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Journal of Toxicology
CLINICAL TOXICOLOGY
Vol. 41, No. 3, pp. 277–290, 2003

ANTIVENOMS

Snake Antivenoms
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David G. Lalloo* and R. David G. Theakston

Liverpool School of Tropical Medicine, Liverpool, UK

HISTORY a century ago. An animal, most commonly a horse, is

inoculated successively over several months with
The concept of antivenoms was first developed by increasing doses of a single venom to produce a
Henry Sewall in 1887 when he demonstrated that pigeons monospecific antivenom or a mixture of venoms to
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could be immunized against the effects of pygmy
rattlesnake venom by successive inoculations of
increasing doses of venom (1). In 1894, Phisalix and
Bertrand first used heat-treated venom for immunization,
and a year later Albert Calmette showed that serum from
inoculated rabbits could protect against the effects of
venom when infused into healthy rabbits before venom
challenge. In the same year, Calmette used serum from
an immunized horse to treat human envenomation
following a cobra bite (2), and this was followed by the
production of the first specific immune serum against
cobra venom by Fraser. The first commercial equine
antivenoms were produced by Calmette in 1898 for use
in Vietnam, and in 1911, Vital Brazil first carried out
large-scale antivenom production in Brazil. Antivenom
was subsequently produced in a number of different
countries including the United States, Australia, Brazil,
and Japan (3,4).
PRINCIPLES OF ANTIVENOM PRODUCTION
The vast majority of antivenoms are produced
according to the same principles used by Calmette over
produce a polyspecific antivenom. This produces a
progressive rise in neutralizing antibodies (IgG) in the
animal without ill effects (if done correctly at the right
dose). Venom was formerly made into toxoid
by complexing with an aldehyde to increase the
tolerability to the animal of the immunization process;
currently adjuvants are commonly used in the inoculation
mix to permit slow antigen release and decrease the risk
to the animal. Ultimately, the animal is bled and the
hyperimmune serum used as a source of antivenom.
The earliest antivenoms consisted of pure equine
serum. In the 1930s, Pope introduced the concept of
ammonium sulfate precipitation to precipitate the IgG
fraction from serum (5). Subsequent modifications
included cleavage of the IgG molecule with pepsin to
produce F(ab0 )2 antivenoms and more recently, with
papain to produce Fab fragments. Caprylic acid has been
used more recently to precipitate all non-IgG protein
from hyperimmune serum, and ion exchange or affinity
chromatography can also be used to further purify
antivenoms (6 – 8). Individual manufacturers use a
combination of these techniques, and there is little
standardization of the process between manufacturers,
with considerable variation in quality of the finished

*Correspondence: David G. Lalloo, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK; E-mail: dlalloo@
liverpool.ac.uk.

277

DOI: 10.1081/CLT-120021113 0731-3810 (Print); 1097-9875 (Online)

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278
product. In the past decade, there has been increasing
interest in the production of IgY antivenoms in hens and
clinical trials have occurred with such products, although
no commercial antivenom is currently produced by this
mechanism (9).
Factors Influencing Antivenom Production
Development of antivenom production techniques
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has undoubtedly been hindered by the relatively limited
commercial value of antivenom production. The need to
produce individual antivenoms for different species and
geographical areas means that there is very little profit in
antivenoms, and hence the involvement of major
pharmaceutical companies has been relatively limited.
In addition, with the exception of Australia, Europe, and
parts of the United States, envenomation is predomi-
nantly a problem of the rural tropics and particularly
affects the poor in those regions. Antivenom production
has therefore been driven predominantly by cost rather
For personal use only.
than quality and the lack of commercial value has led to
crisis in antivenom supply such as that which now exists
in sub-Saharan Africa, where a single manufacturer is
incapable of supplying the needs of the continent (10,11).
Source of Sera for Antivenoms
Horses have been traditionally used for the
manufacture of antivenom. They are docile, produce
large amounts of serum/plasma and can tolerate large
doses of venom to develop neutralizing antibodies,
although local tissue reactions may be problematic.
However, there are also disadvantages: some individuals
are sensitized to equine proteins, making antivenom
reactions more likely. In addition, horses require
considerable expertise to maintain and do not thrive in
tropical regions. This led to the use of sheep by one
manufacturer in the late 1980s/early 1990s. Ovine
antivenoms were found to be cheaper to produce, and
there was the added advantage that care of sheep (or
goats) would be far easier in most countries where
snakebite was endemic (12). However, increasing
concern about transmissible spongiform encephalopa-
thies may limit the future use of sheep as an animal in
which to raise antivenom. Donkeys, cattle, goats, rabbits,
and even llamas have also been used to produce
antivenom for clinical use although practical consider-
ations mean that there are no currently available snake
antivenoms raised in these animals (3).
