[Acute overdose of Zolpidem (Stilnox)]

Zolpidem (Stilnox), an imidazopyridine derivative, is a strong sedative with minor myorelaxant and anticonvulsant properties which exhibits high-affinity binding at a benzodiazepine-receptor subtype. Although the structure of zolpidem differs from the benzodiazepines, the acute toxicity of zolpidem has generally been compared to triazolam (Halcion) and midazolam (Dormicum). 5 years after introduction of zolpidem to the Swiss market we have therefore retrospectively analyzed 91 well documented cases of acute zolpidem intoxication reported to the Swiss Toxicological Information Center. Furthermore, 54 single-drug poisonings with zolpidem were compared with 53 triazolam and 55 midazolam intoxications observed over the same time period. 0.01-0.02 g of zolpidem is the recommended therapeutic dose. But only mild symptoms were observed in acute single-drug poisonings with zolpidem up to 0.6 g. Patients mainly suffered from somnolence. Only one anorectic patient became comatose after ingestion of 0.6 g zolpidem. The acute toxicity of zolpidem was markedly less pronounced than that of the short-acting benzodiazepines triazolam and midazolam. With forty-fold the therapeutic dose no severe symptoms occurred in patients with zolpidem single-drug poisonings, while coma was encountered in 4 cases with triazolam (11% of patients) and 4 cases with midazolam (10%). While only the patient mentioned above was reported to be comatose after overdosing with zolpidem, 6 (11%) and 8 (15%) comatose patients were observed in triazolam and midazolam single-drug poisonings, respectively. On the other hand, in combined intoxications with other CNS active drugs or ethanol a zolpidem dose as low as 0.1-0.15 s induced coma in some patients, even if the amount of the additionally ingested drugs in itself would not have caused a comatose state. Flumazenil (Anexate) was an effective antidote in mono- and combined intoxications involving zolpidem. In conclusion, our results indicate that zolpidem single-drug poisonings are generally benign and require no specific therapeutic measures. In combined intoxications, however, patients may develop coma at relatively low zolpidem doses and should therefore be monitored for approximately 24 hours. If necessary, disturbances of consciousness can be successfully treated with flumazenil.

Acute overdose of zolpidem

Zolpidem (Ambien) is an imidazopyridine hypnotic recently introduced in the USA. We report a case of a fatal overdose of Ambien. A 68-year-old female ingested at least 30 tablets of 10 mg Ambien (300 mg). She was found dead at home. Toxicological analyses revealed blood concentration of 4.1, 19.3 and 2.3 micrograms/ml of zolpidem, meprobamate and carisoprodol, respectively.

Ingestion of poison hemlock (Conium maculatum)

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Leucaena toxicosis and its control in ruminants

Leucaena (Leucaena spp., especially L. leucocephala) is an arboreal, tropical legume that ranges into the cool subtropics and equatorial elevations up to 1,000 m. One of its uses includes forage for livestock, but introduction of leucaena outside its indigenous range often has led to acute and chronic toxicosis. The major toxic constituents of leucaena are the nonprotein free amino acid mimosine and its ruminal degradation product, 3-hydroxy-4(1H)-pyridone (3,4-dihydroxypyridine; 3,4-DHP). Leucaena also contains appreciable quantities of condensed tannins. In ruminants, mimosine is a depilatory agent and 3,4-DHP is a potent goitrogen. In the 1980s, Australian workers demonstrated that the geographical limits of leucaena toxicosis were due to the absence of ruminal bacteria capable of degrading 3,4-DHP, and successfully introduced 3,4-DHP degrading ruminal bacteria from a Hawaiian goat into goats and cattle in Australia. Simple in vitro screening methods have been developed for detection of 3,4-DHP degraders in ruminal samples and feces. Also, several strains of 3,4-DHP degrading ruminal bacteria have been characterized and have been given the genus and species designation, Synergistes jonesii. Ruminal inoculation with ruminal contents from adapted animals, enriched cultures of 3,4-DHP-degrading ruminal bacteria, and pure cultures of S. jonesii have all been used successfully to establish ruminal populations that are capable of degrading 3,4-DHP and preventing leucaena toxicosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute zolpidem poisoning--analysis of 344 cases

