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Bremshey S, Groß J, Renken K, Masseck OA. The role of serotonin in depression-A historical roundup and future directions. J Neurochem 2024. [PMID: 38477031 DOI: 10.1111/jnc.16097] [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: 10/30/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Abstract
Depression is one of the most common psychiatric disorders worldwide, affecting approximately 280 million people, with probably much higher unrecorded cases. Depression is associated with symptoms such as anhedonia, feelings of hopelessness, sleep disturbances, and even suicidal thoughts. Tragically, more than 700 000 people commit suicide each year. Although depression has been studied for many decades, the exact mechanisms that lead to depression are still unknown, and available treatments only help a fraction of patients. In the late 1960s, the serotonin hypothesis was published, suggesting that serotonin is the key player in depressive disorders. However, this hypothesis is being increasingly doubted as there is evidence for the influence of other neurotransmitters, such as noradrenaline, glutamate, and dopamine, as well as larger systemic causes such as altered activity in the limbic network or inflammatory processes. In this narrative review, we aim to contribute to the ongoing debate on the involvement of serotonin in depression. We will review the evolution of antidepressant treatments, systemic research on depression over the years, and future research applications that will help to bridge the gap between systemic research and neurotransmitter dynamics using biosensors. These new tools in combination with systemic applications, will in the future provide a deeper understanding of the serotonergic dynamics in depression.
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Affiliation(s)
- Svenja Bremshey
- Synthetic Biology, University of Bremen, Bremen, Germany
- Neuropharmacology, University of Bremen, Bremen, Germany
| | - Juliana Groß
- Synthetic Biology, University of Bremen, Bremen, Germany
| | - Kim Renken
- Synthetic Biology, University of Bremen, Bremen, Germany
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2
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Sahin O, Akturk G, Cilaker Micili S, Gursoy Doruk O, Karapinar F, Hocaoglu N, Ergur BU, Akan P, Tuncok Y, Kalkan S. Effect of the selective mitochondrial KATP channel opener nicorandil on the QT prolongation and myocardial damage induced by amitriptyline in rats. J Pharm Pharmacol 2023; 75:415-426. [PMID: 36527252 DOI: 10.1093/jpp/rgac089] [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: 05/16/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The aim of this study is to evaluate the protective effect of nicorandil, a selective mitochondrial KATP channel opener, on QT prolongation and myocardial damage induced by amitriptyline. METHODS The dose of amitriptyline (intraperitoneal, i.p.) that prolong the QT interval was found 75 mg/kg. Rats were randomized into five groups the control group, amitriptyline group, nicorandil (selective mitochondrial KATP channel opener, 3 mg/kg i.p.) + amitriptyline group, 5-hdyroxydecanoate (5-HD, selective mitochondrial KATP channel blocker, 10 mg/kg i.p.) + amitriptyline group and 5-HD + nicorandil + amitriptyline group. Cardiac parameters, biochemical and histomorphological/immunohistochemical examinations were evaluated. p < 0.05 was accepted as statistically significant. KEY FINDINGS Amitriptyline caused statistically significant prolongation of QRS duration, QT interval and QTc interval (p < 0.05). It also caused changes in tissue oxidant (increase in malondialdehyde)/anti-oxidant (decrease in glutathione peroxidase) parameters (p < 0.05), myocardial damage and apoptosis (p < 0.01 and p < 0.001). While nicorandil administration prevented amitriptyline-induced QRS, QT, QTc prolongation (p < 0.05), myocardial damage and apoptosis (p < 0.05), it did not affect the changes in oxidative parameters (p > 0.05). CONCLUSIONS Our results suggest that nicorandil, a selective mitochondrial KATP channel opener, plays a protective role in amitriptyline-induced QT prolongation and myocardial damage. Mitochondrial KATP channel opening and anti-apoptotic effects may play a role in the cardioprotective effect of nicorandil.
