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Abstract
ABSTRACTObjective:The use of dantrolene in the treatment of hyperpyrexia related to MDMA (3,4-methylenedioxymethamphetamine) is controversial, with little data available to guide clinical decision-making. Although the treatment is recommended by several poison control centres, published data are primarily in the form of case reports and animal and in vitro experiments. We conducted a systematic review to investigate the published evidence regarding the safety and benefits of dantrolene for MDMA-related hyperpyrexia in humans.Data sources:A systematic search of Embase and MEDLINE was conducted from the earliest possible date to November 2008.Study selection:All human trials and case reports of MDMA-related hyperpyrexia were considered.Data extraction:Data were abstracted systematically and characteristics including use of dantrolene, adverse reactions attributed to dantrolene, peak temperature, complications from MDMA-related hyperpyrexia and survival were recorded.Data synthesis:Our search yielded 668 articles of which 53, reporting 71 cases of MDMA-induced hyperpyrexia, met our inclusion criteria. No clinical trials, randomized controlled trials, observational studies or meta-analyses were identified. Dantrolene was used in 26 cases. Patient characteristics were similar in the dantrolene and no dantrolene groups. The proportion of survivors was higher in the dantrolene group (21/26) than in the no dantrolene group (25/45). This difference was especially pronounced in those with extreme (≥ 42°C) and severe (≥ 40°C) fever, with a survival rate of 8 of 13 and 10 of 10, respectively, in the dantrolene group compared with 0 of 4 and 15 of 27 in the no dantrolene group. There were no reports of adverse events attributable to dantrolene with the exception of a possible association with an episode of transient hypoglycemia.Conclusion:Our systematic review suggests that dantrolene is safe for patients with MDMA-related hyperpyrexia. Dantrolene may also be associated with improved survival and reduced complications, especially in patients with extreme (≥ 42°C) or severe (≥ 40°C) hyperpyrexia, although this conclusion must be interpreted with caution given the risk of reporting or publication bias.
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Kayar Y, Kayar NB, Gangarapu V. Thrombotic thrombocytopenic purpura and focal segmental glomerulosclerosis associated with the use of ecstasy. Indian J Crit Care Med 2015; 19:230-2. [PMID: 25878432 PMCID: PMC4397631 DOI: 10.4103/0972-5229.154561] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ecstasy is a drug, which causes serious side effects and sometimes it can be lethal. These effects are due to idiosyncratic reactions as a result of various stimulations in adrenergic receptors. Here we present a case of a 36-year-old male patient who was diagnosed with thrombotic thrombocytopenic purpura associated with the use of ecstasy. Plasmapheresis along with methylprednisolone treatment restores patient condition to normal.
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Affiliation(s)
- Yusuf Kayar
- Department of Internal Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Nuket Bayram Kayar
- Department of Family Medicine, Bagcilar Education and Research Hospital, Istanbul, Turkey
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Green AR, King MV, Shortall SE, Fone KCF. The preclinical pharmacology of mephedrone; not just MDMA by another name. Br J Pharmacol 2014; 171:2251-68. [PMID: 24654568 DOI: 10.1111/bph.12628] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 12/05/2013] [Accepted: 12/11/2013] [Indexed: 01/15/2023] Open
Abstract
The substituted β-keto amphetamine mephedrone (4-methylmethcathinone) was banned in the UK in April 2010 but continues to be used recreationally in the UK and elsewhere. Users have compared its psychoactive effects to those of 3,4-methylenedioxymethamphetamine (MDMA, 'ecstasy'). This review critically examines the preclinical data on mephedrone that have appeared over the last 2-3 years and, where relevant, compares the pharmacological effects of mephedrone in experimental animals with those obtained following MDMA administration. Both mephedrone and MDMA enhance locomotor activity and change rectal temperature in rodents. However, both of these responses are of short duration following mephedrone compared with MDMA probably because mephedrone has a short plasma half-life and rapid metabolism. Mephedrone appears to have no pharmacologically active metabolites, unlike MDMA. There is also little evidence that mephedrone induces a neurotoxic decrease in monoamine concentration in rat or mouse brain, again in contrast to MDMA. Mephedrone and MDMA both induce release of dopamine and 5-HT in the brain as shown by in vivo and in vitro studies. The effect on 5-HT release in vivo is more marked with mephedrone even though both drugs have similar affinity for the dopamine and 5-HT transporters in vitro. The profile of action of mephedrone on monoamine receptors and transporters suggests it could have a high abuse liability and several studies have found that mephedrone supports self-administration at a higher rate than MDMA. Overall, current data suggest that mephedrone not only differs from MDMA in its pharmacological profile, behavioural and neurotoxic effects, but also differs from other cathinones.
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Affiliation(s)
- A R Green
- School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
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54
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Hysek CM, Schmid Y, Rickli A, Liechti ME. Carvedilol inhibits the cardiostimulant and thermogenic effects of MDMA in humans: Lost in translation. Br J Pharmacol 2014; 170:1273-5. [PMID: 24033079 DOI: 10.1111/bph.12398] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Cédric M Hysek
- Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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55
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Liechti ME. Effects of MDMA on body temperature in humans. Temperature (Austin) 2014; 1:192-200. [PMID: 27626046 PMCID: PMC5008716 DOI: 10.4161/23328940.2014.955433] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Revised: 07/12/2014] [Accepted: 07/28/2014] [Indexed: 01/05/2023] Open
Abstract
Hyperthermia is a severe complication associated with the recreational use of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy). In this review, the clinical laboratory studies that tested the effects of MDMA on body temperature are summarized. The mechanisms that underlie the hyperthermic effects of MDMA in humans and treatment of severe hyperthermia are presented. The data show that MDMA produces an acute and dose-dependent rise in core body temperature in healthy subjects. The increase in body temperature is in the range of 0.2-0.8°C and does not result in hyperpyrexia (>40°C) in a controlled laboratory setting. However, moderately hyperthermic body temperatures >38.0°C occur frequently at higher doses, even in the absence of physical activity and at room temperature. MDMA primarily releases serotonin and norepinephrine. Mechanistic clinical studies indicate that the MDMA-induced elevations in body temperature in humans partially depend on the MDMA-induced release of norepinephrine and involve enhanced metabolic heat generation and cutaneous vasoconstriction, resulting in impaired heat dissipation. The mediating role of serotonin is unclear. The management of sympathomimetic toxicity and associated hyperthermia mainly includes sedation with benzodiazepines and intravenous fluid replacement. Severe hyperthermia should primarily be treated with additional cooling and mechanical ventilation.
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Affiliation(s)
- Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology; Department of Biomedicine and Department of Clinical Research; University Hospital and University of Basel ; Switzerland
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56
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Johnson J, Patel S, Saraf-Lavi E, Aziz-Sultan MA, Yavagal DR. Posterior spinal artery aneurysm rupture after ‘Ecstasy’ abuse. J Neurointerv Surg 2014; 7:e23. [DOI: 10.1136/neurintsurg-2014-011248.rep] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2014] [Indexed: 11/03/2022]
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57
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Johnson J, Patel S, Saraf-Lavi E, Aziz-Sultan MA, Yavagal DR. Posterior spinal artery aneurysm rupture after 'Ecstasy' abuse. BMJ Case Rep 2014; 2014:bcr-2014-011248. [PMID: 24994748 DOI: 10.1136/bcr-2014-011248] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Posterior spinal artery (PSA) aneurysms are a rare cause of subarachnoid hemorrhage (SAH). The commonly abused street drug 3,4-methylenedioxymethamphetamine (MDMA) or 'Ecstasy' has been linked to both systemic and neurological complications. A teenager presented with neck stiffness, headaches and nausea after ingesting 'Ecstasy'. A brain CT was negative for SAH but a CT angiogram suggested cerebral vasculitis. A lumbar puncture showed SAH but a cerebral angiogram was negative. After a spinal MR angiogram identified abnormalities on the dorsal surface of the cervical spinal cord, a spinal angiogram demonstrated a left PSA 2 mm fusiform aneurysm. The patient underwent surgery and the aneurysmal portion of the PSA was excised without postoperative neurological sequelae. 'Ecstasy' can lead to neurovascular inflammation, intracranial hemorrhage, SAH and potentially even de novo aneurysm formation and subsequent rupture. PSA aneurysms may be treated by endovascular proximal vessel occlusion or open surgical excision.