Lalloo and Theakston
In the past decade, there has been increasing interest
in the production of IgY antivenoms. IgY can be purified
from the yolk of hens which have been immunized with
venom preparations (13,14). IgY has the advantage of not
fixing complement, therefore removing one potential
source of reactions, and induces high titres of
neutralizing antibody. Commercial production has
not yet occurred although these antivenoms have been
used in clinical trials in Vietnam. The comparative ease
with which hens can be cared for, particularly in resource
poor settings, may make this a useful alternative for the
preparation of standard antivenoms in the future.
Use of Different Antibody Fragments
Most current commercial antivenoms consist of
F(ab0 )2 portion of the IgG molecule. The use of different
portions of the immunoglobulin molecule has predomi-
nantly been driven by two considerations, differences in
the pharmacokinetics of whole IgG, F(ab0 )2 and Fab and
the theoretical belief that antivenom reaction rates may
differ between the different IgG fragments. In particular,
it was originally considered that the small size of Fab
fragments would lead to a considerable advantage in
distribution to the extravascular compartment and
penetration of tissue spaces (12,15).
Pharmacokinetics
There are a number of studies of the pharmaco-
kinetics of antivenoms in both animals and humans.
Clinical and laboratory experience clearly demonstrate a
difference between IgG, F(ab0 )2, and Fab fragment
antivenoms although the number of studies of anti-
venoms in humans is relatively limited. It is also clear
that the pharmacokinetics of antivenom are modified
considerably in the envenomation situation and that there
are difficulties associated with the extrapolation of
animal studies to the situation in humans (16). Most data
suggest a two-compartment model following IV
administration and in general, volumes of distribution,
tissue concentrations, and speed of distribution of F(ab0 )2
antivenoms are greater than those of whole
IgG antivenoms (17 –19). A study of three different
antivenoms in envenomed humans (two IgG, one F(ab0 )2)
suggested that the volume of distribution of the
antivenoms was two to three times larger than that of
the IgG antivenoms (20). Although the smaller Fab
molecules are generally widely distributed in the
extravascular compartment, some studies show that
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Snake Antivenoms
they do not necessarily reach higher concentrations in or
achieve more rapid distribution to deep or superficial
tissue compartments than F(ab0 )2 (19,21). A number of
studies of pharmacokinetics are summarized in two
reviews (22,23).
Elimination times are also related to molecular size:
IgG and F(ab0 )2 fragments are eliminated predominantly
by nonrenal mechanisms, whereas renal elimination is
important for Fab fragments. Elimination half-life in one
study varied between 45 and 96 hours for two IgG and
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one F(ab0 )2 antivenoms and was not related to the size of
the immunoglobulin fragment (20). The IgG antivenom
used until recently for crotalid envenomation in the
United States has been shown to have a plasma half-life
of 60– 190 hours (24,25). Tan estimated the half-life
of F(ab0 )2 Russell’s viper antivenom to be a mean of
36 hours (26). A clinical study comparing a Fab
antivenom with a standard F(ab0 )2 demonstrated an
elimination half time of approximately 4 hours for the
Fab antivenom compared with 18 hours for a F(ab0 )2
antivenom: Fab was cleared four to five times more
rapidly than F(ab0 )2 (27). Other studies have suggested
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elimination half times for Fab antivenoms of up to
28 hours (28).
Complexing of antivenom with venom components
may alter the pharmacokinetics of antivenom. Study of
this subject has been hampered by the problems
of detecting venom components and antivenom in
vitro. The use of ELISA for venom quantification gives
different results to radioactive labeling (29). Iodination
of low molecular weight proteins may alter their
pharmacokinetics, and not all venom proteins take up
iodination equally: ELISA methods may not detect low
molecular weight venom components (30,31). Anti-
venom complexes with venom proteins within the
circulation and it is likely that venom/antivenom
complexes are eliminated by phagocytosis (21).
The complexing of a small molecule such as Fab with
venom leads to a reduction in renal elimination. Fab
therefore may stay in the circulation for longer unless
dissociation occurs, whereas the terminal plasma half-
life of F(ab0 )2/venom complexes may be shorter than the
Ig fragment alone due to rapid phagocytosis (29).
Fab/venom complexes have been detected in the plasma
for up to nine days after administration (32). Experi-
mentally, antivenom reduces free venom levels in
the central compartment by binding to venom within
the circulation and causes a redistribution of venom
antigens from the extravascular space into the central
compartment, with an increase in plasma total venom
concentrations (21,33,34).
279
ANTIVENOM REACTIONS
Mechanisms
Two main categories of adverse reaction can be
identified, early and late reactions. Early reactions range
from simple febrile reactions at the time of adminis-
tration of antivenom, often due to pyrogens in poorly
manufactured antivenoms, to anaphylactoid reactions
with urticaria, bronchospasm, and hypotension.