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Affiliation(s)
- Orhan Sahin
- Dokuz Eylul University, School of Medicine, Department of Medical Pharmacology, Izmir, Turkey
| | - Gozde Akturk
- Dokuz Eylul University, School of Medicine, Department of Medical Pharmacology, Izmir, Turkey.,Mustafa Kemal University, School of Medicine, Department of Medical Pharmacology, Hatay, Turkey
| | - Serap Cilaker Micili
- Dokuz Eylul University, School of Medicine, Department of Histology and Embryology, Izmir, Turkey
| | - Ozlem Gursoy Doruk
- Dokuz Eylul University, School of Medicine, Department of Medical Biochemistry, Izmir, Turkey
| | - Fazilet Karapinar
- Dokuz Eylul University, School of Medicine, Department of Medical Pharmacology, Izmir, Turkey
| | - Nil Hocaoglu
- Dokuz Eylul University, School of Medicine, Department of Medical Pharmacology, Izmir, Turkey
| | - Bekir Ugur Ergur
- Dokuz Eylul University, School of Medicine, Department of Histology and Embryology, Izmir, Turkey.,Kyrenia University, School of Medicine, Department of Histology and Embryology, Kyrenia, Cyprus
| | - Pinar Akan
- Dokuz Eylul University, School of Medicine, Department of Medical Biochemistry, Izmir, Turkey
| | - Yesim Tuncok
- Dokuz Eylul University, School of Medicine, Department of Medical Pharmacology, Izmir, Turkey
| | - Sule Kalkan
- Dokuz Eylul University, School of Medicine, Department of Medical Pharmacology, Izmir, Turkey
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3
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Nagano A, Muto M, Shida J, Kazama I. Amitriptyline intoxication in bullfrogs causes widening of QRS complexes in electrocardiogram. J Vet Med Sci 2023; 85:175-179. [PMID: 36596558 PMCID: PMC10017290 DOI: 10.1292/jvms.22-0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Amitriptyline intoxication is caused by its suicidal or accidental overdose. In the present study, by intravenously injecting 1.5 or 3.0 mg/kg amitriptyline into bullfrogs, we actually revealed that amitriptyline causes the widening of QRS complexes in electrocardiogram (ECG). In simultaneous recordings of the cardiac action potential, amitriptyline decreased the slope of phase 0 in the action potential, indicating the inhibition of the inward sodium currents during this phase. The following treatment with sodium bicarbonate quickly restored the widened QRS complexes in the ECG, demonstrating the counteraction with the sodium channel blockade caused by amitriptyline. The dual recordings of ECG waveforms and the action potential in cardiomyocytes enabled us to demonstrate the mechanisms of characteristic ECG abnormalities caused by amitriptyline intoxication.
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Affiliation(s)
- Amu Nagano
- School of Nursing, Miyagi University, Miyagi, Japan
| | - Mizuki Muto
- School of Nursing, Miyagi University, Miyagi, Japan
| | - Junko Shida
- Department of Life Sciences, Yamagata University, Yamagata, Japan
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Garrett P, Klupfel S. Esmolol for intractable ventricular arrhythmias in major amitriptyline toxicity. BMJ Case Rep 2022; 15:15/7/e248373. [PMID: 35868803 PMCID: PMC9315894 DOI: 10.1136/bcr-2021-248373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A massive tricyclic overdose of 10 g of amitriptyline resulted in cardiovascular collapse with multiple episodes of ventricular tachycardia and ventricular fibrillation despite aggressive attention to current recommended therapy of sodium bicarbonate and hypertonic saline, and correction of electrolytes. Second-line antiarrhythmic therapies failed to reduce the recurrent deterioration to malignant ventricular rhythms. Progression to extracorporeal support was avoided by the use of a titrated esmolol infusion. We discuss the physiological rationale by which esmolol may prevent tachyarrhythmia and fibrillation in severe amitriptyline toxicity.
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Affiliation(s)
- Peter Garrett
- Intensive Care, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Steven Klupfel
- Intensive Care, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
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5
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Zambrano J, Celano CM, Januzzi JL, Massey CN, Chung WJ, Millstein RA, Huffman JC. Psychiatric and Psychological Interventions for Depression in Patients With Heart Disease: A Scoping Review. J Am Heart Assoc 2020; 9:e018686. [PMID: 33164638 PMCID: PMC7763728 DOI: 10.1161/jaha.120.018686] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Depression in patients with cardiovascular disease is independently associated with progression of heart disease, major adverse cardiac events, and mortality. A wide variety of depression treatment strategies have been studied in randomized controlled trials as the field works to identify optimal depression treatments in this population. A contemporary scoping review of the literature can help to consolidate and synthesize the growing and disparate literature on depression treatment trials in people with cardiovascular disease. We conducted a scoping review utilizing a systematic search of the literature via 4 databases (PubMed, PsycINFO, EMBASE, and Google Scholar) from database inception to March 2020. We identified 42 relevant randomized controlled trials of depression treatment interventions in patients with cardiac disease (n=9181 patients with coronary artery disease, n=1981 patients with heart failure). Selective serotonin reuptake inhibitors appear to be safe in patients with cardiac disease and to have beneficial effects on depression (and some suggestion of cardiac benefit) in patients with coronary artery disease, with less evidence of their efficacy in heart failure. In contrast, psychotherapy appears to be effective for depression in coronary artery disease and heart failure, but with less evidence of cardiac benefit. Newer multimodal depression care management approaches that utilize flexible approaches to patients' care have been less studied but appear promising across cardiac patient groups. Selective serotonin reuptake inhibitors may be preferred in the treatment of patients with coronary artery disease, psychotherapy may be preferred in heart failure, and more flexible depression care management approaches have shown promise by potentially using both approaches based on patient needs.