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Affiliation(s)
- Jeremiah Johnson
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Shnehal Patel
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Efrat Saraf-Lavi
- Department of Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Harvard Medical School/Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami, Miami, Florida, USA
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58
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Abstract
AbstractTwo cases of psychiatric disorder temporally related to the abuse of hallucinogenic amphetamines 3, 4 methylenedi-oxymethamphetamine (MDMA), methylenedioxyamphetamine (MDA) and methylenedioxyethylamphetamine (MDEA) are described, suggesting that a variety of psychiatric morbidity may be precipitated by abuse of these drugs, including paranoid psychosis, mixed affective psychosis and symptoms of obsessive compulsive disorder.
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59
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Abstract
AbstractA seventeen year old man attended the National Drug Treatment Centre with a paranoid psychosis following ingestion of Methylene dioxy methamphetamine (MDMA). He had been taking MDMA on a recreational basis over a five month period. Although chronic psychosis after heavy use of MDMA has been reported there are no pervious reports of psychosis following recreational use. This report highlights the psychological dangers of this drug, which has become widely misused in Dublin over the last two years.
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60
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Downey C, Daly F, O’Boyle K. An in vitro approach to assessing a potential drug interaction between MDMA (ecstasy) and caffeine. Toxicol In Vitro 2014; 28:231-9. [DOI: 10.1016/j.tiv.2013.10.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 10/24/2013] [Accepted: 10/30/2013] [Indexed: 11/27/2022]
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61
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Parrott AC. MDMA is certainly damaging after 25 years of empirical research: a reply and refutation of Doblin et al. (2014). Hum Psychopharmacol 2014; 29:109-19. [PMID: 24590542 DOI: 10.1002/hup.2390] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Human Psychopharmacology recently published my review into the increase in empirical knowledge about the human psychobiology of MDMA over the past 25 years (Parrott, 2013a). Deficits have been demonstrated in retrospective memory, prospective memory, higher cognition, complex visual processing, sleep architecture, sleep apnoea, pain, neurohormonal activity, and psychiatric status. Neuroimaging studies have shown serotonergic deficits, which are associated with lifetime Ecstasy/MDMA usage, and degree of neurocognitive impairment. Basic psychological skills remain intact. Ecstasy/MDMA use by pregnant mothers leads to psychomotor impairments in the children. Hence, the damaging effects of Ecstasy/MDMA were far more widespread than was realized a few years ago. In their critique of my review, Doblin et al. (2014) argued that my review contained misstatements, omitted contrary findings, and recited dated misconceptions. In this reply, I have answered all the points they raised. I have been able to refute each of their criticisms by citing the relevant empirical data, since many of their points were based on inaccurate summaries of the actual research findings. Doblin and colleagues are proponents of the use of MDMA for drug-assisted psychotherapy, and their strongest criticisms were focused on my concerns about this proposal. However, again all the issues I raised were based on sound empirical evidence or theoretical understanding. Indeed I would recommend potentially far safer co-drugs such as D-cycloserine or oxytocin. In summary, MDMA can induce a wide range of neuropsychobiological changes, many of which are damaging to humans.
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Affiliation(s)
- Andrew C Parrott
- Department of Psychology, Swansea University, Swansea, South Wales, UK
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63
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Bruce RD, Altice FL, Friedland GH. Pharmacokinetic drug interactions between drugs of abuse and antiretroviral medications: implications and management for clinical practice. Expert Rev Clin Pharmacol 2014; 1:115-27. [PMID: 24410515 DOI: 10.1586/17512433.1.1.115] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Substance abuse and HIV/AIDS are two of the most serious, yet treatable diseases worldwide. Global access to HIV treatment continues to expand. In settings where both active illicit drug use and HIV treatment are concurrent, potentional problematic pharmacokinetic drug interactions may arise and complicate therapy. Clinical case series and carefully controlled pharmacokinetic interaction studies have been conducted between only a few drugs of abuse and approved antiretroviral therapies. Important pharmacokinetic drug interactions have been described for benzodiazepines, 3,4-methylenedioxymethamphetamine, methadone and buprenorphine; however, most have not been studied and few well-controlled studies have been conducted to adequately address the clinical implications of these interactions. The metabolism of drugs of abuse, description of the known interactions, and clinical implications and management of these interactions are reviewed. Certain interactions between drugs of abuse and antiretroviral therapies are known and others are likely based upon shared metabolic pathways. These may result in important clinical consequences. To optimize care, clinicians must be alert, knowledgeable about known and possible interactions and equipped to clinically manage the medical consequences. Moreover, there is considerable need for carefully controlled studies in this important and emerging area.
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Affiliation(s)
- R Douglas Bruce
- Yale University AIDS Program, 135 College Street, Suite 323, New Haven, CT 06511, USA.
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64
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Seibert J, Hysek CM, Penno CA, Schmid Y, Kratschmar DV, Liechti ME, Odermatt A. Acute effects of 3,4-methylenedioxymethamphetamine and methylphenidate on circulating steroid levels in healthy subjects. Neuroendocrinology 2014; 100:17-25. [PMID: 24903002 DOI: 10.1159/000364879] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 05/26/2014] [Indexed: 11/19/2022]
Abstract
3,4-Methylenedioxymethamphetamine (MDMA, 'ecstasy') and methylphenidate are widely used psychoactive substances. MDMA primarily enhances serotonergic neurotransmission, and methylphenidate increases dopamine but has no serotonergic effects. Both drugs also increase norepinephrine, resulting in sympathomimetic properties. Here we studied the effects of MDMA and methylphenidate on 24-hour plasma steroid profiles. 16 healthy subjects (8 men, 8 women) were treated with single doses of MDMA (125 mg), methylphenidate (60 mg), MDMA + methylphenidate, and placebo on 4 separate days using a cross-over study design. Cortisol, cortisone, corticosterone, 11-dehydrocorticosterone, aldosterone, 11-deoxycorticosterone, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), androstenedione, and testosterone were repeatedly measured up to 24 h using liquid chromatography-tandem mass spectroscopy. MDMA significantly increased the plasma concentrations of cortisol, corticosterone, 11-dehydrocorticosterone, and 11-deoxycorticosterone and also tended to moderately increase aldosterone levels compared with placebo. MDMA also increased the sum of cortisol + cortisone and the cortisol/cortisone ratio, consistent with an increase in glucocorticoid production. MDMA did not alter the levels of cortisone, DHEA, DHEAS, androstenedione, or testosterone. Methylphenidate did not affect any of the steroid concentrations, and it did not change the effects of MDMA on circulating steroids. In summary, the serotonin releaser MDMA has acute effects on circulating steroids. These effects are not observed after stimulation of the dopamine and norepinephrine systems with methylphenidate. The present findings support the view that serotonin rather than dopamine and norepinephrine mediates the acute pharmacologically induced stimulation of the hypothalamic-pituitary-adrenal axis in the absence of other stressors.
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Affiliation(s)
- Julia Seibert
- Swiss Center for Applied Human Toxicology and Division of Molecular and Systems Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
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65
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Narang RK, Jadun CK, Carr B. A Case of MDMA Toxicity with Unusual Clinical and Neuroradiological Features 2CO1. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
The use of illicit substances is a growing concern in emergency medicine and results in an increasing number of hospital admissions and fatalities. MDMA (3,4-methylenedioxymethamphetamine) and LSD (lysergic acid diethylamide) are two such drugs which have similar physical and psychological effects and are normally detected in blood and urine testing within 24–48 hours of ingestion. We present a case of a 22-year-old man who was found unconscious and unresponsive. History suggested the ingestion of illicit substances within the past 24 hours; however, urine and blood toxicology screening was negative. The patient was initially diagnosed with and treated for meningoencephalitis; however, CSF findings were negative. During the patient's recovery, he developed upper motor neurone neurological signs with pupillary dilatation. An MRI scan of the head was performed which revealed unusual features consistent with toxic leukoencephalopathy, most likely as a result of illicit substance intake. Further history was acquired confirming that the patient had ingested MDMA and LSD. The patient's presentation and course of admission is presented, with the clinical features of MDMA toxicity and the finding of toxic leukoencephalopathy reviewed.
