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Sharif AF, Alshammari RY, Alghamdi FT, Almutairi SA, AlGhamdi AS, Al-Nazhan AS, AlNasser S, Al-Mulhim KA. Assessment of co-ingestion effects on poisoning patterns, drug-drug interactions, and adverse outcomes in acute toxic exposure. Toxicol Rep 2024; 13:101705. [PMID: 39224455 PMCID: PMC11367109 DOI: 10.1016/j.toxrep.2024.101705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2024] [Revised: 07/23/2024] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
Multiple toxic exposures are increasing nowadays. In cases of acute poisoning involving multiple agents, there is a potential for additional toxicity that goes beyond the effects and toxicity of each drug. Very scarce studies have investigated the problem of multiple toxic exposures where the information on drug-drug interactions (DDIs) originates from clinical experience, which is inconclusive and cannot be generalized to patients. Therefore, the current study aimed to explore the influence of co-ingestion on the clinical presentation of exposed patients and to identify the common associated DDIs and their effect on poisoning outcomes, including the need for mechanical ventilation (MV), intensive care unit (ICU) utilization, and prolonged hospital stay. The current study is a retrospective cross-sectional study that was conducted using medical records of 169 adult patients admitted to a poison control center and diagnosed with acute drug poisoning. Of them, 40.8 % were exposed to multiple drugs. The total number of drugs reported in the current study was 320 preparations, with an average of 1.9 drugs per patient. There were about 726 potential DDIs; more than half of these interactions were significant (n = 486). Antidepressants and psychotropics showed the highest total number of DDIs. Patients with multiple ingestion were significantly older and this pattern of exposure was more frequent among suicidal attempters, substance abusers, cardiac patients, and patients diagnosed with neurological and psychological problems. Moreover, patients with multiple ingestions showed severe presentations indicated by higher grades of Poison Severity Score and lower Glasgow Coma Scale. Multiple ingestion was associated with higher liability for MV, ICU admission, and prolonged length of hospital stay (p < 0.001). There was a significant moderate direct correlation between the number of drugs consumed and the number of resulting DDIs (r = 0.542, p < 0.001). There was a significant direct correlation between the occurrence of significant chronic/chronic drug interactions from one side and the history of substance abuse (r = 0.596, p = 0.041) and psychological illness (r = 0.662, p = 0.019) from the other side. Moreover, significant acute/acute drug interactions were correlated with being male (r = 0.969, p < 0.001) of older age (r = 0.672, p = 0.024). Similarly, significant acute/chronic drug interactions were moderately correlated with being a male (r = 0.692, p = 0.013). The presence of epilepsy and psychological problems were the main significant predictors of multiple acute toxic exposures. Among the patients exposed acutely to more than one agent who were on long-term treatment, exposure to three drugs or more could significantly predict the need for MV with excellent area under the curve (AUC) of 0.896 and 77.0 % accuracy. Moreover, and it was a fair predictor of ICU admission (AUC = 0.625), with an 88.9 % ability to exclude patients unlikely to need ICU admission. Particular attention should be paid to the patients at risk of potential DDIs. When prescribing drugs, the minimum number of drugs with the lowest effective doses, and minimal potential DDIs should be prioritized.