The frequency of early reactions varies considerably
between individual antivenoms, between different
batches of antivenom from the same manufacturer, and
may even vary within the same batch of antivenom
depending upon the clinical observer (35). Anaphylac-
toid reactions occur with a frequency that ranges from
less than 0.5% up to 87%, although only a small
proportion of reactions are life threatening (36). Early
anaphylactoid reactions may need to be differentiated
from venom hypersensitivity which occurs in a small
proportion of patients who have had extensive exposure
to venom (usually snake handlers) in whom circulating
IgE can be detected (15). Late reactions, often referred to
as serum sickness, commonly occur one to two weeks
after treatment and comprise fever, itching and urticaria,
arthralgia, lymphadenopathy, and proteinuria. The
frequency may be as high as 75% following treatment
with some antivenoms (37).
Antivenom reactions are more common when the
same antivenom is given intravenously rather than
intramuscularly (38). Although the slow infusion of
antivenom (rather than direct IV injections) has been
advocated as a way of reducing reaction rates, the only
comparative study of routes of administration found no
difference in the rates and severity of reactions between a
30-minute infusion and direct intravenous injections over
10 minutes, although only 25 patients were studied (39).
The same study showed no evidence that routine
sensitivity test doses of antivenom can predict reactions.
Mechanism of Reactions
The mechanism of antivenom reactions remains
uncertain. Early reactions may be due to type 1
hypersensitivity, but antivenom reactions frequently
occur in those with no previous exposure to equine
proteins. Commercial antivenoms are anticomplemen-
tary in vitro, in part due to the presence of high molecular
weight aggregates (39,40). Studies of patients with
antivenom reactions have not clearly demonstrated
complement activation, although complement activation
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280
due to immune complexes may be detected in patients
given other Ig products (12,39 – 41). Current thoughts are
that early reactions are most likely to be due to a
combination of type I hypersensitivity, complement
activation, and the effect of aggregates of Ig or Ig
fragments including Fc, which may be found in even
highly refined antivenoms (42).
Late reactions to antivenom are thought to be due
to serum-sickness-like reactions attributable to
immune complexes as a result of an immune response
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against heterologous proteins. Experiments in mice
suggest that equine IgG induces a stronger immune
response than F(ab0 )2, although the total foreign
protein load may be important (43).
In theory, the cleaving of the IgG molecule into
smaller fragments should reduce the incidence of
antivenom reactions. Although anticomplementary
activity can occur with both IgG antivenoms and
F(ab 0 ) 2 antivenoms, removing the Fc fragment
decreases the likelihood of complement fixation
(43,44). One of the other theoretical advantages of
Fab antivenoms is that their ability to cause type III
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hypersensitivity is reduced because they only have a
single antigen binding site and therefore cannot form
immune complexes of a sufficient size. However,
clinical studies do not always confirm these theoretical
advantages, and it is clear that the manufacturing
process and degree of purification of the produce are as
important as the type of molecule. In a Brazilian
comparative study of three antivenoms (two IgG, one
F(ab0 )2), the early reaction rate was significantly lower
with one of the whole IgG antivenoms (11.1%) than
with the F(ab0 )2 antivenom (36.7%). This may be
because the IgG antivenom with the low reaction rate
was produced by caprylic acid methodology, which
gives a purer IgG preparation (45). Other data
comparing two IgG antivenoms (one prepared by
caprylic acid and one by ammonium sulfate precipi-
tation) demonstrated early reaction rates that were
significantly lower in the caprylic acid group
(25% vs. 50% p ¼ 0:04): ammonium sulfate precipi-
tation appears to lead to higher amounts of protein
aggregates and nonimmunoglobulin proteins than
caprylic acid methodology. Both products demon-
strated anticomplementary activity, although this
was significantly less in the one produced using
caprylic acid technology (8). High rates of early
reactions (34 – 48%) have been reported with one
Fab antivenom, possibly due to inadequate removal of
Fc fragments (28,35), and early reaction rates
of 14% have been recorded with a highly refined
Fab antivenom (46). F(ab0 )2 antivenoms may be
Lalloo and Theakston
contaminated by aggregates or Fc components if
poorly processed (42).