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Affiliation(s)
- Juliana Zambrano
- Department of Psychiatry Massachusetts General Hospital Boston MA
| | - Christopher M Celano
- Department of Psychiatry Massachusetts General Hospital Boston MA.,Harvard Medical School Boston MA
| | - James L Januzzi
- Department of Psychiatry Massachusetts General Hospital Boston MA.,Division of Cardiology Massachusetts General Hospital Boston MA
| | - Christina N Massey
- Department of Psychiatry Massachusetts General Hospital Boston MA.,Harvard Medical School Boston MA
| | - Wei-Jean Chung
- Department of Psychiatry Massachusetts General Hospital Boston MA.,Harvard Medical School Boston MA
| | - Rachel A Millstein
- Department of Psychiatry Massachusetts General Hospital Boston MA.,Harvard Medical School Boston MA
| | - Jeff C Huffman
- Department of Psychiatry Massachusetts General Hospital Boston MA.,Harvard Medical School Boston MA
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Gajendran M, Sifuentes J, Bashashati M, McCallum R. Cannabinoid hyperemesis syndrome: definition, pathophysiology, clinical spectrum, insights into acute and long-term management. J Investig Med 2020; 68:1309-1316. [PMID: 33115959 DOI: 10.1136/jim-2020-001564] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Abstract
Although cannabinoid hyperemesis syndrome (CHS) was first reported more than 15 years ago, it still remains an unfamiliar clinical entity among physicians worldwide. CHS is categorized by Rome IV classification as a functional gastroduodenal disorder. It is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, with cycles decreasing by the cessation of cannabis. CHS is also associated with abdominal pain reduced by hot baths and showers with comparative well-being between attacks. Thus, its clinical presentation resembles 'classic' cyclic vomiting syndrome, but eliciting a cannabis history is crucial in diagnosing this entity. In acute attacks, parenteral benzodiazepines are very effective. For prevention and long-term management, tricyclic antidepressants such as amitriptyline are the mainstay of therapy requiring doses in the range of 50-200 mg/d to achieve symptom control. In addition, counseling to achieve marijuana cessation, accompanied by antianxiety medications, is necessary for sustaining clinical outcomes. Once the patient is in remission and off marijuana for a period of 6-12 months, then tapering the dose of amitriptyline can be implemented, with the goal of no therapy being achieved in the majority of patients over time. With the legalization of marijuana in many states, CHS will become an increasingly prevalent clinical entity, so educating about CHS is an important goal, particularly for emergency department physicians who generally first encounter these patients.