Zolpidem is a new short acting hypnotic agent, first launched in France in 1988. Three hundred forty-four cases of intentional acute overdoses are reviewed retrospectively. Patients were predominantly female (70%) in their third or fourth decade. Ingested doses of zolpidem ranged between 10 and 1400 mg (one pack or less in 80%). Half of the patients ingested other substances (psychotropic drugs and alcohol) concomitantly. Signs of intoxication were observed in two thirds of the population but could be attributed to zolpidem in only 105 cases: drowsiness (N = 89) occurred at doses of 140 to 440 mg; coma (N = 4) or respiratory failure (N = 1). Other symptoms were rare (excepted vomiting, N = 7). Of the rare electrocardiographic or biological abnormalities, none appeared to be directly related to zolpidem. Therapy for intoxication was usually limited to supportive measures and/or gastric lavage. Symptoms of intoxication rapidly remitted in 91% of cases. Three percent of patients with multiple drug ingestion recovered despite severe complications during intensive care. Fatalities were reported for 6% but could not be directly linked to zolpidem. Previous published reports are confirmed: zolpidem acute overdose is generally benign and requires no specific therapeutic measures.

A fatality involving two unusual compounds--zolpidem and acepromazine

A fatality due to ingestion of zolpidem, a recently developed nonbenzodiazepine hypnotic, and acepromazine, a phenothiazine sedative used in veterinary practice, is reported. Both drugs were identified and quantified using high-performance liquid chromatography with diode-array detection. Zolpidem and acepromazine blood concentrations were 3.29 and 2.40 micrograms/ml, respectively. It is the first report of a death involving either of these two drugs. The results are discussed in the light of the existing literature and may suggest a reciprocal potentiation of the toxic effects of zolpidem and phenothiazines.

High-performance liquid chromatographic assay with diode-array detection for toxicological screening of zopiclone, zolpidem, suriclone and alpidem in human plasma

A high-performance liquid chromatographic assay with diode-array detection has been developed for the toxicological screening of the newly developed non-benzodiazepine hypnotics and anxiolytics zopiclone, zolpidem, suriclone and alpidem. After single-step liquid-liquid extraction of plasma at pH 9.5 using chloroform-2-propanol-n-heptane (60:14:26, v/v), the substances are separated on a Nova-Pak C18 4-microns column (300 mm x 3.9 mm, I.D.), with methanol-tetrahydrofuran-pH 2.6 phosphate buffer (65:5:30, v/v) as the mobile phase (flow-rate 0.8 ml/min). Full ultraviolet spectra from 200 to 400 nm are recorded on-line during the entire analysis and may be automatically compared to spectra stored in a library. The retention times of the four drugs are 4.05 min (zopiclone), 4.66 min (zolpidem), 6.74 min (suriclone) and 10.97 min (alpidem). The analysis is performed in 15 min. The method is simple, rapid and highly specific. It is the first assay to be described for convenient screening of cyclopyrrolones and imidazopyridines.

Determination of zolpidem, a new sleep-inducing agent, and its metabolites in biological fluids: pharmacokinetics, drug metabolism and overdosing investigations in humans

For the determination of zolpidem, a new sleep inducer, and its metabolites in human plasma and urine, three methods were developed that are suitable for pharmacokinetics, drug metabolism and overdosing investigations. The methods used for pharmacokinetic and drug metabolism studies are based on column-switching high-performance liquid chromatography; they do not require any sample manipulation because the plasma or diluted urine is injected into a pre-column where clean-up and preconcentration take place. The analytes are transferred by valve-switching to the C18 analytical column for chromatography. To investigate overdose cases, urine samples only are used: the method is simple, because the diluted urine can be injected directly into the analytical column (phenyl type). This allows the identification and quantification of the principal urinary metabolite of zolpidem, the unchanged drug being practically undetectable. All the methods use fluorescence detection, which affords high sensitivity and selectivity. It is necessary to use a method capable of the determination of metabolites even if these are apparently pharmacologically inactive, because in different physiopathological populations the qualitative and quantitative metabolic profiles of zolpidem could be different. The method designed for the investigation of (accidental or deliberate) overdose cases is, as required on such occasions, simple and rapid, with good selectivity with respect to commonly prescribed psychotropic drugs.

HPLC quantification of zolpidem and prothipendyl in a voluntary intoxication

Zolpidem, a recently developed sleep inducer, and prothipendyl, a neuroleptic azaphenothiazine, were involved in a voluntary intoxication along with ethanol. After administration of flumazenil, a specific benzodiazepines antagonist, respiratory depression was corrected. HPLC with UV detection methods after selective extraction were developed to measure simultaneously prothipendyl and zolpidem without flumazenil interaction. These methods could be applied in drug monitoring and in emergency toxicology.

