High-performance liquid chromatographic method with diode array detection to identify and quantify atypical antipsychotics and haloperidol in plasma after overdose

For toxicological purposes, an HPLC assay was developed for the simultaneous determination of haloperidol and atypical antipsychotics (risperidone, 9-hydroxyrisperidone, olanzapine, clozapine) in human plasma. After a double-step liquid-liquid extraction, compounds were separated on a C(8) column eluted with a gradient of acetonitrile and phosphate buffer 50 mM pH 3.8. A sequential ultraviolet detection was used (260, 280 and 240 nm). Calibration curves were linear in the range 10-1000 ng/ml. The limits of quantification were 5 ng/ml for all drugs. Average accuracy at four concentrations ranged from 93 to 109%. Both inter- and intra-day variation coefficients were lower than 11% for all drugs. This simple and rapid method (run time<15 min) is currently used for poison management.

Cardiotoxicity associated with intentional ziprasidone and bupropion overdose

BACKGROUND

Ziprasidone (Geodon) and bupropion (Wellbutrin) are medications prescribed for mood and behavior disorders. They have apparently safe cardiac safety profiles in both therapeutic and supra-therapeutic doses.

CASE REPORT

A 17-year-old male developed a widened QRS and a prolonged QTc interval following an overdose of ziprasidone and bupropion. He required hospital admission for aggressive cardiac monitoring and antidysrhythmic therapy, stabilizing to baseline by 80 hours post-ingestion.

CONCLUSIONS

We present a case that underscores the potential cardiotoxicities of these medications. Ziprasidone and bupropion ingestion can be associated with cardiotoxicities that may require several days of aggressive cardiac monitoring and treatment.

A case series of ziprasidone overdoses

In recent years, prescriptions for atypical antipsychotic medications have surpassed traditional antipsychotic agents because of improved treatment of the negative symptoms associated with schizophrenia and a relatively safer side effect profile. The relatively new atypical antipsychotic agent ziprasidone has become a popular treatment for schizophrenia, and like other psychiatric medications has potential for misuse. This series reports 3 cases of ziprasidone overdose. Diligence in cardiac monitoring and obtaining a history of possible co-ingestion are vital in the management of these patients.

Minimal myocardial damage after tricyclic neuroleptic overdose - a case report

A great number of acute, severe self-poisoning cases are due to tricyclic neuroleptic overdose. These drugs may induce several effects on the myocardium, mainly related to arrhythmias and electrical conduction and excitation abnormalities. These abnormalities are particularly evident after massive ingestion of these drugs for suicidal purposes. More recently, abnormal ventricular repolarization, in association with QRS widening, that mimics an acute ischemic event has been reported. However, these transient ECG abnormalities have never been associated with organic cardiac alterations. We report the case of a young woman who - according to ECG, enzyme release, and echocardiography - developed transient acute myocardial ischemia and minimal myocardial damage following self-poisoning with promazine hydrochloride. To our knowledge, this is the first case of documented minimal myocardial damage after tricyclic drugs overdose.

Clozapine intoxication in a dog

Intoxication with clozapine in a dog, suspected from history and clinical signs at presentation, was confirmed by demonstration of decreasing serum levels of this drug. Clozapine is a tricyclic dibenzodiazepine used for treatment of human schizophrenia, and clinical signs of intoxication in humans include tachycardia, seizures, muscle fasciculations, agitation, and sialorrhea. This dog showed ptyalism, hyperthermia, tachycardia, and was easily excited by tactile or auditory stimulation. The calculated peak concentration of clozapine in this dog was approximately 6,000 ng/mL, and the elimination half-life (t(1/2)) was 5 hours. Charcoal administration and supportive care led to a successful outcome in this patient.

Massive gabapentin and presumptive quetiapine overdose

Previous reports of gabapentin overdose have described mild symptoms of somnolence, ataxia and slurred speech. Quetiapine has produced a false positive for cyclic antidepressants on immunoassay drugscreens. Quetiapine overdose is associated with coma, QTc prolongation and hypotension. We report a case of massive gabapentin and presumptive quetiapine overdose with the highest recorded serum gabapentin concentration (104.5 u/ml) associated with coma, respiratory depression requiring mechanical ventilation, and hypotension.