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Affiliation(s)
- Asmaa Fady Sharif
- Department of Clinical Medical Sciences, College of Medicine, Dar AL-Uloom University, Al Falah, Riyadh 13314, Kingdom of Saudi Arabia
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, El Bahr St., Tanta, Gharbia Governorate 31111, Egypt
| | | | | | | | | | | | - Shahd AlNasser
- Saudi Food and Drug Authority, Hittin, Riyadh 13513, Kingdom of Saudi Arabia
| | - Khalid A. Al-Mulhim
- Emergency Medicine Department, King Fahad Medical City, Sulimaniyah, Riyadh 12231, Kingdom of Saudi Arabia
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Bai R, Xie B, Cong B, Ma CL, Wen D. Epidemiological Characteristics of Sedative-Hypnotics and Opioid Painkillers at High-Frequency Exposure. FA YI XUE ZA ZHI 2021; 37:694-698. [PMID: 35187923 DOI: 10.12116/j.issn.1004-5619.2020.300702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Drug poisoning has a high incidence and serious consequences in medical institutions; its epidemiological characteristics also directly affect the changes in national laws and policies and the implementation of local management policies. Chinese statistics on drug-related abnormal death cases generally come from judicial appraisal centers and medical units. However, due to differences in work content and professional restrictions, there are differences in information management forms, which makes it difficult for appraisers to conduct a professional and systematic analysis of drug-related cases. This article focuses on the analysis of epidemiological characteristics of sedative-hypnotics and opioid painkillers and their exposure patterns in cases of poisoning death by analyzing the annual report of the American Association of Poison Control Center, combined with the characteristics of drug exposure in China.
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Affiliation(s)
- Rui Bai
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Bing Xie
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Bin Cong
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Chun-Ling Ma
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Di Wen
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
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Mohabansi NP, Satone AK, Hirani SN. Partial and Аpparent Мolar Volume of Аzithromycin in Its Solutions in Еthanol, 1-Рropanol, and 1-Butanol at 300.15, 305.15, 310.15 K and Ambient Pressure. RUSSIAN JOURNAL OF PHYSICAL CHEMISTRY A 2021. [PMCID: PMC8128087 DOI: 10.1134/s0036024421140132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Nita P. Mohabansi
- Department of Chemistry, Bajaj College of Science, Jamanalal Bajaj Marg, Civil Lines, Wardha, India
| | - Anita K. Satone
- Department of Chemistry, Bajaj College of Science, Jamanalal Bajaj Marg, Civil Lines, Wardha, India
| | - Sonia N. Hirani
- Department of Chemistry, Bajaj College of Science, Jamanalal Bajaj Marg, Civil Lines, Wardha, India
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Rahikainen AL, Vauhkonen P, Pett H, Palo JU, Haukka J, Ojanperä I, Niemi M, Sajantila A. Completed suicides of citalopram users-the role of CYP genotypes and adverse drug interactions. Int J Legal Med 2018; 133:353-363. [PMID: 30173302 DOI: 10.1007/s00414-018-1927-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/24/2018] [Indexed: 12/25/2022]
Abstract
Depression is known to be a risk factor for suicide. Currently, the most used antidepressants are selective serotonin reuptake inhibitors (SSRIs). Not all users, however, benefit from them. In such cases, treatment failure can be explained in part by genetic differences. In this study, we investigated the role of pharmacogenetic factors in citalopram-positive completed suicides (n = 349). Since citalopram is metabolized by CYP2C19 and CYP2D6 enzymes, the study population was genotyped for clinically relevant CYP2C19 and CYP2D6 polymorphisms and CYP2D6 copy number variation. To assess genetic differences between suicide cases and Finns in general, Finnish population samples (n = 855) were used as controls. Also, the role of drug interactions among suicide cases was evaluated. We found enrichment of a combined group of genetically predicted poor and ultrarapid metabolizer phenotypes (gMPs) of CYP2C19 among suicide victims compared to controls 0.356 [0.31-0.41] vs. 0.265 [0.24-0.30] (p = 0.0065). In CYP2D6 gMPs, there was no difference between cases and controls when the study population was analyzed as a whole. However, there were significantly more poor metabolizers among females who committed suicide by poisoning compared to female controls. In 8% of all drug poisoning deaths, lifetime drug-drug interaction was evaluated having a contribution to the fatal outcome. From clinical perspective, pharmacogenetic testing prior to initiation of SSRI drug could be beneficial. It may also be useful in medico-legal settings as it may elucidate obscure poisoning cases. Also, the possibility of unintentional drug interactions should be taken into account in drug poisoning deaths.