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Affiliation(s)
- Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Joshua Sifuentes
- Department of Gastroenterology, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Mohammad Bashashati
- Department of Gastroenterology, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Richard McCallum
- Department of Gastroenterology, Center for Neurogastroenterology and GI Motility, Texas Tech University Health Sciences Center El Paso, Paul L Foster School of Medicine, El Paso, Texas, USA
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Brueckle MS, Thomas ET, Seide SE, Pilz M, Gonzalez-Gonzalez AI, Nguyen TS, Harder S, Glasziou PP, Gerlach FM, Muth C. Adverse drug reactions associated with amitriptyline - protocol for a systematic multiple-indication review and meta-analysis. Syst Rev 2020; 9:59. [PMID: 32183872 PMCID: PMC7079360 DOI: 10.1186/s13643-020-01296-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Unwanted anticholinergic effects are both underestimated and frequently overlooked. Failure to identify adverse drug reactions (ADRs) can lead to prescribing cascades and the unnecessary use of over-the-counter products. The objective of this systematic review and meta-analysis is to explore and quantify the frequency and severity of ADRs associated with amitriptyline vs. placebo in randomized controlled trials (RCTs) involving adults with any indication, as well as healthy individuals. METHODS A systematic search in six electronic databases, forward/backward searches, manual searches, and searches for Food and Drug Administration (FDA) and European Medicines Agency (EMA) approval studies, will be performed. Placebo-controlled RCTs evaluating amitriptyline in any dosage, regardless of indication and without restrictions on the time and language of publication, will be included, as will healthy individuals. Studies of topical amitriptyline, combination therapies, or including < 100 participants, will be excluded. Two investigators will screen the studies independently, assess methodological quality, and extract data on design, population, intervention, and outcomes ((non-)anticholinergic ADRs, e.g., symptoms, test results, and adverse drug events (ADEs) such as falls). The primary outcome will be the frequency of anticholinergic ADRs as a binary outcome (absolute number of patients with/without anticholinergic ADRs) in amitriptyline vs. placebo groups. Anticholinergic ADRs will be defined by an experienced clinical pharmacologist, based on literature and data from Martindale: The Complete Drug Reference. Secondary outcomes will be frequency and severity of (non-)anticholinergic ADRs and ADEs. The information will be synthesized in meta-analyses and narratives. We intend to assess heterogeneity using meta-regression (for indication, outcome, and time points) and I2 statistics. Binary outcomes will be expressed as odds ratios, and continuous outcomes as standardized mean differences. Effect measures will be provided using 95% confidence intervals. We plan sensitivity analyses to assess methodological quality, outcome reporting etc., and subgroup analyses on age, dosage, and duration of treatment. DISCUSSION We will quantify the frequency of anticholinergic and other ADRs/ADEs in adults taking amitriptyline for any indication by comparing rates for amitriptyline vs. placebo, hence, preventing bias from disease symptoms and nocebo effects. As no standardized instrument exists to measure it, our overall estimate of anticholinergic ADRs may have limitations. SYSTEMATIC REVIEW REGISTRATION Submitted to PROSPERO; assignment is in progress.
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Affiliation(s)
- Maria-Sophie Brueckle
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Elizabeth T. Thomas
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Svenja E. Seide
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Pilz
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Ana Isabel Gonzalez-Gonzalez
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Truc Sophia Nguyen
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Sebastian Harder
- Goethe University, Institute of Clinical Pharmacology, Frankfurt, Germany
| | - Paul P. Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Ferdinand M. Gerlach
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Christiane Muth
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
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8
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Bourcier A, Barthe M, Bedioune I, Lechêne P, Miled HB, Vandecasteele G, Fischmeister R, Leroy J. Imipramine as an alternative to formamide to detubulate rat ventricular cardiomyocytes. Exp Physiol 2019; 104:1237-1249. [PMID: 31116459 DOI: 10.1113/ep087760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/21/2019] [Indexed: 12/18/2022]
Abstract
NEW FINDINGS What is the central question of this study? Can imipramine, an antidepressant agent that is a cationic amphiphilic drug that interferes with the phosphatidylinositol 4,5-bisphosphate (PI(4,5)P2 ) interactions with proteins maintaining the tubular system, be validated as a new detubulating tool? What is the main finding and its importance? Imipramine was validated as a more efficient and less toxic detubulating agent of cardiomyocytes than formamide. New insights are provided on how PI(4,5)P2 is crucial to maintaining T-tubule attachment to the cell surface and on the cardiotoxic effects of imipramine overdoses. ABSTRACT Cardiac T-tubules are membrane invaginations essential for excitation-contraction coupling (ECC). Imipramine, like other cationic amphiphilic drugs, interferes with phosphatidylinositol 4,5-bisphosphate (PI(4,5)P2 ) interactions with proteins maintaining the tubular system connected to the cell surface. Our main purpose was to validate imipramine as a new detubulating agent in cardiomyocytes. Staining adult rat ventricular myocytes (ARVMs) with di-4-ANEPPS, we showed that unlike formamide, imipramine induces a complete detubulation with no impact on cell viability. Using the patch-clamp technique, we observed a ∼40% decrease in cell capacitance after imipramine pretreatment and a reduction of ICa,L amplitude by ∼72%. These parameters were not affected in atrial cells, excluding direct side effects of imipramine. β-Adrenergic receptor (β-AR) stimulation of the remaining ICa,L with isoproterenol (Iso) was still effective. ECC was investigated in ARVMs loaded with Fura-2 and paced at 1 Hz, allowing simultaneous measurement of the Ca2+ transient (CaT) and sarcomere shortening (SS). Amplitude of both CaT and SS was decreased by imipramine and partially restored by Iso. Furthermore, detubulated cells exhibited Ca2+ homeostasis perturbations. Real-time cAMP variations induced by Iso using a Förster resonance energy transfer biosensor revealed ∼27% decreased cAMP elevation upon β-AR stimulation. To conclude, we validated a new cardiomyocyte detubulation method using imipramine, which is more efficient and less toxic than formamide. This antidepressant agent induces the hallmark effects of detubulation on ECC and its β-AR stimulation. Besides, we provide new insights on how an imipramine overdose may affect cardiac function and suggest that PI(4,5)P2 is crucial for maintaining T-tubule structure.