Prevention
Routine prophylaxis against antivenom reactions is
commonly used in many parts of the world although the
evidence base for its efficacy is limited: only two well-
conducted trials have been performed (47). Routine
prophylaxis with adrenaline, antihistamines, and corti-
costeroids has all been advocated and used. Sutherland
advocated the use of routine adrenaline and antihista-
mine prophylaxis and attributed the low reaction rates of
CSL antivenom to this practice (48). A placebo
randomized controlled trial examined the value of
antihistamines in 101 patients. No difference in early
reaction rates was found between the two groups,
although the numbers of severe reactions were small
(49). There has also been one double-blind placebo
controlled trial of routine adrenaline prophylaxis in 105
patients (50). The amount of 0.25 mL of 1 in 1000
adrenaline given subcutaneously prior to antivenom
reduced the reaction rate from 43% to 11% (relative risk
0.25, 95% confidence intervals 0.11 –0.57). Adrenaline
was particularly effective in reducing moderate and
severe side effects (RR 0.11, 95% CI 0.01 –0.81). A total
of 8.1% of patients receiving antivenom were excluded
because of contraindications to adrenaline, and numbers
in the study were too small to assess the safety of this
approach adequately. It is also not clear whether the
benefits of adrenaline would occur in antivenoms with
lower reaction rates.
There has been concern expressed in Australia
about case reports of intracerebral bleeding in patients
with incoagulable blood given adrenaline as prophy-
laxis, although adrenaline was given inappropriately in a
number of cases, and some regions do not advocate
routine adrenaline prophylaxis (51 – 53). A small follow-
up study by the authors of the original adrenaline paper
found no changes in pulse rate or blood pressure
following adrenaline administration, but they concluded
that more studies on the safety of prophylactic
adrenaline are required before its routine use (54).
Most clinicians currently advocate no routine prophy-
laxis but suggest that patients should be closely
observed during and after antivenom therapy and that
adrenaline, antihistamines, and corticosteroids should be
drawn up ready to treat an early reaction. Late reactions
usually respond well to antihistamines and oral
corticosteroids.
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Snake Antivenoms
ANTIVENOM EFFICACY
Laboratory Investigation of Antivenom Efficacy
A number of different methodologies have been
used to assess antivenom efficacy. The standard test
recommended by WHO has been the assessment of the
ability of an antivenom to save the life of an
experimental animal, usually assessed as the ED50
(median effective dose) (55). Different doses of
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antivenom are incubated with a standardized dose of
venom (often 5 £ IV LD50) and then injected
intravenously into mice. Survival is then recorded after
24 hours. Although this tests the ability of an antivenom
to prevent lethality, the individual properties of an
antivenom cannot be assessed. WHO therefore also
advocates that the ability of antivenom to neutralize the
individual properties of venom components should also
be tested. This can be done either in vivo, for example in
the neutralizing of hemorrhagic effects or necrosis after
venom/antivenom mixtures are injected subcutaneously
into rodents, or in vitro, whereby the ability of an
For personal use only.
antivenom to neutralize the procoagulant effect of a
venom is measured (55 – 57). Quantitative ELISA
techniques have also been used to assay the neutralizing
ability of an antivenom (58).
These experimental results are difficult to extra-
polate to the clinical efficacy of an antivenom. Artificial
systems do not mimic the subcutaneous deposition of
venom that occurs in human envenomation and
subsequent intravenous administration of antivenom.
Venom components that cause lethality in mice may not
be the same as the ones that cause the major clinical
problems in humans and on occasions, poor correlations
between laboratory and clinical trial results have been
observed (59,60). Preclinical testing may be useful to
compare the neutralizing potency of different anti-
venoms, but ultimately, clinical testing must be used as
the most important determinant of antivenom efficacy.
Experimental Efficacy of Different
Antivenom Molecules
There is little evidence to suggest that the theoretical
advantages attributed to Fab molecules are translated
into a practical improvement in therapy. A number of
experimental studies were performed in mice using IgG,
F(ab0 )2 or Fab antivenoms manufactured from the same
pool of hyperimmune serum and adjusted to equivalent
in vitro potency. No significant differences were
observed between these antivenoms in their ability to
281
neutralize experimentally induced edema and hemor-
rhage or systemic effects of venom after intravenous
administration of the antivenom (43,61,62). Other
workers equally found no difference in the ability of a
Fab or F(ab0 )2 antivenom to neutralize the hemorrhagic
effects of Vipera berus venom after intravenous
administration in mice (63). The lack of difference in
different molecules in their experimental neutralizing
ability of local effects may be explained by the
observation that alterations in the microvasculature
may occur in envenomation by some species. The
concentration of IgG and F(ab0 )2 was the same in muscle
tissue in experimentally induced envenomation presu-
mably reflecting similar extravasation rates of the two
products despite differences in molecular size (43). Fab
fragments may in fact be inferior in neutralizing venom
effects; comparison of Fab and F(ab)2 antivenom showed
that Fab was inferior in causing redistribution of venom
from the extracellular space to the central compartment
and that neutralization was incomplete in comparison
with F(ab)2 (21).
