Snake envenoming is a major public health issue in the rural tropics, with large numbers of envenomings and deaths.^1,2 However, there continues to be limited evidence on the clinical features, epidemiology, and treatment of these patients.^1,2 In some parts of the world, there is a continuing shortage of antivenom.³ Agarwal et al⁴ attempt to answer a pertinent clinical question in their region. The study aims to justify a reduced dose of antivenom (thus reducing cost of treatment) in their hospital and surrounding regions. However, while the study provides useful insight into the issues of snakebite management in the tropics, there are a number of problems with the design, and the study cannot be generalized to other parts of the world. The appropriate design for the study would be a randomised, controlled trial (RCT), but these are not often undertaken because of the difficulties with RCT in this setting and the resources needed to measure venom concentrations in envenomed patients.

RCTs of antivenom are difficult to undertake for a number of reasons. The clear efficacy in many …