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Affiliation(s)
- Aurelia Bourcier
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Marion Barthe
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Ibrahim Bedioune
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Patrick Lechêne
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Hela Ben Miled
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Grégoire Vandecasteele
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Rodolphe Fischmeister
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
| | - Jérôme Leroy
- Inserm UMR-S 1180, Faculte de Pharmacie, Univ. Paris-Sud, Université Paris-Saclay, F-92296, Chatenay-Malabry, France
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Chen Y, Liu Y, Zhang L, Xie P, Wang Z, Zhou A, Fang Z, Ma J. Efficient degradation of imipramine by iron oxychloride-activated peroxymonosulfate process. JOURNAL OF HAZARDOUS MATERIALS 2018; 353:18-25. [PMID: 29631043 DOI: 10.1016/j.jhazmat.2018.03.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 03/12/2018] [Accepted: 03/26/2018] [Indexed: 06/08/2023]
Abstract
Synthesized iron oxychloride (FeOCl) was firstly applied to activate peroxymonosulfate (PMS) to degrade imipramine (IMI), a tricyclic antidepressant. Compared to some other Fe-based materials including zero valent iron, Fe2O3, Fe3O4 and ferric ions, FeOCl presented an impressive catalytic activity on PMS at near-neutral condition due to its unique structure containing abundant unsaturated iron atoms and oxo-bridged configuration. With an increase of FeOCl dose, PMS dose or initial pH in ranges of 0.02 - 0.5 g/L, 0.1 - 2.5 mM and 4.0 - 8.0, the degradation efficiency of IMI was effectively raised by 64.0%, 48.5% and 50.6%, respectively. The presence of either bicarbonate or chloride stimulated the removal of IMI. Moreover, 70.4% of IMI was degraded under the background of real water with 2 mM PMS. The possible reactive species were identified as sulfate and hydroxyl radicals. The formed hypochlorite through the reaction of PMS and the released chloride ions may also contribute to the degradation of IMI. Among the oxidants, sulfate radical was proven to be the dominate one in the system. Additionally, the FeOCl/PMS system can overall effectively degrade six other organic compounds including amitriptyline, desipramine, propranolol, nitrobenzene, methyl-paraben and ethyl-paraben, further suggesting the possible application of this system in treatment of vast aquatic micro-organic pollutants.
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Affiliation(s)
- Yiqun Chen
- School of Civil Engineering, Wuhan University, Wuhan 430072, China
| | - Yanpeng Liu
- School of Environmental Science and Engineering, Huazhong University of Science and Technology (HUST), Wuhan 430074, China; Key Laboratory of Water & Wastewater Treatment (HUST), MOHURD, Wuhan 430074, China
| | - Li Zhang
- School of Environmental Science and Engineering, Huazhong University of Science and Technology (HUST), Wuhan 430074, China; Key Laboratory of Water & Wastewater Treatment (HUST), MOHURD, Wuhan 430074, China
| | - Pengchao Xie
- School of Environmental Science and Engineering, Huazhong University of Science and Technology (HUST), Wuhan 430074, China; Key Laboratory of Water & Wastewater Treatment (HUST), MOHURD, Wuhan 430074, China.
| | - Zongping Wang
- School of Environmental Science and Engineering, Huazhong University of Science and Technology (HUST), Wuhan 430074, China; Key Laboratory of Water & Wastewater Treatment (HUST), MOHURD, Wuhan 430074, China
| | - Aijiao Zhou
- School of Environmental Science and Engineering, Huazhong University of Science and Technology (HUST), Wuhan 430074, China; Key Laboratory of Water & Wastewater Treatment (HUST), MOHURD, Wuhan 430074, China.