Clinical Studies of Antivenom Efficacy
There have been no formal placebo controlled trials of
antivenoms because of the ethical issues involved in
withholding potentially life-saving treatment. Clinical
evidence for the efficacy of antivenom therefore is usually
derived from descriptive responses or comparative studies
of different antivenoms. Most antivenoms in routine use
have never been formally evaluated in clinical studies.
Comparative studies often show a difference between the
efficacy of antivenoms from different manufacturers,
allowing selection of the most appropriate antivenoms in a
specific clinical situation. Some investigators have used
snakebite severity scores to objectively assess improvement
after antivenom (64). The effects of venom can be divided
into two main categories, those that affect dynamic
processes that can be interrupted and reversed by antivenom
(such as a coagulopathy) and those that are a consequence of
the venom that may be difficult to reverse, such as tissue
edema and necrosis due to venom-induced cellular damage.
Local Effects
The evidence for the efficacy of antivenom
in local envenomation is relatively limited. Few
studies convincingly demonstrate resolution of local
swelling, and local swelling often worsens after the
administration of antivenom (65). Recent studies in
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282
the United States demonstrated no improvement in
local signs after antivenom despite improvement in all
other manifestations of envenomation (66). There has
not been a randomized placebo-controlled comparison,
which makes it difficult to evaluate whether
antivenom has prevented worsening of local edema
or subsequent necrosis. Some studies have demon-
strated progression of edema and development
of necrosis despite adequate antivenom therapy in
cobra bites, and although others have reported high
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incidences of necrosis in untreated patients, it is not
clear that the frequency is different in those treated
with antivenom (67 –69). Russell has argued that
increasing doses of antivenom in the United States
reduced the incidence of necrosis but similar increases
in dosage in Brazil did not show any difference
[Ribeiro and Jorge, reported in Refs. (36,70)]. One
comparative study of antivenoms in Sri Lanka showed
a significant difference in the degree of swelling
between the two antivenoms, suggesting a beneficial
effect of antivenom (35). Retrospective studies of
European adder bites have shown lower incidence of
For personal use only.
severe edema in those not receiving antivenom than in
those treated with antivenom (71). Further studies are
required to determine the true value of antivenom in
local envenomation alone.
Coagulation and Bleeding
A number of different venomous snakes produce
venoms that contain components that can act at various
points in the coagulation cascade to cause incoagulable
blood due to fibrinogen consumption. Bleeding may also
occur as a result of endothelial damage by metalloprotei-
nases. Successful neutralization of those venom com-
ponents allows hepatic resynthesis of clotting factors
leading to restoration of coagulability and cessation of
bleeding. The efficacy of antivenom in reversing coagulo-
pathy and bleedinghas beenshown inmanydifferent studies
of different species (27,60,65,72,73). Bleeding commonly
stops within minutes of adequate doses of antivenom;
restoration of coagulability (as measured by the 20-mintute
whole blood clotting test) takes a minimum of 3 hours, and
most studies report restoration of coagulability between 4 to
12 hours after administration of adequate doses of
antivenom (65,74,75).
Lalloo and Theakston
Neurotoxicity
Neurotoxicity is a common and life-threatening
complication of envenomation by elapid snakes, some-
times leading to death by respiratory paralysis. Venoms
produce neurotoxicity by two predominant mechanisms.
Some neurotoxins are phospholipase A2 molecules.
These are found in snakes such as the Papuan taipan
(Oxyuranus scutellatus) and the common krait
(Bungarus caeruleus). These toxins bind to the presyn-
aptic membrane and cause paralysis predominantly by
disruption of the neuromuscular junction (76,77).
Antivenom therapy in these individuals rarely appears
to reverse established neurotoxicity, possibly because the
toxin becomes inaccessible to antivenom once nerve
activity occurs and because nerve terminal damage
rapidly occurs (73,78 –80). In fact, in some individuals,
neurotoxicity will continue to worsen after antivenom is
given. Studies have shown that the earlier antivenom is
given after the bite, the lower the severity of
neurotoxicity, indicating that antivenom is effective in
neutralizing circulating neurotoxins before they bind to
the nerve terminal (73).
In contrast, venoms of other species such as the
Philippine cobra (Naja naja philippinensis) and the
Australasian death adder (Acanthophis sp.) cause
neurotoxicity predominantly by post-synaptic compe-
tition at the acetylcholine receptor. Antivenom following
envenomation in these species is more commonly
associated with clinical improvement, although in the
case of the Philippine cobra, the magnitude of
improvement is variable (81 –83). The use of anti-
cholinesterases is associated with considerable improve-
ment in neurotoxicity in bites by species with these
predominantly post-synaptically acting toxins and may
be more effective than antivenom (83 –86).