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Affiliation(s)
- Ravi K Narang
- Foundation Doctor Intensive Care Medicine, Department of Anaesthesia and Intensive Care
- University Hospital of North Staffordshire, Stoke-on-Trent
| | - Changez K. Jadun
- Consultant Neuroradiologist, Department of Radiology
- University Hospital of North Staffordshire, Stoke-on-Trent
| | - Bryan Carr
- Consultant in Intensive Care Medicine, Department of Anaesthesia and Intensive Care
- University Hospital of North Staffordshire, Stoke-on-Trent
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Barbosa DJ, Capela JP, Silva R, Ferreira LM, Branco PS, Fernandes E, Bastos ML, Carvalho F. "Ecstasy"-induced toxicity in SH-SY5Y differentiated cells: role of hyperthermia and metabolites. Arch Toxicol 2013; 88:515-31. [PMID: 24177245 DOI: 10.1007/s00204-013-1147-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/07/2013] [Indexed: 01/10/2023]
Abstract
3,4-Methylenedioxymethamphetamine (MDMA; "ecstasy") is a recreational hallucinogenic drug of abuse known to elicit neurotoxic properties. Hepatic formation of neurotoxic metabolites is thought to play a major role in MDMA-related neurotoxicity, though the mechanisms involved are still unclear. Here, we studied the neurotoxicity mechanisms and stability of MDMA and 6 of its major human metabolites, namely α-methyldopamine (α-MeDA) and N-methyl-α-methyldopamine (N-Me-α-MeDA) and their correspondent glutathione (GSH) and N-acetyl-cysteine (NAC) conjugates, under normothermic (37 °C) or hyperthermic conditions (40 °C), using cultured SH-SY5Y differentiated cells. We showed that MDMA metabolites exhibited toxicity to SH-SY5Y differentiated cells, being the GSH and NAC conjugates more toxic than their catecholic precursors and MDMA. Furthermore, whereas the toxicity of the catechol metabolites was potentiated by hyperthermia, NAC-conjugated metabolites revealed higher toxicity under normothermia and GSH-conjugated metabolites-induced toxicity was temperature-independent. Moreover, a time-dependent decrease in extracellular concentration of MDMA metabolites was observed, which was potentiated by hyperthermia. The antioxidant NAC significantly protected against the neurotoxic effects of MDMA metabolites. MDMA metabolites increased intracellular glutathione levels, though depletion in thiol content was observed in MDMA-exposed cells. Finally, the neurotoxic effects induced by the MDMA metabolite N-Me-α-MeDA involved caspase 3 activation. In conclusion, this study evaluated the stability of MDMA metabolites in vitro, and demonstrated that the catechol MDMA metabolites and their GSH and NAC conjugates, rather than MDMA itself, exhibited neurotoxic actions in SH-SY5Y differentiated cells, which were differently affected by hyperthermia, thus highlighting a major role for reactive metabolites and hyperthermia in MDMA's neurotoxicity.
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Affiliation(s)
- Daniel José Barbosa
- REQUIMTE (Rede de Química e Tecnologia), Toxicology Laboratory, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira 228, 4050-313, Porto, Portugal,
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Severe chronic hepatitis secondary to prolonged use of ecstasy and cocaine. Clin Res Hepatol Gastroenterol 2013; 37:e109-13. [PMID: 23910059 DOI: 10.1016/j.clinre.2013.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 06/18/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Severe acute hepatotoxicity is a well known complication following the ingestion of ecstasy (3,4-methylenedioxymethamphetamine [MDMA] ecstasy). Hepatic dysfunction has also been reported after acute cocaine intoxication. However, chronic hepatitis after prolonged use of ecstasy and/or cocaine has rarely been reported. METHODS We report the case of a 27-year-old woman hospitalized with edema, ascites and severe liver failure (prothrombin rate 33%), following the use of ecstasy and cocaine over the previous 9 months. Clinical, biological, radiological and pathology findings were recorded at admission and over 8 years' follow-up. RESULTS Liver biopsy showed architectural distortion caused by bridging fibrosis, proliferation of cholangioles, and lesions of active interface hepatitis. Other causes of acute and chronic liver disease were excluded. Magnetic resonance imaging showed marked liver fibrosis. After withdrawal of both substances clinical examination and liver function tests progressively normalized. Long-term monitoring with magnetic resonance imaging showed progressive regression of fibrosis. CONCLUSION Use of ecstasy and cocaine may cause chronic hepatitis leading to marked liver fibrosis, which may regress after withdrawal of both substances.
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Dias da Silva D, Silva E, Carmo H. Cytotoxic effects of amphetamine mixtures in primary hepatocytes are severely aggravated under hyperthermic conditions. Toxicol In Vitro 2013; 27:1670-8. [DOI: 10.1016/j.tiv.2013.04.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/16/2013] [Accepted: 04/18/2013] [Indexed: 11/15/2022]
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Dias da Silva D, Carmo H, Lynch A, Silva E. An insight into the hepatocellular death induced by amphetamines, individually and in combination: the involvement of necrosis and apoptosis. Arch Toxicol 2013; 87:2165-85. [PMID: 23820845 DOI: 10.1007/s00204-013-1082-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 05/29/2013] [Indexed: 02/06/2023]
Abstract
The liver is a vulnerable target for amphetamine toxicity, but the mechanisms involved in the drug's hepatotoxicity remain poorly understood. The purpose of the current research was to characterize the mode of death elicited by four amphetamines and to evaluate whether their combination triggered similar mechanisms in immortalized human HepG2 cells. The obtained data revealed a time- and temperature-dependent mortality of HepG2 cells exposed to 3,4-methylenedioxymethamphetamine (MDMA, ecstasy; 1.3 mM), methamphetamine (3 mM), 4-methylthioamphetamine (0.5 mM) and D-amphetamine (1.7 mM), alone or combined (1.6 mM mixture). At physiological temperature (37 °C), 24-h exposures caused HepG2 death preferentially by apoptosis, while a rise to 40.5 °C favoured necrosis. ATP levels remained unaltered when the drugs where tested at normothermia, but incubation at 40.5 °C provoked marked ATP depletion for all treatments. Further investigations on the apoptotic mechanisms triggered by the drugs (alone or combined) showed a decline in BCL-2 and BCL- XL mRNA levels, with concurrent upregulation of BAX, BIM, PUMA and BID genes. Elevation of Bax, cleaved Bid, Puma, Bak and Bim protein levels was also seen. To the best of our knowledge, Puma, Bim and Bak have never been linked with the toxicity induced by amphetamines. Time-dependent caspase-3/-7 activation, but not mitochondrial membrane potential (∆ψm) disruption, also mediated amphetamine-induced apoptosis. The cell dismantling was confirmed by poly(ADP-ribose)polymerase proteolysis. Overall, for all evaluated parameters, no relevant differences were detected between individual amphetamines and the mixture (all tested at equieffective cytotoxic concentrations), suggesting that the mode of action of the amphetamines in combination does not deviate from the mode of action of the drugs individually, when eliciting HepG2 cell death.