| | - Zheng Fang
- School of Civil Engineering, Wuhan University, Wuhan 430072, China
| | - Jun Ma
- State Key Laboratory of Urban Water Resource & Environment, Harbin Institute of Technology, Harbin 150090, China
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Villatoro-Gómez K, Pacheco-Rojas DO, Moreno-Galindo EG, Navarro-Polanco RA, Tristani-Firouzi M, Gazgalis D, Cui M, Sánchez-Chapula JA, Ferrer T. Molecular determinants of Kv7.1/KCNE1 channel inhibition by amitriptyline. Biochem Pharmacol 2018; 152:264-271. [PMID: 29621539 DOI: 10.1016/j.bcp.2018.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 03/15/2018] [Indexed: 12/11/2022]
Abstract
Amitriptyline (AMIT) is a compound widely prescribed for psychiatric and non-psychiatric conditions including depression, migraine, chronic pain, and anorexia. However, AMIT has been associated with risks of cardiac arrhythmia and sudden death since it can induce prolongation of the QT interval on the surface electrocardiogram and torsade de pointes ventricular arrhythmia. These complications have been attributed to the inhibition of the rapid delayed rectifier potassium current (IKr). The slow delayed rectifier potassium current (IKs) is the main repolarizing cardiac current when IKr is compromised and it has an important role in cardiac repolarization at fast heart rates induced by an elevated sympathetic tone. Therefore, we sought to characterize the effects of AMIT on Kv7.1/KCNE1 and homomeric Kv7.1 channels expressed in HEK-293H cells. Homomeric Kv7.1 and Kv7.1/KCNE1 channels were inhibited by AMIT in a concentration-dependent manner with IC50 values of 8.8 ± 2.1 μM and 2.5 ± 0.8 μM, respectively. This effect was voltage-independent for both homomeric Kv7.1 and Kv7.1/KCNE1 channels. Moreover, mutation of residues located on the P-loop and S6 domain along with molecular docking, suggest that T312, I337 and F340 are the most important molecular determinants for AMIT-Kv7.1 channel interaction. Our experimental findings and modeling suggest that AMIT preferentially blocks the open state of Kv7.1/KCNE1 channels by interacting with specific residues that were previously reported to be important for binding of other compounds, such as chromanol 293B and the benzodiazepine L7.
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Affiliation(s)
- Kathya Villatoro-Gómez
- Centro Universitario de Investigaciones Biomédicas de la Universidad de Colima, Colima, Col., Mexico
| | - David O Pacheco-Rojas
- Centro Universitario de Investigaciones Biomédicas de la Universidad de Colima, Colima, Col., Mexico
| | - Eloy G Moreno-Galindo
- Centro Universitario de Investigaciones Biomédicas de la Universidad de Colima, Colima, Col., Mexico
| | - Ricardo A Navarro-Polanco
- Centro Universitario de Investigaciones Biomédicas de la Universidad de Colima, Colima, Col., Mexico
| | - Martin Tristani-Firouzi
- Nora Eccles Harrison CVRTI, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Division of Pediatric Cardiology, University of Utah School of Medicine, Salt Lake City, UT 83113, USA
| | - Dimitris Gazgalis
- Department of Pharmaceutical Sciences, Northeastern University School of Pharmacy, Boston, MA 02115, USA
| | - Meng Cui
- Department of Pharmaceutical Sciences, Northeastern University School of Pharmacy, Boston, MA 02115, USA
| | - José A Sánchez-Chapula
- Centro Universitario de Investigaciones Biomédicas de la Universidad de Colima, Colima, Col., Mexico
| | - Tania Ferrer
- Centro Universitario de Investigaciones Biomédicas de la Universidad de Colima, Colima, Col., Mexico.