Zolpidem intoxication mimicking narcotic overdose: response to flumazenil

Zolpidem is a recently introduced sleep-inducer which is thought to act on the central-type benzodiazepine receptors. This observation is the first report of drug poisoning with this compound. The toxic response was characterized by the development of a profound but short-lasting coma, associated with pin-point pupils and respiratory depression, as observed in a narcotic overdose. These clinical signs were not influenced by the administration of naloxone, but responded dramatically to flumazenil. Some analytical data on zolpidem toxicokinetics are presented.

[Outcome of acute renal failure caused by voluntary ingestion of Cortinarius orellanus]

Orellanin poisoning is characterized by an acute renal failure which can be lethal if the appropriate treatment is not given. A 31-year old woman was admitted to hospital 10 days after she had deliberately ingested 2 raw carpophores of the mushroom Cortinarius orellanus. Acute renal failure (creatininaemia 1,100 mumol/l) developed, requiring 6 sessions of haemodialysis, one of plasmapheresis and the administration of diltiazem and aminoacids. Plasma and tissue assays of orellanin, the mushroom's toxin, were performed by two-dimensional thin layer chromatography. Before haemodialysis and 10 days after ingestion of the poison, the plasma contained orellanin. Eighteen months after the attempted suicide, the plasma creatinine level was 181 mumol/l.

Intoxication by Cortinarius orellanus: detection and assay of orellanine in biological fluids and renal biopsies

A woman suffering from acute tubulo-interstitial nephritis was admitted to the hospital ten days after deliberate intoxication by ingestion of Cortinarius orellanus. Orellanine, the main toxin responsible for orellanine poisoning, was detected in biological fluids and renal biopsies. It was assayed by direct spectrofluorimetry on two-dimensional thin-layer chromatograms after specific photodecomposition into orelline. The orellanine concentration was 6.12 mg/l in the plasma (10 days after ingestion). Orellanine levels in renal biopsies were 7 micrograms per 25 mm3 of the first biopsy (13 days after ingestion) and 24 micrograms per 8 mm3 of the second biopsy (6 months later).

Nyquil-associated liver injury

Acetaminophen, a commonly used medication, is present in many over-the-counter remedies. In recent years, its potential to cause severe liver injury has been increasingly appreciated. Chronic abusers of alcohol may be particularly susceptible to hepatotoxicity from acetaminophen. We report two cases of unintentional liver injury associated with ingestion of Nyquil, a liquid cold remedy containing acetaminophen and 25% alcohol.

Effect of intrastriatal and intranigral administration of synthetic neuromelanin on the dopaminergic neurotoxicity of MPTP in rodents

Previous studies showed that the neurotoxin MPTP and its toxic metabolites bind with high affinity to neuromelanin (NM). Therefore, the presence of NM in human and primate but not in rodent substantia nigra, theoretically may be responsible for the species-selective dopaminergic (DA) toxicity of MPTP. We measured DA levels in rodent striatum 7 days after an acute single challenge with MPTP (40 mg/kg, s.c.) given alone or 24 h following unilateral intrastriatal injections of synthetic DA-NM in mice and intrastriatal or intranigral pigment administration in rats. Ipsilateral striatal DA levels were unaffected in control rodents treated with unilateral intrastriatal or intranigral DA-NM. In mice, systemic MPTP produced marked striatal DA depletions which were mildly increased in the striata given prior DA-NM injections. In rats, a species resistant to MPTP, administration of toxin did not affect striatal DA levels. However, after pretreatment with unilateral intrastriatal DA-NM, MPTP induced mild DA falls in ipsilateral striata. By contrast, intranigral administration of DA-NM followed by MPTP, did not alter ipsilateral striatal DA in rats. The findings suggest that intrastriatal DA-NM in mice and rats may augment or initiate, respectively. MPTP-induced damage to sensitive DA-nerve-terminals perhaps by its action as a depot for binding and protracted release and action of the toxin. Lack of effect of intranigral DA-NM which is retained extraneuronally suggests that role of NM in the toxicity of MPTP may depend on its location within DA cell bodies in the nigra.

Acute ultrastructural and behavioral effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) in mice

Acute actions of MPTP on behavior and on neostriatal ultrastructure were examined in young C57 Black mice. Autonomic, motor, and toxic effects of MPTP exhibited dependence on dose (20-40 mg/kg) and time during the first 4 h after subcutaneous injection. The ultrastructure of the neostriatum was altered very quickly (2-24 h) after single injections of MPTP. Darkened glial processes were found within 2-8 h, followed by dark degeneration of synaptic boutons, especially those making small symmetric synapses. More rarely, swollen axons and postsynaptic degeneration were also observed.