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Parrott AC. Human psychobiology of MDMA or 'Ecstasy': an overview of 25 years of empirical research. Hum Psychopharmacol 2013; 28:289-307. [PMID: 23881877 DOI: 10.1002/hup.2318] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Accepted: 03/22/2013] [Indexed: 01/26/2023]
Abstract
AIMS This paper aimed to review how scientific knowledge about the human psychobiology of MDMA has developed over time. METHODS In this paper, the empirical findings from earlier and later studies will be reviewed. RESULTS When MDMA was a 'novel psychoactive substance', it was not seen as a drug of abuse, as it displayed loss of efficacy. However, recreational users display a unique pattern of increasing doses, deteriorating cost-benefit ratios, and voluntary cessation. MDMA increases body temperature and thermal stress, with cortisol levels increased by 800% in dance clubbers. It can be extremely euphoric, although negative moods are also intensified. MDMA causes apoptosis (programmed cell death) and has been investigated for cancer therapy because of its anti-lymphoma properties. Recreational users show deficits in retrospective memory, prospective memory, higher cognition, problem solving, and social intelligence. Basic cognitive skills remain intact. Neuroimaging studies show reduced serotonin transporter levels across the cerebral cortex, which are associated with neurocognitive impairments. Deficits also occur in sleep architecture, sleep apnoea, complex vision, pain, neurohormones, and psychiatric status. Ecstasy/MDMA use during pregnancy leads to psychomotor impairments in the children. CONCLUSIONS The damaging effects of Ecstasy/MDMA are far more widespread than was realized a few years ago, with new neuropsychobiological deficits still emerging.
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Affiliation(s)
- Andrew C Parrott
- Department of Psychology, Swansea University, Swansea, South Wales, UK.
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da Silva DD, Silva E, Carmo H. Combination effects of amphetamines under hyperthermia - the role played by oxidative stress. J Appl Toxicol 2013; 34:637-50. [PMID: 23765447 DOI: 10.1002/jat.2889] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 03/11/2013] [Accepted: 03/26/2013] [Indexed: 11/11/2022]
Abstract
Rise in body temperature is a life-threatening consequence of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) abuse. We evaluated the impact of hyperthermia on the cytotoxicity of combinations of MDMA and three other amphetamines, often co-ingested. For this, Hep G2 cells were exposed to MDMA, d-amphetamine, methamphetamine and 4-methylthioamphetamine, individually or combined, at 40.5 °C. The results were compared with normothermia data (37.0 °C). Mixture additivity expectations were calculated by independent action and concentration addition (CA) models. To delineate the mechanism(s) underlying the elicited effects, a range of stress endpoints was evaluated, including quantification of reactive oxygen/nitrogen species (ROS/RNS), lipid peroxidation, reduced/oxidized glutathione (GSH/GSSG), ATP and mitochondrial membrane potential (Δψm) changes. Our data show that, in hyperthermia, amphetamines acted additively and mixture effects were accurately predicted by CA. At 40.5 °C, even slight increases in the concentrations of each drug/mixture promoted significant rises in cytotoxicity, which quickly shifted from roughly undetectable to maximal mortality. Additionally, the increase of RNS/ROS production, decrease of GSH, ATP depletion and mitochondrial impairment were exacerbated under hyperthermia. Importantly, when equieffective cytotoxic concentrations of the mixture and individual amphetamines were compared for all tested stress endpoints, mixture effects did not deviate from those elicited by individual treatments, suggesting that these amphetamines have a similar mode of action, which is not altered in combination. Concluding, our data indicate that amphetamine mixtures produce deleterious effects, even when individual drugs are combined at negligible concentrations. These effects are strongly exacerbated in hyperthermia, emphasizing the potential increased risks of ecstasy intake, especially when hyperthermia occurs concurrently with polydrug abuse.
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Affiliation(s)
- Diana Dias da Silva
- Faculdade de Medicina, Universidade do Porto, 4200-319, Porto, Portugal; Institute for the Environment, Brunel University, Uxbridge, Middlesex, UB8 3PH, UK; REQUIMTE (Rede de Química e Tecnologia), Laboratório de Toxicologia, Departamento de Ciências Biológicas, Faculdade de Farmácia, Universidade do Porto, 4050-313, Porto, Portugal
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Zhuo L, Liu Q, Liu L, Sun TY, Wang RS, Qu GQ, Liu Q, Liu Y, Ren L. Roles of 3,4-methylenedioxymethamphetamine (MDMA)-induced alteration of connexin43 and intracellular Ca(2+) oscillation in its cardiotoxicity. Toxicology 2013; 310:61-72. [PMID: 23747752 DOI: 10.1016/j.tox.2013.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 05/16/2013] [Accepted: 05/28/2013] [Indexed: 01/27/2023]
Abstract
UNLABELLED Although it is well known that 3,4-methylenedioxymethamphetamine (MDMA) can cause various cardiovascular abnormalities and even sudden death from cardiac arrhythmia, whether it has any effect on myocardial gap junctions, which might be one of the targets mediating MDMA-induced cardiotoxicity, remains unclear. OBJECTIVE To test the hypothesis that MDMA may affect the myocardial gap junction protein connexin43 (Cx43) and induce cardiac dysrhythmia. METHOD (1) In vivo study: adult rats were treated with a single dose MDMA administration (20mg/kg, i.p.). Electrocardiogram detection and immunohistochemical analysis were performed to evaluate cardiac function and expression of Cx43, respectively; (2) in vitro study: cultured ventricular myocytes of neonatal rats were treated with MDMA (10, 100, 1000μmol/L) for 1h. Western blotting and real-time quantitative polymerase chain reaction (RT-qPCR) were performed to investigate the total Cx43 mRNA expression. Immunofluorescent analysis was used to evaluate the amount of junctional Cx43. The phosphorylation status of Cx43 at site Ser368 and intracellular Ca(2+) oscillation were also studied. RESULTS Obvious changes in electrocardiographic patterns were found in rats following MDMA administration. They were characterized by prolonged QRS duration associated with increased amplitude of QRS complex. The heart rates in treated rats were significantly decreased compared to the rats in the control group. The immunohistochemical findings revealed a significant decrease in Cx43 expression. The in vitro study also showed a marked decline in total Cx43 protein associated with reduction of Cx43 mRNA, whereas the phosphorylated Cx43 at Ser368 was increased. Decrease of junctional Cx43 was found correlated with reduction in N-cadherin induced by high concentration of MDMA. Additionally, confocal microscopy findings revealed alteration of intracellular calcium oscillation patterns characterized by high frequency and increasing influx Ca(2+). CONCLUSIONS MDMA reduces expression of cardiac gap junction protein Cx43. The increase of phosphorylation status of Cx43 at Ser368 induced by MDMA is attributed, at least in part, to the Ca(2+)-dependent regulation of protein kinase C (PKC) activity. Our findings provide first evidence of MDMA-mediated changes in those cardiac gap junctions that may underlie MDMA-induced cardiac arrhythmia.
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Affiliation(s)
- Luo Zhuo
- Department of Forensic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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Mixtures of 3,4-methylenedioxymethamphetamine (ecstasy) and its major human metabolites act additively to induce significant toxicity to liver cells when combined at low, non-cytotoxic concentrations. J Appl Toxicol 2013; 34:618-27. [PMID: 23670916 DOI: 10.1002/jat.2885] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 03/08/2013] [Accepted: 03/18/2013] [Indexed: 11/07/2022]
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74
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Taniguchi M, Yamamoto Y, Nishi K. Comparative <i>in Vitro</i> Studies of the Metabolism of Six 4-Substituted Methamphetamines and Their Inhibition of Cytochrome P450 2D6 by GC-MS with Trifluoroacetyl Derivatization. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ajac.2013.44022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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75
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Hysek C, Schmid Y, Rickli A, Simmler LD, Donzelli M, Grouzmann E, Liechti ME. Carvedilol inhibits the cardiostimulant and thermogenic effects of MDMA in humans. Br J Pharmacol 2012; 166:2277-88. [PMID: 22404145 DOI: 10.1111/j.1476-5381.2012.01936.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND PURPOSE The use of ± 3,4-methylenedioxymethamphetamine (MDMA, 'ecstasy') is associated with cardiovascular complications and hyperthermia. EXPERIMENTAL APPROACH We assessed the effects of the α(1) - and β-adrenoceptor antagonist carvedilol on the cardiostimulant, thermogenic and subjective responses to MDMA in 16 healthy subjects. Carvedilol (50 mg) or placebo was administered 1 h before MDMA (125 mg) or placebo using a randomized, double-blind, placebo-controlled, four-period crossover design. KEY RESULTS Carvedilol reduced MDMA-induced elevations in blood pressure, heart rate and body temperature. Carvedilol did not affect the subjective effects of MDMA including MDMA-induced good drug effects, drug high, drug liking, stimulation or adverse effects. Carvedilol did not alter the plasma exposure to MDMA. CONCLUSIONS AND IMPLICATIONS α(1) - and β-Adrenoceptors contribute to the cardiostimulant and thermogenic effects of MDMA in humans but not to its psychotropic effects. Carvedilol could be useful in the treatment of cardiovascular and hyperthermic complications associated with ecstasy use.