Although a broad distinction can be made between
pre- and post-synaptically acting toxins, some patients
envenomed by species with predominantly post-synaptic
toxins do not appear to respond rapidly to antivenom
although antivenom may reduce the duration of
neurotoxicity (87). In bites by other species, the response
of neurotoxicity to antivenom may be variable, and this
may reflect that these species have varying combinations
of pre- and post-synaptic toxins in their venom (84).
Myotoxicity
Very little data exist on the efficacy of antivenom in
treating this complication. Two studies in Sri Lanka
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Snake Antivenoms
suggested that antivenom had little effect in preventing
or improving subclinical or overt myotoxicity (88,89).
Shock
Shock is a common complication of envenomation
by many viper species. This is related to a number of
causes including venom-induced vasodilatation, hemor-
rhage, increased vascular permeability, and autopharma-
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cological release of endogenous vasoactive compounds.
In some cases, shock responds to volume expansion
alone but antivenom in puff adder (Bitis arietans) bites
was associated with an improvement in hypotension and
bradycardia (90). Antivenom could not be expected to
reverse shock due to hemorrhage but was also ineffective
in reversing the shock seen in Russell’s viper (Daboia
russelii) victims in Burma, which is thought to be due to
venom-induced vasodilatation (91). Treatment of
patients bitten by the European adder (Vipera berus)
with a new Fab antivenom led to a resumption of normal
circulation in all patients within 30 minutes of the
For personal use only.
infusion (32).
Nephrotoxicity
There is little convincing evidence that adminis-
tration of antivenom prevents the development of
nephrotoxicity in the small number of species of snake
that cause renal failure. Renal failure occurred in 38%
victims of Russell’s viper bites in Burma despite
receiving antivenom within four hours of the bite (91).
Mortality
There has never been a controlled trial that has
examined the reduction of mortality by antivenom, due
to its unethical nature. However, ample evidence using
historical data illustrates the major difference that
antivenom therapy has made to mortality. For example,
Warrell recorded a reduction in mortality from an
untreated level of 10 –20% to 2.8% in envenomation by
the West African carpet viper (Echis ocellatus) following
antivenom therapy (92).
Other Indications
Antivenom has been shown to reduce the occurrence
of cerebral thrombosis following bites by Bothrops
283
lanceolatus (Lance-heated pit viper) in Martinique and
also to significantly reduce the length of hospital
admission (93,94).
Problems in Neutralizing Ability of Antivenoms
Some antivenoms appear less effective in clinical
use than in laboratory testing. One of the explanations for
this lies in the mode of production of antivenoms. As
whole venom mixtures are usually used in inoculation of
animals, the production of neutralizing antibodies may
not always be directed against the most toxic elements in
the venom, thus leading to poor effectiveness of
antivenom. Some studies have shown that some
commercially available antivenoms are poor in neutra-
lizing important toxins. For example, Australian brown
snake antivenom has been shown to poorly neutralize the
prothrombin activator component in comparison to its
activity against other components of the venom; this may
explain reports of poor clinical responses with standard
doses of antivenom (95 –97). Poor efficacy may also
occur because the antivenom is inappropriate for use in
that particular region. Haffkine antivenom was observed
to clear venom antigenaemia poorly and to be relatively
ineffective when studied in Russell’s viper bites in
Sri Lanka. The antivenom used was raised using venom
from Indian species of Russell’s viper, which have a
different venom composition and hence poorly neutral-
ized the effects in patients envenomed by Sri Lankan
Russell’s viper (88).
Recurrence of Signs After Antivenom
A number of studies have shown apparent
recurrence of signs, most commonly coagulopathy,
after successful initial treatment with antivenom. This
has classically been attributed to continued absorption of
venom from the bite site following elimination of
circulating antivenom and has been associated with a
recurrence of venom antigenaemia (28,60,98,99). Other
potential mechanisms include dissociation of the
venom – antivenom complex and redistribution of
venom into the circulation as demonstrated experimen-
tally in rabbits (21). Recurrence of signs is more
commonly observed with Fab antivenoms, presumably
because of the rapid clearance of these molecules from
the circulation. Frequencies of recurrence of coagulo-
pathy with F(ab0 )2 antivenom are 5 –17% in large studies
but may reach 66% (27,28,60,75). Experience with Fab
antivenom for management of North American crotalid
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284
bites has demonstrated recurrence of a coagulopathy in
as many as 69% of the patients at intervals which ranged
from 2– 14 days after antivenom administration (99).
One comparative study of a new Fab antivenom and the
standard F(ab0 )2 antivenom demonstrated recurrence of
coagulopathy in two-thirds of both groups, but
recurrence of venom antigenaemia and coagulopathy
was more common in patients given Fab antivenom than
the standard Haffkine antivenom in Sri Lanka (27,35).