Rhabdomyolysis complicating doxylamine overdose

A 16-year-old male presenting with anticholinergic symptoms was found to have hematuria and oliguria. Evaluation of the patient revealed a serum creatinine of 2.2 mg/dl, myoglobinuria, and a creatine phosphokinase (CPK) level of 78, 750 IU/l with 99 percent fraction 3 isoenzyme. A toxic screen showed the presence of doxylamine, an antihistamine of the ethanolamine class, at a level of 75 times therapeutic. The patient did not have a history of trauma or seizures. The extremely high CPK level with the doxylamine overdose suggests that doxylamine may be associated with nontraumatic rhabdomyolysis. This is the first case report of rhabdomyolysis being associated with an antihistamine overdose.

MPTP-induced up-regulation of in vivo dopaminergic radioligand-receptor binding in humans

We measured in vivo dopaminergic receptor binding using positron emission tomography and 18F-spiperone in an untreated symptomatic subject with MPTP-induced parkinsonism. Our technique determines four variables related to entry of 18F-spiperone into brain tissue and subsequent binding to receptors: (1) the combined forward-rate constant k1' (equal to the product of the maximum number of available specific binding sites, Bmax, times the association rate constant [ka] of 18F-spiperone and receptor); (2) the binding site dissociation rate constant k-1; (3) the free fraction of radioligand not specifically bound in brain tissue, f2; and (4) the regional permeability-surface-area product (PS) of the blood-brain barrier for spiperone. PS and f2 in the patient were not different from that of 10 normal volunteers, whereas the combined forward-rate constant (left caudate: k1' = 67.6 sec-1, normal = 0.140 +/- 0.056) and the dissociation rate constant (left caudate: k-1 = 0.116 sec-1, normal = 0.000339 +/- 0.000149) were evaluated. These findings provide potential new insights not only into the pathophysiology of this disease but into the clinical importance of dopamine receptor function as well.

Poisoning with over-the-counter doxylamine preparations: an evaluation of 109 cases

One hundred and nine cases of monointoxication with doxylamine were evaluated with respect to age distribution, amount ingested, plasma level, and clinical symptomatology. The age of 60% of the patients ranged between 16 and 30 years. In about 60% of the cases 10 to 40 times a single therapeutic dose (25 mg) was ingested. Doxylamine plasma concentrations exceeded the maximum plasma level after a therapeutic dose by a factor of 10 to 40 in two-thirds of cases. The most frequent symptoms included impaired consciousness, seizures, tachycardia, mydriasis and a 'psychosis' similar to that in catatonic stupor. A serious complication may be rhabdomyolysis with subsequent impairment of renal function and acute renal failure. No symptoms were observed in 39% of the patients. No correlation was found between the amount ingested or doxylamine plasma level and the clinical symptomatology. Primary detoxication included gastric lavage, administration of activated charcoal and sodium sulfate. Regarding the high frequency of doxylamine overdose and its possible complications the question arises as to whether doxylamine-containing preparations should be subjected to prescription.

Effects of MPTP poisoning on central somatostatin and substance P levels in the mouse

The effects of MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) on the levels of the neuropeptides somatostatin and substance P, were examined in various brain regions of C57 mice. Two weeks after injections of MPTP (2 X 30, 2 X 40 and 2 X 50 mg/kg i.p.) a dose-dependent decrease in striatal catecholamine levels was observed. There was also a dose-dependent increase in nigral somatostatin immunoreactivity and no reduction in striatonigral substance P levels. These results are in contrast with the changes observed in peptide levels in post-mortem Parkinson's brains.

Saccade responses to dopamine in human MPTP-induced parkinsonism

Depletion of dopamine content in the substantia nigra resulting from 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP) toxicity produces parkinsonism. Management of 3 patients with MPTP-induced parkinsonism required drug holidays during which there was a state of dopamine depletion followed by dopamine replacement. We used this opportunity to study the effect of the selective loss of pars compacta dopaminergic cells on vertical and horizontal saccade (fast) eye movements. During the drug holidays, visually guided saccades were hypometric and had long latencies but retained a normal saccade velocity-amplitude relationship. Dopamine agonists or precursors improved the accuracy and reaction times of saccades in all directions, but not their velocity. Two of the three patients also had intermittent blepharospasm during dopamine depletion. During the episodes of blepharospasm, saccade responses became slow eye movements. MPTP causes a dopaminergic-responsive disorder of saccade initiation that is similar to idiopathic parkinsonism. The inhibition of voluntary eyelid opening during MPTP-induced blepharospasm further increases this impairment of fast eye movements and altered saccade velocity, presumably via the pars reticulata of the substantia nigra.