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Sabah KMN, Chowdhury AW, Islam MS, Saha BP, Kabir SR, Kawser S. Amitriptyline-induced ventricular tachycardia: a case report. BMC Res Notes 2017; 10:286. [PMID: 28709467 PMCID: PMC5513042 DOI: 10.1186/s13104-017-2615-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 07/08/2017] [Indexed: 11/30/2022] Open
Abstract
Background In Bangladesh, each emergency physician faces amitriptyline overdose nearly a day. An acute cardiovascular complication, one of the worst complications is mainly responsible for the mortality in tricyclic overdose. Recently, we managed ventricular tachycardia in a young female presented with an impaired consciousness 10 h after intentionally ingesting 2500 mg amitriptyline. Here, we report it, discuss how the electrocardiography is vital to acknowledge and predict it and its’ complications and also the recent update of the management of it. Case presentation A young married Bangladeshi-Bengali girl, 25-year-old, having a history of disharmony with her husband, came with an impaired consciousness after intentionally ingesting 2500 mg amitriptyline about 10 h before arrival. There was blood pressure 140/80 mmHg, heart rate 140 beats-per-min, temperature 103 °F, Glasgow coma scale 10/15, wide complex tachycardia with QRS duration of 178 ms in electrocardiography, blood pH 7.36. Initially, treated with 100 ml 8.4% sodium bicarbonate. After that, QRS duration came to 100 ms in electrocardiography within 10 min of infusion. To maintain the pH 7.50–7.55 over the next 24 h, the infusion of 8.4% sodium bicarbonate consisting of 125 ml dissolved in 375 ml normal saline was started and titrated according to the arterial blood gas analysis. Hence, a total dose of 600 mmol sodium bicarbonate was given over next 24 h. In addition to this, gave a 500 ml intravenous lipid emulsion over 2 h after 24 h of admission as she did not regain her consciousness completely. Afterward, she became conscious, though, in electrocardiography, ST/T wave abnormality persisted. So that, we tapered sodium bicarbonate infusion slowly and stopped it later. At the time of discharge, she was by heart rate 124/min, QRS duration 90 ms in electrocardiogram along with other normal vital signs. Conclusion Diagnosis of amitriptyline-induced ventricular tachycardia is difficult when there is no history of an overdose obtained. Nevertheless, it should be performed in the clinical background and classic electrocardiographic changes and wise utilization of sodium bicarbonate, intravenous lipid emulsion, and anti-arrhythmic drugs may save a life.
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Affiliation(s)
| | | | | | | | | | - Shamima Kawser
- Dr. Sirajul Islam Medical College & Hospital Ltd, Dhaka, Bangladesh
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Chaudhary S, Rajuria SS. EFFECTS OF ELECTROCONVULSIVE THERAPY ON CARDIOVASCULAR SYSTEM. Med J Armed Forces India 2017; 51:31-33. [PMID: 28769237 DOI: 10.1016/s0377-1237(17)30915-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Effects of electroconvulsive therapy on the pulse rate, blood pressure and electrocardiogram were studied in forty consecutive physically healthy inpatients undergoing ECT for their psychiatric disabilities. Tachycardia and elevated blood pressure occurred frequently. Sinus arrhythmias, atrial and ventricular premature beats and minor ST-T changes were also observed. All these changes reversed within thirty minutes.
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Affiliation(s)
- S Chaudhary
- Classified Specialist (Psychiatry). Military Hospital, Meerut 250 001
| | - S S Rajuria
- Senior Adviser (Anaesthesiology), 158 BH, C/O 99 APO
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Mease PJ, Zimetbaum PJ, Duh MS, Vekeman F, Guérin A, Boerstoel-Streefland M, Jiang W, Lefebvre P. Epidemiologic Evaluation of Cardiovascular Risk in Patients Receiving Milnacipran, Venlafaxine, or Amitriptyline: Evidence from French Health Data. Ann Pharmacother 2017; 45:179-88. [DOI: 10.1345/aph.1p391] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND: Milnacipran, a selective serotonin and norepinephrine reuptake inhibitor, is approved by the Food and Drug Administration for the management of fibromyalgia. It has been available for many years in several countries outside the US for the treatment of depression. OBJECTIVE: To conduct population-based analyses comparing the risk of serious cardiovascular (CV) events (eg, acute myocardial infarction, stroke, congestive heart failure) associated with treatment with milnacipran compared with venlafaxine and amitriptyline, 2 other commonly prescribed drugs that also inhibit reuptake of norepinephrine and serotonin. METHODS: Information from the French Thales electronic health record database from 2001 to 2007 was used. Patients with 1 or more prescriptions for milnacipran, venlafaxine, or amitriptyline; 180 or more days of continuous eligibility prior to the first prescription; and no prior CV event diagnoses during the 180-day baseline period were included. A retrospective, matched-cohort design was employed. The incidence rates of CV events between cohorts receiving milnacipran, venlafaxine, and amitriptyline were compared using unadjusted incidence rate ratio (IRR) and adjusted conditional IRR based on Poisson regression. RESULTS: We identified 4452 milnacipran-venlafaxine and 3761 milnacipran-amitriptyline matched pairs. The matched cohorts had similar baseline characteristics. The unadjusted IRRs of any CV events, comparing milnacipran with venlafaxine or amitriptyline, were 1.02 (95% CI 0.73 to 1.44) and 1.30 (95% CI 0.90 to 1.89), respectively. Adjusted IRRs confirmed the statistical similarity in the CV event risk between milnacipran and venlafaxine (adjusted IRR = 1.29, 95% CI 0.76 to 2.17) or amitriptyline (adjusted IRR = 1.06, 95% CI 0.59 to 1.89). CONCLUSIONS: This French population-based study found that the risk of CV events was not significantly different for patients receiving milnacipran versus those receiving venlafaxine or amitriptyline.
