at http://cjhp.msubmit.net.
We would also like to thank Scot Simpson (2006–2017) and Lalitha Raman-Wilms (2006–2017) 
for their important contributions to the CJHP during their terms as Associate Editors.


Tribute to the Reviewers of the Canadian Journal of Hospital Pharmacy

Walker, Scott

Oui, vous lisez bien le Journal canadien de la pharmacie hospitalière

Leslie, Bill

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