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Affiliation(s)
- Cm Hysek
- Clinical Pharmacology and Toxicology, Department of Biomedicine and Department of Internal Medicine, University Hospital and University of Basel, Switzerland
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76
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Akkina SK, Ricardo AC, Patel A, Das A, Bazzano LA, Brecklin C, Fischer MJ, Lash JP. Illicit drug use, hypertension, and chronic kidney disease in the US adult population. Transl Res 2012; 160:391-8. [PMID: 22735028 PMCID: PMC3461092 DOI: 10.1016/j.trsl.2012.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 05/24/2012] [Accepted: 05/25/2012] [Indexed: 11/19/2022]
Abstract
Illicit drug use has been associated with chronic kidney disease (CKD) in select populations, but it is unknown whether the same association exists in the general population. By using data from the National Health and Nutrition Examination Survey 2005-2008, we conducted a cross-sectional analysis of 5861 adults who were questioned about illicit drug use, including cocaine, methamphetamines, and heroin, during their lifetime. The primary outcome was CKD as defined by an estimated glomerular filtration rate ≤60 mL/min/1.73 m(2) using the Chronic Kidney Disease Epidemiology Collaboration equation or by microalbuminuria. We also examined the association between illicit drug use and blood pressure (BP) ≥120/80, ≥130/85, and ≥140/90 mm Hg. Logistic regression was used to examine the association between illicit drug use and CKD and BP. Mean estimated glomerular filtration rate was similar between illicit drug users and nonusers (100.7 vs 101.4 mL/min/1.73 m(2), P = 0.4), as was albuminuria (5.7 vs 6.0 mg/g creatinine, P = 0.5). Accordingly, illicit drug use was not significantly associated with CKD in logistic regression models (odds ratio [OR], 0.98; confidence interval [CI], 0.75-1.27) after adjusting for other important factors. However, illicit drug users had higher systolic (120 vs 118 mm Hg, P = 0.04) and diastolic BP (73 vs 71 mm Hg, P = 0.0003) compared with nonusers. Cocaine use was independently associated with BP ≥130/85 mm Hg (OR, 1.24; CI, 1.00-1.54), especially when used more during a lifetime (6-49 times; OR, 1.42; CI, 1.06-1.91). In a representative sample of the US population, illicit drug use was not associated with CKD, but cocaine users were more likely to have elevated BP.
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Affiliation(s)
- Sanjeev K Akkina
- Medicine/Nephrology, University of Illinois at Chicago, Chicago, IL 60612-7315, USA.
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77
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de la Torre R, Yubero-Lahoz S, Pardo-Lozano R, Farré M. MDMA, methamphetamine, and CYP2D6 pharmacogenetics: what is clinically relevant? Front Genet 2012; 3:235. [PMID: 23162568 PMCID: PMC3495276 DOI: 10.3389/fgene.2012.00235] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 10/16/2012] [Indexed: 11/17/2022] Open
Abstract
In vitro human studies show that the metabolism of most amphetamine-like psychostimulants is regulated by the polymorphic cytochrome P450 isozyme CYP2D6. Two compounds, methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA), were selected as archetypes to discuss the translation and clinical significance of in vitro to in vivo findings. Both compounds were chosen based on their differential interaction with CYP2D6 and their high abuse prevalence in society. Methamphetamine behaves as both a weak substrate and competitive inhibitor of CYP2D6, while MDMA acts as a high affinity substrate and potent mechanism-based inhibitor (MBI) of the enzyme. The MBI behavior of MDMA on CYP2D6 implies that subjects, irrespective of their genotype/phenotype, are phenocopied to the poor metabolizer (PM) phenotype. The fraction of metabolic clearance regulated by CYP2D6 for both drugs is substantially lower than expected from in vitro studies. Other isoenzymes of cytochrome P450 and a relevant contribution of renal excretion play a part in their clearance. These facts tune down the potential contribution of CYP2D6 polymorphism in the clinical outcomes of both substances. Globally, the clinical relevance of CYP2D6 polymorphism is lower than that predicted by in vitro studies.
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Affiliation(s)
- Rafael de la Torre
- Human Pharmacology and Clinical Neurosciences Research Group, Neurosciences Research Program, IMIM-Hospital del Mar Medical Research Institute Barcelona, Spain ; Department of Experimental and Health Sciences, Universitat Pompeu Fabra Barcelona, Spain
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78
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Penders TM, Gestring RE, Vilensky DA. Excited delirium following use of synthetic cathinones (bath salts). Gen Hosp Psychiatry 2012; 34:647-50. [PMID: 22898445 DOI: 10.1016/j.genhosppsych.2012.06.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 02/04/2023]
Abstract
Synthetic analogs of the cathinone molecule have seen increasing recreational use as substitutes for cocaine, 3,4-methylenedioxymethamphetamine (ecstasy) and methamphetamine. Repeated use of these drugs is associated with a paranoid hallucinatory delirium. A subset of patients using these substances develops a syndrome of extreme agitation and violent behavior that has been reported following the use of other stimulant drugs that also produce rapid changes in brain monoamines. This syndrome, characterized as "excited delirium," presents to the acute care setting with a challenging combination of paranoia, severe agitation and violent behavior. These patients frequently suffer from dehydration, skeletal muscle damage and renal failure that may lead to multiorgan failure and death. Management of these individuals requires careful consideration of the consequences of interventions commonly implemented in medical settings to control dangerous aggressive behavior.
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Affiliation(s)
- Thomas M Penders
- Department of Psychiatric Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27834, USA.
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79
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Bath salts: a newly recognized cause of acute kidney injury. Case Rep Nephrol 2012; 2012:560854. [PMID: 24555135 PMCID: PMC3914251 DOI: 10.1155/2012/560854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 10/03/2012] [Indexed: 11/17/2022] Open
Abstract
Bath salts are substance of abuse that are becoming more common and are difficult to recognize due to negative toxicology screening. Acute kidney injury due to bath salt use has not previously been described. We present the case of a previously healthy male who developed acute kidney injury and dialysis dependence after bath salt ingestion and insufflation. This was self-reported with negative toxicology screening. Clinical course was marked by severe hyperthermia, hyperkalemia, rhabdomyolysis, disseminated intravascular coagulation, oliguria, and sepsis. We discuss signs and symptoms, differential diagnoses, potential mechanisms of injury, management, and review of the literature related to bath salt toxicity.