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Affiliation(s)
- Anna-Liina Rahikainen
- Department of Forensic Medicine, University of Helsinki, P.O.Box 40, Kytösuontie 11, 00014, Helsinki, Finland.
| | - P Vauhkonen
- Forensic Medicine Unit, National Institute for Health and Welfare, P.O.Box 30, Mannerheimintie 166, 00271, Helsinki, Finland
| | - H Pett
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Clinical Pharmacology, University of Helsinki and Helsinki University Central Hospital, P.O.Box 20, Tukholmankatu 8C, 00014, Helsinki, Finland
| | - J U Palo
- Department of Forensic Medicine, University of Helsinki, P.O.Box 40, Kytösuontie 11, 00014, Helsinki, Finland.,Forensic Genetics Unit, National Institute for Health and Welfare, P.O.Box 30, Mannerheimintie 166, 00271, Helsinki, Finland
| | - J Haukka
- Department of Public Health, University of Helsinki, P.O.Box 20, Tukholmankatu 8B, 00014, Helsinki, Finland
| | - I Ojanperä
- Department of Forensic Medicine, University of Helsinki, P.O.Box 40, Kytösuontie 11, 00014, Helsinki, Finland.,Forensic Toxicology Unit, National Institute for Health and Welfare, P.O.Box 30, Mannerheimintie 166, 00271, Helsinki, Finland
| | - M Niemi
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Central Hospital, P.O.Box 20, Tukholmankatu 8C, 00014, Helsinki, Finland
| | - Antti Sajantila
- Department of Forensic Medicine, University of Helsinki, P.O.Box 40, Kytösuontie 11, 00014, Helsinki, Finland.
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Post-mortem concentrations of drugs determined in femoral blood in single-drug fatalities compared with multi-drug poisoning deaths. Forensic Sci Int 2016; 267:96-103. [DOI: 10.1016/j.forsciint.2016.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/26/2016] [Accepted: 08/05/2016] [Indexed: 11/17/2022]
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A limited number of prescribed drugs account for the great majority of drug-drug interactions. Eur J Clin Pharmacol 2014; 70:1375-83. [PMID: 25190295 DOI: 10.1007/s00228-014-1745-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/26/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to investigate the prevalence of prescribed combinations of interacting drugs in the Swedish population. METHODS This study design was retrospective and cross-sectional, based on a national register of dispensed prescription drugs during the period from January 1 to April 30, 2010. Prescription data was linked to the drug-drug interaction database SFINX to yield the prevalence of interacting combinations dispensed in the population. The study focused in particular on C- (clinically relevant interactions that can be handled, e.g. by dose adjustments), and D-interactions (clinically relevant interactions that should be avoided). RESULTS Thirty-eight and 3.8 % of the population were dispensed combinations of drugs classified as C- or D- interactions, respectively, i.e. clinically relevant, involving all therapeutic areas. Half of the D-interactions were associated with increased risk of adverse drug reactions whereas the other half were considered interactions with a potential to cause therapeutic failure. We identified a top 15 list of D-interactions that included 80 % of the total number of interacting drug combinations. Regarding individual drugs, a group of only ten drugs was involved in as much as 94 % of all D-interactions. CONCLUSIONS This study reveals that the majority of prescribed interacting drug combinations in Sweden involve a limited number of drugs. The findings may increase the awareness among prescribers of these most common drug interactions in clinical practice and highlight an area for pharmacological education. It may also serve as an inventory of potential interactions within different therapeutic areas for further research.