The frequency of recurrence does depend upon the initial
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 06/15/13
dose of antivenom: higher doses of Fab or other
antivenoms lead to a reduced frequency of recurrent
antigenaemia and coagulopathy.
PRACTICAL CONSIDERATIONS IN
ADMINISTERING ANTIVENOM
There have been few systematic examinations of the
indications for antivenom. The data presented illustrate
some of the difficulties in deciding whether antivenom
should be given to individuals with local swelling alone.
For personal use only.
Pragmatically, many clinicians have advocated the use of
antivenom for individuals with extensive swelling that
extends over 50% of the bitten limb and swelling that
affects the digits or that is rapidly progressing
(100 –102). The indications for those with systemic
envenomation are less controversial and most clinicians
would advocate antivenom for anyone with bleeding,
laboratory or bedside evidence of a coagulopathy,
hypotension or shock, neurotoxicity or evidence of
muscle tenderness and myotoxicity (100 – 102). In some
geographical regions, schemata for scoring the severity
of snakebite have been developed to help determine the
need for and dose of antivenom, although there has been
concern that use of such schemata may be misleading
(64,103,104).
The appropriate antivenom for an envenomed
patient depends upon the species of the snake that has
bitten the individual. There may be significant geo-
graphical variations in venom composition of certain
species, e.g., Russell’s viper, and therefore antivenom
should ideally be used which has been raised against
venom from species in the same geographical region as
that in which the individual has been bitten. In many
clinical situations, the biting species cannot be defined
because the snake is not seen. In such situations,
polyspecific (polyvalent) antivenom should be used. This
is usually a mixture of monospecific antivenoms for the
species of snake commonly found in a particular region
but is occasionally processed from hyperimmune sera in
which venom of a number of different species have been
Lalloo and Theakston
used in the inoculating mixture. The main disadvantage
of polyspecific antivenoms is that a higher dose of
foreign protein is administered, thus theoretically
increasing the risk of late antivenom reactions.
The dose of antivenom varies considerably between
different manufacturers, and there has been little attempt
to even standardize nomenclature. The dose of
antivenom required is clearly dependent upon the
amount of venom injected. However, this is extremely
difficult to determine. Some manufacturers have
calculated starting doses of antivenom upon the basis
of the average venom yield obtained by milking captive
snakes. However, in some cases, these estimations of
average yield have been shown to be wildly inaccurate,
leading to reconsideration of appropriate doses of
antivenom (97). Many clinicians believe that the severity
of clinical signs is a good indicator of the amount of
venom injected and therefore the amount of antivenom
required to neutralize circulating venoms. A number of
studies have shown a good correlation between scores of
severity of envenomation and venom antigen levels in
the serum or urine, usually measured by ELISA
(105 – 107). This supports the common clinical practice
of determining initial antivenom doses on the clinical
severity at presentation.
Rapid techniques to determine circulating venom
levels could theoretically allow individualization of
antivenom doses (107). However, although there are
correlations in most studies between severity and venom
levels, there is a considerable overlap between levels in
individuals in different severity groups. The fact that
individuals present at different time intervals after a bite
coupled with the complex dynamics of venom absorption
from a subcutaneous site may make this difficult in
practice (108). The best way to determine the correct
dose for treatment of envenomed patients is by
conducting randomized clinical trials, which has been
done for a number of different antivenoms (36,59,66,72).
There is ample evidence that the earlier antivenom is
given, the better the clinical response. Antivenom can be
effective in reversing coagulopathy for several days after
the bite (65).
All snake antivenoms should be given intravenously,
and standard recommendations are that antivenom
should be given as an infusion over 30 to 45 minutes,
although direct slow intravascular injection does not
seem to be associated with an increased rate of
antivenom reactions (39). Intravenous infusion does
have the advantage of more accurate control overt the
infusion rate and allows easier cessation of antivenom
administration should a reaction occur (38). Although
intramuscular administration of antivenom has been
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Snake Antivenoms
advocated as easier to give in resource poor or remote
area settings, laboratory evidence suggests that the
intramuscular route is inferior and that higher doses of
IM antivenom are needed. Intramuscular administration
leads to lower bioavailability, a longer time to reach
Cmax, and delayed and incomplete neutralization of
venom components (17,21,33). Clinical human data is
limited but suggests better efficacy with IV adminis-
tration (109).
Detection of venom either at the bite site or in the
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 06/15/13
circulation may potentially be useful in a number of ways
related to antivenom therapy. As already discussed, in
many settings, there may be considerable difficulty in
identifying the biting species and rapid immunodetection
may allow administration of the appropriate monospeci-
fic antivenom. Assessing venom levels could also give an
indication of the severity of envenomation (see previous
discussion) although this has not been practically
achieved. Finally, looking at venom and antivenom
levels after treatment with antivenom may allow
assessment of the efficacy of antivenom therapy.