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80
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Patel A, Moreland T, Haq F, Siddiqui F, Mikul M, Qadir H, Raza S. Persistent Psychosis After a Single Ingestion of "Ecstasy" (MDMA). Prim Care Companion CNS Disord 2012; 13:11l01200. [PMID: 22454798 DOI: 10.4088/pcc.11l01200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Ankit Patel
- Department of Psychiatry, University of South Alabama, Mobile
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81
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Catecholaminergic polymorphic ventricular tachycardia found in an adolescent after a methylenedioxymethamphetamine and marijuana-induced cardiac arrest. Crit Care Med 2012; 40:2223-6. [PMID: 22584762 DOI: 10.1097/ccm.0b013e318250a870] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To illustrate the challenges of managing patients with acute, undiagnosed arrhythmias through a case that demonstrates a possible association between catecholaminergic polymorphic ventricular tachycardia, a genetically determined severe arrhythmia disorder that often presents as either syncope or sudden death, and 3,4-Methylenedioxymethamphetamine ("Ecstasy") combined with marijuana, which are often considered safe drugs by users. DESIGN Case report. SETTING Pediatric intensive care unit. PATIENT A 15-yr-old male collapsed suddenly after ingesting an unknown substance and smoking marijuana. He was successfully resuscitated by first-responder chest compressions and rescue breaths along with a single 100-J shock by paramedics. He was intubated and transferred to a pediatric intensive care unit. Initial cardiac workup was negative but severe instability on vasopressors and a family history of intermittent palpitations and syncope in his brother raised suspicion for catecholaminergic polymorphic ventricular tachycardia. Identification of the unknown substance required coordination with a toxicology laboratory. INTERVENTIONS The patient had extremely labile cardiovascular responses to vasopressors. On day 5, his blood pressure was stable and he was extubated. A full cardiac workup, including a catheterization (preadmission to pediatric intensive care unit), electrocardiogram, cardiac magnetic resonance imaging were done to screen out most structural arrythmogenic diseases. A specific genetic test for catecholaminergic polymorphic ventricular tachycardia was sent. MEASUREMENTS AND MAIN RESULTS The patient's methylenedioxymethamphetamine blood level was 87 ng/mL approximately 12 hrs after ingestion. Given the 3-8 hr half-life of methylenedioxymethamphetamine, it is likely that levels were toxic at the time of ingestion (>110 ng/mL). Marijuana may have provided a synergistic critical catecholamine release to trigger an arrhythmia. Genetic testing showed a ryanodine receptor-2 mutation that was consistent with catecholaminergic polymorphic ventricular tachycardia. CONCLUSIONS While an initial cardiac workup for an acute, undiagnosed arrhythmia may be negative, family history may be a simple, essential component of patient management and disease diagnosis. This case demonstrates a possible association between methylenedioxymethamphetamine, marijuana, and catecholaminergic polymorphic ventricular tachycardia. All genetic and structural arrythmogenic disorders should be considered when working up a patient with presumed toxin-induced arrhythmias.
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82
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Kahn DE, Ferraro N, Benveniste RJ. 3 cases of primary intracranial hemorrhage associated with "Molly", a purified form of 3,4-methylenedioxymethamphetamine (MDMA). J Neurol Sci 2012; 323:257-60. [PMID: 22998806 DOI: 10.1016/j.jns.2012.08.031] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Revised: 08/27/2012] [Accepted: 08/30/2012] [Indexed: 11/26/2022]
Abstract
3,4-Methylenedioxymethamphetamine (MDMA, or "Ecstasy" in tablet form) is a powerful sympathomimetic drug that is commonly perceived as safer than other stimulants such as methamphetamine or cocaine. "Molly" is a purified form of MDMA that is perceived by users as being even safer, as it is free of adulterants such as methamphetamine. Previously, all reports of intracranial hemorrhages in MDMA abusers were associated with coingestion of other sympathomimetic drugs, or with pre-existing cerebrovascular lesions. We describe a series of three young, otherwise healthy patients with various types of intracranial hemorrhages associated with "Molly" ingestion. All three patients underwent extensive workup including catheter angiography that did not demonstrate aneurysm, arteriovenous malformation, or vasculitis. We suggest that even the purified form of MDMA can cause serious intracranial hemorrhagic complications and should not be thought of as a safe recreational drug.
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Affiliation(s)
- D Ethan Kahn
- University of Miami Miller School of Medicine, Department of Neurology, USA.
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83
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Abstract
A variety of neuropathological findings has been described in illicit drug abusers. The majority of these alterations result from the consequences of hypoxia-ischemia and from cerebrovascular diseases. Within the last few years, widespread morphological alterations of the cellular elements of the brain have been detected. These changes consist of neuronal loss, a numerical reduction of astrocytes, widespread axonal damage with concomitant microglial activation and reactive and degenerative changes of the cerebral microvessels. Based on various studies there is also concern that drug abusers develop neurodegeneration or Parkinsonism as they age. However, whether or to what extent neurodegeneration occurs in human drug abusers remains to be established. In the present paper a brief overview on the neuropathological changes in drug abuse is presented for the forensic pathologist/toxi-cologist with reference to the most pertinent literature.
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Affiliation(s)
- Andreas Büttner
- Forensic Pathology and the Director and Chair of the Institute of Legal Medicine at the Medical University of Rostock, Germany. Ethical Commission at the Medical University of Rostock
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84
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85
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Penders TM, Gestring RE, Vilensky DA. Intoxication delirium following use of synthetic cathinone derivatives. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2012; 38:616-7. [PMID: 22783894 DOI: 10.3109/00952990.2012.694535] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND In published reports of hallucinatory delirium following use of "bath salts" analytic laboratory testing has demonstrated the synthetic cathinone derivative methylenedioxypyrovalerone (MDPV). MDPV can cause a false-positive screening immunoassay result for phencyclidine (PCP). Patients using MDPV are prone to development of the syndrome of excited delirium (ExD), a condition also described with PCP. OBJECTIVE This review summarize reports from several series of cases of delirium associated with MDPV emphasizing the features of both intoxication and excited delirium. METHODS Literature review and clinical description of a series of patients from Eastern North Carolina. CONCLUSION MDPV is likely the responsible agent in production of both toxic and excited delirium syndromes identified with the recreational use of "bath salts" in the United States over the past two years. SCIENTIFIC SIGNIFICANCE Patients using MDPV are prone to the development of toxic delirum with some developing ExD. a condition associated with considerable risk for serious medical morbidity. Commonly used interventions directed at extreme agitation and paranoia may exacerbate the pathophysiology of ExD.
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86
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Green AR, King MV, Shortall SE, Fone KCF. Lost in translation: preclinical studies on 3,4-methylenedioxymethamphetamine provide information on mechanisms of action, but do not allow accurate prediction of adverse events in humans. Br J Pharmacol 2012; 166:1523-36. [PMID: 22188379 PMCID: PMC3419898 DOI: 10.1111/j.1476-5381.2011.01819.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 11/18/2011] [Accepted: 11/29/2011] [Indexed: 11/28/2022] Open
Abstract
3,4-Methylenedioxymethamphetamine (MDMA) induces both acute adverse effects and long-term neurotoxic loss of brain 5-HT neurones in laboratory animals. However, when choosing doses, most preclinical studies have paid little attention to the pharmacokinetics of the drug in humans or animals. The recreational use of MDMA and current clinical investigations of the drug for therapeutic purposes demand better translational pharmacology to allow accurate risk assessment of its ability to induce adverse events. Recent pharmacokinetic studies on MDMA in animals and humans are reviewed and indicate that the risks following MDMA ingestion should be re-evaluated. Acute behavioural and body temperature changes result from rapid MDMA-induced monoamine release, whereas long-term neurotoxicity is primarily caused by metabolites of the drug. Therefore acute physiological changes in humans are fairly accurately mimicked in animals by appropriate dosing, although allometric dosing calculations have little value. Long-term changes require MDMA to be metabolized in a similar manner in experimental animals and humans. However, the rate of metabolism of MDMA and its major metabolites is slower in humans than rats or monkeys, potentially allowing endogenous neuroprotective mechanisms to function in a species specific manner. Furthermore acute hyperthermia in humans probably limits the chance of recreational users ingesting sufficient MDMA to produce neurotoxicity, unlike in the rat. MDMA also inhibits the major enzyme responsible for its metabolism in humans thereby also assisting in preventing neurotoxicity. These observations question whether MDMA alone produces long-term 5-HT neurotoxicity in human brain, although when taken in combination with other recreational drugs it may induce neurotoxicity.