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Launiainen T, Ojanperä I. Drug concentrations in post-mortem femoral blood compared with therapeutic concentrations in plasma. Drug Test Anal 2013; 6:308-16. [PMID: 23881890 PMCID: PMC4237191 DOI: 10.1002/dta.1507] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/06/2013] [Accepted: 06/06/2013] [Indexed: 12/04/2022]
Abstract
Therapeutic drug concentrations measured in plasma are of limited value as reference intervals for interpretation in post-mortem (PM) toxicology. In this study, drug concentration distributions were studied in PM femoral venous blood from 57 903 Finnish autopsy cases representing all causes of death during an 11-year period. Cause-of-death information was obtained from death certificates issued by forensic pathologists. Median, mean, and upper percentile (90th, 95th, 97.5th) concentrations were calculated for 129 drugs. To illustrate how PM median concentrations relate to established therapeutic ranges in plasma, a PM blood/plasma relationship was calculated for each drug. Males represented 75% of the subjects and showed a lower median age (55 yrs) than females (59 yrs). In 43% of these cases, blood alcohol concentration was higher than 0.2‰, and the median was 1.8‰. Sixty-one (47%) of the 129 drugs showed a PM blood/plasma relationship of 1. For 22 drugs (17%), the relationship was <1, and for 46 drugs (35%), the relationship was >1. No marked correlation was found between the PM blood/plasma relationship and the volume of distribution (Vd). For 36 drugs, more than 10% of cases were fatal poisonings attributed to this drug as the main finding. These drug concentration distributions based on a large database provide a helpful reference not only to forensic toxicologists and pathologists but also to clinical pharmacologists in charge of interpreting drug concentrations in PM cases. © 2013 The Authors. Drug Testing and Analysis published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Terhi Launiainen
- University of Helsinki, Hjelt Institute, Department of Forensic Medicine, PO Box 40 (Kytösuontie 11), FI-00014, Helsinki, Finland
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Karlsson L, Green H, Zackrisson AL, Bengtsson F, Jakobsen Falk I, Carlsson B, Ahlner J, Kugelberg FC. ABCB1 gene polymorphisms are associated with fatal intoxications involving venlafaxine but not citalopram. Int J Legal Med 2013; 127:579-86. [PMID: 23515680 DOI: 10.1007/s00414-013-0849-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 03/06/2013] [Indexed: 01/11/2023]
Abstract
P-glycoprotein (P-gp), encoded by the ABCB1/MDR1 gene, is a drug transporter at the blood-brain barrier. Several polymorphisms in the ABCB1 gene are known to affect the activity and/or expression of P-gp, thereby influencing the treatment response and toxicity of P-gp substrates like citalopram and venlafaxine. In this study, we aimed to investigate the frequency of ABCB1 genotypes in forensic autopsy cases involving these two antidepressants. Further, the distribution of ABCB1 genotypes in deaths related to intoxication was compared to cases not associated to drug intoxication. The study included 228 forensic autopsy cases with different causes and manners of deaths. The ABCB1 single nucleotide polymorphisms (SNPs) G1199A, C1236T, C3435T and G2677T/A for these individuals were determined. The SNPs C1236T and C3435T in venlafaxine-positive cases were significantly different between the intoxication cases and non-intoxications. This was not seen for cases involving citalopram, indicating that the effect of genetic variants might be substrate specific. This novel finding should, however, be confirmed in future studies with larger number of cases.
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Affiliation(s)
- L Karlsson
- Division of Drug Research, Clinical Pharmacology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Häkkinen M, Launiainen T, Vuori E, Ojanperä I. Comparison of fatal poisonings by prescription opioids. Forensic Sci Int 2012; 222:327-31. [DOI: 10.1016/j.forsciint.2012.07.011] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 07/11/2012] [Accepted: 07/22/2012] [Indexed: 10/28/2022]
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Benzodiazepines and alcohol are associated with cases of fatal buprenorphine poisoning. Eur J Clin Pharmacol 2011; 68:301-9. [DOI: 10.1007/s00228-011-1122-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Accepted: 08/24/2011] [Indexed: 01/29/2023]
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Launiainen T, Broms U, Keskitalo-Vuokko K, Pitkäniemi J, Pelander A, Kaprio J, Ojanperä I. Nicotine, Alcohol, and Drug Findings in Young Adults in a Population-Based Postmortem Database. Nicotine Tob Res 2011; 13:763-71. [DOI: 10.1093/ntr/ntr069] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Neuvonen AM, Palo JU, Sajantila A. Post-mortem ABCB1 genotyping reveals an elevated toxicity for female digoxin users. Int J Legal Med 2011; 125:265-9. [DOI: 10.1007/s00414-011-0550-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 01/10/2011] [Indexed: 10/18/2022]