Atypical antipsychotic overdose in the pediatric population

Risperidone is an atypical antipsychotic medication commonly used to treat psychotic illnesses in adults. It is being used with increasing frequency in children and adolescents, even though it has yet to be approved for use in this population by the Food and Drug Administration. There are few reports in the literature regarding its safety in those younger than 18 years of age. We present the case of a 15-year-old who ingested 110 mg of risperidone in a suicide attempt and developed only transient lethargy, hypotension, and tachycardia without any other significant effects. We review the literature regarding risperidone overdose in all age groups and review the current literature regarding pediatric overdose with the other atypical antipsychotics currently available in the United States. From those cases it seems that special care may be warranted with all pediatric cases of atypical antipsychotic overdose, including monitoring in a high-intensity clinical setting to manage potential respiratory or cardiac difficulties.

[Fatal poisonings with antidepressive drugs and neuroleptics. Analysis of a correlation with prescriptions in Vienna 1991 to 1997]

As a result of the increasing use of selective serotonin reuptake inhibitors (SSRI), the number of antidepressants (AD) prescribed in Vienna doubled from 1991 to 1997. In the same period, autopsies and chemical analyses performed at the Institute of Forensic Medicine, University of Vienna, revealed a total of 164 fatal intoxications by means of AD. In this study, the number of fatal intoxications per million defined daily doses prescribed was determined and referred to as the fatal toxicity index (f-index). For both single- and multiple-substance intoxications, it proved to be significantly (p < 0.001) lower with SSRI than with tricyclic antidepressants (TCA). Single-substance intoxications (n = 30) were seen exclusively in TCA. Concerning neuroleptics (NL), the increase in prescriptions observed in the study period (plus 30%) was less pronounced, and they were found to be involved in 85 fatal intoxications. Also in NL, those of the tricyclic type (TCNL) showed a significantly (p < 0.001) higher f-index than other groups. Out of a total of 17 single-substance intoxications, 14 were caused by TCNL and none by butyrophenones or haloperidol. The present study demonstrates that the prescription of TCA or TCNL involves a relatively high risk of fatal intoxication.

Acute quetiapine overdose in an eleven-year-old girl

We present a case of acute Quetiapine (SeroQuel) overdose in an 11-y-old girl who ingested 1,300 mg (22.2 mg/kg bw). Initial lethargy developed within I h followed by an episode of agitation and combativeness 3 h after ingestion. After treatment with lorazepam the patient experienced extended somnolence followed by return to normal mental status 16 h after ingestion. No cardiotoxic or laboratory abnormalities were found. This is the first report of acute Quetiapine overdose in an adolescent and suggests a relatively benign clinical course.

[Thioridazine intoxication of therapeutic error as the cause of death of a three-year girl]

Intoxication with drugs and xenobiotics in children, particularly under the age of 7 years, represents a serious diagnostic and therapeutic challenge considering the relatively immature enzymatic detoxication systems, greater susceptibility to organ lesions, easily destabilized homeostasis (including water-electrolyte balance) and limited compensatory mechanisms in acidosis or alkalosis. We present the case of a 3-year-old girl, who died 30 hours after admission to hospital, with suspicion of ingestion of two or three 100-mg tablets of thioridazine. The medical documentation and results of autopsy are in favor of acute cardiopulmonary failure caused by extensive cerebral and pulmonary edema as a complication of "water poisoning" i.e. acute hypotonic overhydration of the child.

[Drug correction of hypoxia aftereffects in patients with toxic coma caused by acute neurotropic poisoning]

Seventy-eight patients with acute neurotropic poisoning (soporifics, neuroleptics, antidepressants, ethanol and its surrogates, narcotics) were examined and treated. Study of the pathogenesis of hypoxic injuries in acute neurotropic poisoning demonstrated the efficiency of using Perfluorane, an infusion solution with oxygen transporting functions, and Cytoflavine, a substrate antihypoxant, for correction of the detected disorders.