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Affiliation(s)
- A R Green
- School of Biomedical Sciences, Queen's Medical Centre, University of Nottingham, UK.
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87
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Russell T, Riazi S, Kraeva N, Steel AC, Hawryluck LA. Ecstacy-induced delayed rhabdomyolysis and neuroleptic malignant syndrome in a patient with a novel variant in the ryanodine receptor type 1 gene. Anaesthesia 2012; 67:1021-4. [PMID: 22734812 DOI: 10.1111/j.1365-2044.2012.07226.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We present the case of a 20-year-old woman who developed rhabdomyolysis, disseminated intravascular coagulopathy and multi-organ failure induced by ecstasy. Following initial improvement, she developed delayed rhabdomyolysis then haloperidol-induced neuroleptic malignant syndrome, which was treated with a total of 50 mg.kg(-1) dantrolene. Subsequent genetic testing revealed a novel potentially pathogenic variant in the ryanodine receptor type 1 gene. However, caffeine-halothane contracture testing of the patient's mother who carried the same gene variant was negative for malignant hyperthermia.
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Affiliation(s)
- T Russell
- Anaesthesia Department, Sir Charles Gairdner Hospital, Perth, Western Australia.
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88
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Carvalho M, Carmo H, Costa VM, Capela JP, Pontes H, Remião F, Carvalho F, Bastos MDL. Toxicity of amphetamines: an update. Arch Toxicol 2012; 86:1167-231. [PMID: 22392347 DOI: 10.1007/s00204-012-0815-5] [Citation(s) in RCA: 261] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 02/02/2012] [Indexed: 01/06/2023]
Abstract
Amphetamines represent a class of psychotropic compounds, widely abused for their stimulant, euphoric, anorectic, and, in some cases, emphathogenic, entactogenic, and hallucinogenic properties. These compounds derive from the β-phenylethylamine core structure and are kinetically and dynamically characterized by easily crossing the blood-brain barrier, to resist brain biotransformation and to release monoamine neurotransmitters from nerve endings. Although amphetamines are widely acknowledged as synthetic drugs, of which amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) are well-known examples, humans have used natural amphetamines for several millenniums, through the consumption of amphetamines produced in plants, namely cathinone (khat), obtained from the plant Catha edulis and ephedrine, obtained from various plants in the genus Ephedra. More recently, a wave of new amphetamines has emerged in the market, mainly constituted of cathinone derivatives, including mephedrone, methylone, methedrone, and buthylone, among others. Although intoxications by amphetamines continue to be common causes of emergency department and hospital admissions, it is frequent to find the sophism that amphetamine derivatives, namely those appearing more recently, are relatively safe. However, human intoxications by these drugs are increasingly being reported, with similar patterns compared to those previously seen with classical amphetamines. That is not surprising, considering the similar structures and mechanisms of action among the different amphetamines, conferring similar toxicokinetic and toxicological profiles to these compounds. The aim of the present review is to give an insight into the pharmacokinetics, general mechanisms of biological and toxicological actions, and the main target organs for the toxicity of amphetamines. Although there is still scarce knowledge from novel amphetamines to draw mechanistic insights, the long-studied classical amphetamines-amphetamine itself, as well as methamphetamine and MDMA, provide plenty of data that may be useful to predict toxicological outcome to improvident abusers and are for that reason the main focus of this review.
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Affiliation(s)
- Márcia Carvalho
- REQUIMTE, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Portugal
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Parrott AC. MDMA and temperature: a review of the thermal effects of 'Ecstasy' in humans. Drug Alcohol Depend 2012; 121:1-9. [PMID: 21924843 DOI: 10.1016/j.drugalcdep.2011.08.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 07/20/2011] [Accepted: 08/12/2011] [Indexed: 10/17/2022]
Abstract
AIMS To review the thermal effects of MDMA in humans, and discuss the practical implications. METHODS The literature on Ecstasy/MDMA, body temperature, and subjective thermal self-ratings was reviewed, and explanatory models for the changes in thermal homeostasis were examined and debated. RESULTS In human placebo-controlled laboratory studies, the effects of MDMA were dose related. Low doses had little effect, moderate doses increased body temperature by around +0.4°C, and higher doses caused a mean increase of +0.7°C. With Ecstasy/MDMA using dance clubbers, the findings showed greater variation, due possibly to uncontrolled factors such as physical activity, ambient temperature, and overcrowding. Some real world studies found average body temperature increases of over +1.0°C. Thermal homeostasis involves a balance between heat production and heat dissipation, and MDMA affects both aspects of this homeostatic equation. Cellular metabolic heat output is increased, and heat dissipation mechanisms are stressed, with the onset of sweating delayed. Subjective responses of 'feeling hot' or 'hot-cold flushes' are frequent, but can show individual variation. Some recreational users report that heat increases or reinstates the positive mood effects of Ecstasy/MDMA. The dangers of acute hyperthermia can include rare fatalities. It is unclear why moderate hyperthermia can occasionally progress to severe hyperpyrexia, although it may reflect a combination or cascade of events. In chronic terms, the bioenergetic stress model notes that the adverse psychobiological effects of MDMA are heightened by various co-stimulatory factors, including heat stress. CONCLUSIONS MDMA increases core body temperature and thermal stress in humans.
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Affiliation(s)
- A C Parrott
- Department of Psychology, Swansea University, Swansea SA2 8PP, United Kingdom.
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90
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Martins J, Castelo-Branco M, Batista A, Oliveiros B, Santiago AR, Galvão J, Fernandes E, Carvalho F, Cavadas C, Ambrósio AF. Effects of 3,4-methylenedioxymethamphetamine administration on retinal physiology in the rat. PLoS One 2011; 6:e29583. [PMID: 22216322 PMCID: PMC3246479 DOI: 10.1371/journal.pone.0029583] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 11/30/2011] [Indexed: 01/28/2023] Open
Abstract
3,4-Methylenedioxymethamphetamine (MDMA; ecstasy) is known to produce euphoric states, but may also cause adverse consequences in humans, such as hyperthermia and neurocognitive deficits. Although MDMA consumption has been associated with visual problems, the effects of this recreational drug in retinal physiology have not been addressed hitherto. In this work, we evaluated the effect of a single MDMA administration in the rat electroretinogram (ERG). Wistar rats were administered MDMA (15 mg/kg) or saline and ERGs were recorded before (Baseline ERG), and 3 h, 24 h, and 7 days after treatment. A high temperature (HT) saline-treated control group was also included. Overall, significantly augmented and shorter latency ERG responses were found in MDMA and HT groups 3 h after treatment when compared to Baseline. Twenty-four hours after treatment some of the alterations found at 3 h, mainly characterized by shorter latency, tended to return to Baseline values. However, MDMA-treated animals still presented increased scotopic a-wave and b-wave amplitudes compared to Baseline ERGs, which were independent of temperature elevation though the latter might underlie the acute ERG alterations observed 3 h after MDMA administration. Seven days after MDMA administration recovery from these effects had occurred. The effects seem to stem from specific changes observed at the a-wave level, which indicates that MDMA affects subacutely (at 24 h) retinal physiology at the outer retinal (photoreceptor/bipolar) layers. In conclusion, we have found direct evidence that MDMA causes subacute enhancement of the outer retinal responses (most prominent in the a-wave), though ERG alterations resume within one week. These changes in photoreceptor/bipolar cell physiology may have implications for the understanding of the subacute visual manifestations induced by MDMA in humans.