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Launiainen T, Rasanen I, Vuori E, Ojanperä I. Fatal venlafaxine poisonings are associated with a high prevalence of drug interactions. Int J Legal Med 2010; 125:349-58. [PMID: 20432045 DOI: 10.1007/s00414-010-0461-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 04/15/2010] [Indexed: 10/19/2022]
Abstract
Venlafaxine (VEN) is an antidepressant found to possess a higher fatal toxicity index (FTI, i.e., deaths in proportion to consumption) than other newer antidepressants and selective serotonin reuptake inhibitors (SSRIs). The aim of this study was to elucidate using post-mortem cases whether the apparent high toxicity of VEN is associated with adverse drug interactions, pharmacogenetic factors and/or the manner of death. Within a 2-year period, a comprehensive post-mortem database and death certificates were searched for cases with laboratory findings of VEN, findings of other drugs, associated background information and the cause and manner of death. In 123 cases, the concentrations of VEN and its two metabolites, O-desmethylvenlafaxine (O-VEN) and N-desmethylvenlafaxine (N-VEN), and the CYP2D6 genotype were determined in post-mortem blood. The median concentrations of VEN, O-VEN and N-VEN were 560, 420 and 49 µg/l, respectively. A prominent feature of the VEN-positive cases was the high abundance of interacting drugs (46%), being more common with higher VEN concentrations. Compared to other common antidepressants, VEN-positive cases showed the highest suicide frequency, but also the proportion of suicidal VEN poisonings of all suicides was substantially higher than that of mirtazapine or SSRIs. Relative CYP2D6 activity did not predispose to high VEN concentrations, and the frequency of the extreme phenotypes followed the general population. In conclusion, the high suicide potential of VEN in combination with the high prevalence of drugs causing adverse interactions could be the reason for the observed high FTI.
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Affiliation(s)
- Terhi Launiainen
- Department of Forensic Medicine, University of Helsinki, P.O. Box 40, FI-00014, Helsinki, Finland.
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Adverse interaction of warfarin and paracetamol: evidence from a post-mortem study. Eur J Clin Pharmacol 2009; 66:97-103. [PMID: 19779704 DOI: 10.1007/s00228-009-0727-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 09/03/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE The aim of the study was to establish the prevalence and nature of potential adverse drug combinations of warfarin in a large post-mortem toxicology database. The concomitant use of warfarin and non-steroidal anti-inflammatory drugs (NSAIDs) was of interest as these drugs have been associated with internal bleeding both in clinical and post-mortem study settings. Another purpose was to obtain facts related to the questioned safety of warfarin-paracetamol and warfarin-tramadol combinations. METHODS The post-mortem database was searched for a 1-year period. All warfarin-positive cases and cases containing interacting drugs, as defined by the SFINX interaction database (Swedish, Finnish, Interaction X-referencing), were included. For controls, all cases containing paracetamol or tramadol were also included, and for each warfarin-positive case, an age-, sex- and alcohol-matched control case was sourced. The contribution of anticoagulant use to the deaths was evaluated from the death certificates based on medico-legal autopsies. RESULTS In 33% of the 328 warfarin-positive cases, at least one interacting drug was present, and paracetamol was the most abundant, accounting for 49% (n = 53). When paracetamol and warfarin were detected simultaneously, the number of fatal bleeds was 4.6 and 2.7 times higher compared to paracetamol or warfarin use alone respectively. The presence of an NSAID in combination with warfarin was rare, as only six cases were identified. A majority (66%) of the post-mortem blood samples had a warfarin concentration below 0.5 mg/l, and for the rest of the cases, the mean concentration was 0.70 mg/l. CONCLUSIONS This study supports the clinical evidence suggesting that warfarin-paracetamol interactions may create significant life-threatening conditions. It also accentuates the significant role post-mortem database research can have in improving drug safety.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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