A case of child abuse: haloperidol poisoning of a child caused by his mother

This presentation focused on a hyperactive child admitted to the emergency department because of ataxia and imbalance. It was later discovered that the child had been abused by his mother. In cases where there is conflict between the clinical findings, the patient and the family's history in a clinical state which cannot be explained satisfactorily by the medical staff, the need for taking the history again from other relatives whilst taking into account the parents' physiological well-being, is time well spent.

HPLC-ESI-MS/MS determination of zuclopenthixol in a fatal intoxication during psychiatric therapy

The first non-suicidal fatality due to intramuscular administration of Cisordinol (zuclopenthixol, ZPT) is described. A new, rapid, and sensitive method for the determination of ZPT in postmortem specimens has been developed. High performance liquid chromatography electrospray ionization tandem mass spectrometry (HPLC-ESI-MS/MS) was employed for drug confirmation and quantitation. Sample clean up was performed using a simple liquid-liquid extraction procedure. The postmortem concentration of ZPT in heart blood was 0.68 microg/ml. Furthermore, zotepine, carbamazepine, and chlorprotixene were detected in body fluids. The proposed method enables the unambiguous identification and quantitation of ZPT and other neuroleptic drugs in clinical and forensic specimens.

Acute intoxication with orphenadrine and clozapine

This report describes a fatal intoxication with two different drugs: clozapine and orphenadrine. A 38-year-old man was found dead in the bedroom of his residence. Near the body were found various empty pharmaceutical boxes, employed in schizophrenic therapy, two of them containing clozapine and orphenadrine. High concentrations of clozapine and orphenadrine detected in blood, urine and gastric content were related to death. These compounds were identified and quantitated by liquid-liquid extraction followed by gas chromatographic/mass spectrometry (GC/MS) analysis.

Ping-pong gaze in combined intoxication with tranylcypromine, thioridazine, and clomipramine

OBJECTIVE

This paper reports the occurrence of ping-pong gaze, a neuro-ophthalmological syndrome usually related to severe structural brain damage, in a patient intoxicated with tranylcypromine, thioridazine, and clomipramine.

BACKGROUND

Although there have been some reports about the occurence of Ping-pong gaze after intoxications, it is usually related to severe bilateral hemispheric brain damage following stroke or traumatic injuries.

METHOD

We report the case of a 56-year old woman who developed a neurotoxic syndrome with coma, hyperthermia, muscular rigidity, myoclonic jerks and tachycardia following an intoxication. Additionally rhythmic and pendular conjugate horizontal eye movements could be observed for three days, so that the diagnosis of ping-pong gaze was made.

RESULTS

A treatment with dantrolene lead to complete remission of the neurotoxic syndrome with no signs of neurological or physical deficits. At the stage of regaining consciousness the eye movements became normal.

CONCLUSION

In our case the combined intoxication with an monoamine oxidase inhibitor, a neuroleptic and a tricyclic agent lead to a neurotoxic syndrome and the occurrence of a rare neuro-ophthalmological syndrome usually related to bilateral hemispheric brain dysfunction.

Priapism from quetiapine overdose: first report and proposal of mechanism

We report a case of priapism occurring after an overdose of the newly approved atypical antipsychotic quetiapine. A review of its previously published receptor-binding studies suggests that alpha-adrenergic blockade may be the responsible mechanism. To our knowledge, this is the first report of priapism associated with quetiapine, and we recommend the inclusion of priapism in its list of potential adverse effects in cases of overdose.

[Correction of free radical processes by a succinic acid drug (reamberine) in intensive care of patients with acute neurotropic poisoning]

Sixty-six patients with acute poisonings with neurotropic toxins (soporiphics, neuroleptics, antidepressants, ethanol and its surrogates) were examined and treated. Clinical data and correction of disorders in free-radical processes in acute poisonings with these toxins indicate the efficiency of adding reamberine to combined therapy of this patient population.