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Affiliation(s)
- João Martins
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Centre for Neuroscience and Cell Biology (CNC), University of Coimbra, Coimbra, Portugal
| | - Miguel Castelo-Branco
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana Batista
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Bárbara Oliveiros
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Ana Raquel Santiago
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Joana Galvão
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Eduarda Fernandes
- REQUIMTE - Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Félix Carvalho
- REQUIMTE - Department of Chemical Sciences, Faculty of Pharmacy, University of Porto, Porto, Portugal
| | - Cláudia Cavadas
- Centre for Neuroscience and Cell Biology (CNC), University of Coimbra, Coimbra, Portugal
- Faculty of Pharmacy, University of Coimbra, Coimbra, Portugal
| | - António F. Ambrósio
- Centre of Ophthalmology and Vision Sciences, IBILI, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Centre for Neuroscience and Cell Biology (CNC), University of Coimbra, Coimbra, Portugal
- AIBILI, Coimbra, Portugal
- * E-mail:
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91
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Antolino-Lobo I, Meulenbelt J, van den Berg M, van Duursen MB. A mechanistic insight into 3,4-methylenedioxymethamphetamine (“ecstasy”)-mediated hepatotoxicity. Vet Q 2011; 31:193-205. [DOI: 10.1080/01652176.2011.642534] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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92
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Mohamed WM, Hamida SB, Cassel JC, de Vasconcelos AP, Jones BC. MDMA: Interactions with other psychoactive drugs. Pharmacol Biochem Behav 2011; 99:759-74. [DOI: 10.1016/j.pbb.2011.06.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 05/10/2011] [Accepted: 06/28/2011] [Indexed: 10/18/2022]
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93
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Fulceri F, Ferrucci M, Lenzi P, Soldani P, Bartalucci A, Paparelli A, Gesi M. MDMA (ecstasy) enhances loud noise-induced morphofunctional alterations in heart and adrenal gland. Microsc Res Tech 2011; 74:874-87. [PMID: 23939676 DOI: 10.1002/jemt.20971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 10/26/2010] [Indexed: 11/09/2022]
Abstract
Noise is an environmental stressor increasingly more present in modern life and, in particular, in a variety of recreational contexts. The aim of this work is to show the effects of noise on the myocardium and adrenal gland, through a careful review of the literature dealing with the peripheral effects of noise exposure in experimental and clinical studies. Noise induces adverse effects in human health, principally involving the cardiovascular and autonomic nervous systems, and the endocrine apparatus. Several factors in recreational environments potentially worsen the effects induced by loud noise. Among these, the intake of 3,4-methylenedioxymethamphetamine (MDMA) is frequently associated with noise exposure in recreational situations, because of its high compliance within social and relaxation settings. For this reason, MDMA is defined as a club drug--as its intake by young people often occurs in association with other factors, such as aggregation, high temperatures, and noise. It is known that self-administration of MDMA by humans causes severe toxicity. In particular, the myocardium is affected early after MDMA intake--resulting in tachycardia, hypertension, and arrhythmia. Furthermore, MDMA alters the activity of the adrenal glands by elevating catecholamines and corticosterone levels. This review shows that combining MDMA and loud noise exposure potentiates the effects that are produced by each single stimulant alone as seen in experimental animal models. The convergence of the effects of prolonged loud noise exposure and the consumption of MDMA on the same system might explain the sudden fatal events that happen in recreational situations.
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Affiliation(s)
- Federica Fulceri
- Department of Human Morphology and Applied Biology, University of Pisa, Pisa, Italy
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94
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95
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Yubero-Lahoz S, Pardo R, Farré M, OʼMahony B, Torrens M, Mustata C, Pérez-Mañá C, Carbó M, de la Torre R. Sex Differences in 3,4-Methylenedioxymethamphetamine (MDMA; Ecstasy)-Induced Cytochrome P450 2D6 Inhibition in Humans. Clin Pharmacokinet 2011; 50:319-29. [DOI: 10.2165/11584550-000000000-00000] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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96
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Banks ML, Sprague JE. From Bench to Bedside: Understanding the Science behind the Pharmacologic Management of MDMA- and other Sympathomimetic-Mediated Hyperthermia. J Pharm Technol 2011. [DOI: 10.1177/875512251102700305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To evaluate the scientific rationale and efficacy of pharmacologic and nonpharmacologic treatments for sympathomimetic-induced hyperthermia and related sequelae. Data Sources: Literature was accessed through MEDLINE (1940-September 2010) using the terms MDMA [3,4-methylenedioxymethamphetamine], methamphetamine, toxicity, and hyperthermia. In addition, reference citations from identified publications were reviewed. Study Selection and Data Extraction: All articles written in English identified from data sources were evaluated. Data Synthesis: The treatment of sympathomimetic-induced hyperthermia is a challenging problem for health-care professionals. The lack of clinical trials further complicates the development of evidence-based treatment algorithms. Preclinical studies have mostly been with the sympathomimetic MDMA and have demonstrated a reversal of MDMA-induced hyperthermia with a mixed serotonin 5-HT1A agonist/5-HT2A antagonist or mixed α1- and β1,2,3-adrenergic receptor antagonists. Conclusions: Because of the nature by which patients are exposed to these agents, therapeutic interventions for sympathomimetic-mediated hyperthermia still lack evidence from clinical trials with human subjects. Pharmacologic treatments that should be avoided are antipyretics and the ryanodine receptor antagonist dantrolene. Promising future therapies may involve mixed 5-HT1A agonist/5-HT2A antagonists such as the atypical antipsychotic olanzapine, or mixed α1- and β1,2,3-adrenergic receptor antagonists such as carvedilol, as current preclinical research suggests.
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Affiliation(s)
- Matthew L Banks
- MATTHEW L BANKS PharmD PhD, Assistant Professor, Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA
| | - Jon E Sprague
- JON E SPRAGUE RPh PhD, Professor of Pharmacology and Dean, The Raabe College of Pharmacy, Ohio Northern University, Ada, OH
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97
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Fallon JK, Kicman AT, Hutt AJ, Cowan DA, Henry JA. Enantiomeric analysis of MDMA (Ecstasy) in plasma and urine by capillary gc: A preliminary investigation of the stereoselective disposition in man. J Pharm Pharmacol 2011. [DOI: 10.1111/j.2042-7158.1998.tb02317.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- J K Fallon
- Drug Control Centre and Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - A T Kicman
- Drug Control Centre and Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - A J Hutt
- Drug Control Centre and Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - D A Cowan
- Drug Control Centre and Department of Pharmacy, King’s College London, Manresa Road, London SW3 6LX
| | - J A Henry
- Academic Department of Accident and Emergency Medicine, Imperial College School of Medicine, St Mary’s Hospital, London W2 1NY
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98
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“Ecstasy” associated deaths: what is a fatal concentration ? Analysis of a case series. Forensic Sci Med Pathol 2011; 7:248-52. [DOI: 10.1007/s12024-010-9220-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2010] [Indexed: 11/25/2022]
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100
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Review: Pharmacogenetic aspects of the effect of cytochrome P450 polymorphisms on serotonergic drug metabolism, response, interactions, and adverse effects. Forensic Sci Med Pathol 2010; 7:162-84. [PMID: 21052868 DOI: 10.1007/s12024-010-9188-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2010] [Indexed: 12/26/2022]
Abstract
The field of pharmacogenetics contains a wealth of potential for the enhancement of clinical practice by providing a more effective match between patient and drug, consequently reducing the probability of an adverse drug reaction. Although a relatively novel concept in the forensic context, pharmacogenetics has the capability to assist in the interpretation of drug related deaths, particularly in unintentional drug poisonings where the cause of death remains unclear. However, the complex pharmacology of the drugs when subjected to genetic variations in metabolism makes interpretation of the expected response and adverse events difficult. Many possess multiple metabolic pathways, narrow therapeutic indices and active metabolites or enantiomers which may be eliminated via different pathways to the parent drug. A number of these drugs, which are metabolised primarily by the CYP450 system, are also associated with serotonin syndrome, or serotonin toxicity, especially when used concomitantly with other serotonin active drugs which rely on the same metabolic pathways for drug elimination. A comprehensive understanding of polymorphic drug metabolism and its expected outcomes is therefore essential when interpreting the involvement of drugs in adverse reactions. This review examines the genetically variable CYP450-mediated metabolism of a number of serotonin-active drugs that are often implicated in cases of serotonin toxicity, to assess the impact of pharmacogenetics on drug metabolism, response, interactions and adverse effects.
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