Trethowie was the first to demonstrate that venom
For personal use only.
could be detected at a bite site by immunodiffusion
(110). Subsequently, immunodiffusion, radioimmuno-
assay, and ELISA techniques have been used to detect
venom antigen (98,111 –114). Venom detection has been
used to determine the biting species in a large number of
studies (73,106). Workers in Australia have modified
ELISA techniques to allow rapid detection of venom
within 30 minutes at the bedside, allowing administration
of the correct monospecific antivenom (115).
Venom assays have also been used to monitor the
effectiveness of antivenom therapy, usually retrospec-
tively as a research tool, although there is potential for
rapid determination of venom levels to guide further
antivenom therapy, particularly if improvement in
clinical parameters is difficult to evaluate (98). Most
studies have shown that one can correlate venom levels
after antivenom with clinical responses for factors such a
coagulopathy: for example, recurrence of venom
antigenaemia after antivenom treatment has been
associated with worsening coagulopathy in a number of
studies (27,105). Poor clearance of venom antigenaemia
has also been associated with poor clinical responses
(89,116). However, some studies have shown no
association between venom levels and coagulation, and
the association between the measurement of venom
levels and clinical neurotoxicity or local edema is far less
clear (117). Most currently used techniques detect whole
venom. However, as the immunogenic components of
venom may not be the same as the toxic components, the
use of assays to detect specific toxic components of
285
venom might better reflect the relationship between
levels and clinical events.
As discussed above, the efficacy of antivenom is
highly dependent upon the clinical manifestation that is
being observed: for example, monitoring the progression
of swelling may be misleading as would expecting rapid
resolution of neurotoxicity in an individual bitten by a
snake with predominantly presynaptically acting toxins.
In those individuals with a coagulopathy, monitoring the
20-minute whole blood clotting test (20 WBCT),
prothrombin time or fibrinogen concentration may help
to determine whether adequate doses of antivenom have
been given. Patients with previously incoagulable blood
should demonstrate considerable improvement in the
prothrombin time, should have measurable fibrinogen
levels, or should have clotting blood on the 20 WBCT
4– 6 hours after the start of antivenom administration if
venom components have been adequately neutralized,
although fibrinogen concentrations may take over
24 hours to return to normal (74). As recurrence of a
coagulopathy in particular may occur, the 20WBCT, PT
or APTT of patients should be monitored at six hourly
intervals after antivenom for at least 24 hours and less
frequently thereafter until discharge; this is particularly
important if a Fab antivenom has been used (60,65,99).
Recurrence of a coagulopathy is an indication for further
antivenom treatment. In practical terms, recurrence of
other signs is less common, but worsening of signs of
systemic envenomation, particularly hemodynamic
status or a recurrence of bleeding, is also an indication
for further antivenom. The failure to reverse neurotoxi-
city as an indication for further antivenom depends upon
the envenoming species and the predominant site of
action of the neurotoxin. Opinions are divided upon
whether worsening edema warrants further antivenom.
Close observation of patients is therefore crucial after
antivenom has been given. Clinical experience with Fab
antivenoms in Africa and the United States has suggested
that many patients will require repeated doses of
antivenoms to control clinical signs as an initial dose
of a Fab antivenom may not produce adequate persistent
circulating levels of antivenom (27,66).
FUTURE DEVELOPMENT OF ANTIVENOM
Recent development in the production of antivenom
such as the use of caprylic acid means that the purity of
antivenom preparations can be improved with a
consequent reduction in antivenom reactions. Tech-
niques such as affinity purification also have the potential
to improve the specificity of antivenoms and have been
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286
used in some recent commercial antivenoms, although
this increases the cost of the product significantly
(6,118). Monoclonal antibodies have also been suggested
as a potentially important means of treating specific
problems such as neurotoxicity, where avid binding of
the antibody to the neurotoxin might reverse neurotoxi-
city better than a crude antivenom, although costs have
precluded the commercial development of this approach
(119). Other attempts to focus on raising antivenom
against toxic components, rather than whole venom, also
Clinical Toxicology Downloaded from informahealthcare.com by Washington University Library on 06/15/13
have the potential to improve the neutralizing ability of
antivenom. Work is also being carried out to explore the
potential for DNA immunization to elicit immune
responses in animals against conserved region of toxins
such as hemorrhagins that may lead to anti-sera that
might be used to treat envenomation by a number of
different species of snake (120).
Available Antivenoms
A list of snake antivenoms available worldwide is
For personal use only.
provided in Table A1 in “Appendix: Antivenom Tables”
(121).
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