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Poisoning. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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David DJ, Tritschler L, Guilloux JP, Gardier AM, Sanchez C, Gaillard R. [Pharmacological properties of vortioxetine and its pre-clinical consequences]. Encephale 2016; 42:1S12-23. [PMID: 26879252 DOI: 10.1016/s0013-7006(16)30015-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Selective Serotonin Reuptake Inhibitors (SSRIs) are extensively used for the treatment of major depressive disorder (MDD). SSRIs are defined as indirect receptor agonists since the activation of postsynaptic receptors is a consequence of an increase in extracellular concentrations of serotonin (5-HT) mediated by the blockade of serotonin transporter. The activation of some serotoninergic receptors (5-HT1A, post-synaptic, 5-HT1B post-synaptic, 5-HT2B, and 5-HT4), but not all (5-HT1A, pre-synaptic, 5-HT1B pre-synaptic, 5-HT2A, 5-HT2C, 5-HT3, and probably 5-HT6), induces anxiolytic/antidepressive - like effects. Targetting specifically some of them could potentially improve the onset of action and/or efficacy and/or prevent MD relapse. Vortioxetine (Brintellix, 1- [2-(2,4-dimethylphenyl-sulfanyl)-phenyl]-piperazine) is a novel multi-target antidepressant drug approved by the Food and Drug Administration (FDA) and by European Medicines Agency. Its properties are markedly different from the extensively prescribed SSRIs. Compared to the SSRIs, vortioxetine is defined as a multimodal antidepressant drug since it is not only a serotonin reuptake inhibitor, but also a 5-HT1D, 5-HT3, 5-HT7 receptor antagonist, 5-HT1B receptor partial agonist and 5-HT1A receptor agonist. This specific pharmacological profile enables vortioxetine to affect not only the serotoninergic and noradrenergic systems, but also the histaminergic, cholinergic, gamma-butyric acid (GABA) ergic and glutamatergic ones. Thus, vortioxetine not only induces antidepressant-like or anxiolytic-like activity but also improves cognitive parameters in several animal models. Indeed, vortioxetine was shown to improve working memory, episodic memory, cognitive flexibility and spatial memory in young adult rodents and also in old animal models. These specific effects of the vortioxetine are of interest considering that cognitive dysfunction is a common comorbidity to MDD. Altogether, even though this molecule still needs to be investigated further, especially in the insufficient-response to antidepressant drugs, vortioxetine is already an innovative therapeutic option for the treatment of major depression.
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Affiliation(s)
- D J David
- Inserm UMR-S 1178 Santé Mentale et Santé Publique, Université Paris-Sud, Fac Pharmacie, Université Paris Saclay, Châtenay-Malabry, France; DJD et LT ont contribué de façon équivalente à l'élaboration du manuscrit
| | - L Tritschler
- Inserm UMR-S 1178 Santé Mentale et Santé Publique, Université Paris-Sud, Fac Pharmacie, Université Paris Saclay, Châtenay-Malabry, France; DJD et LT ont contribué de façon équivalente à l'élaboration du manuscrit
| | - J-P Guilloux
- Inserm UMR-S 1178 Santé Mentale et Santé Publique, Université Paris-Sud, Fac Pharmacie, Université Paris Saclay, Châtenay-Malabry, France
| | - A M Gardier
- Inserm UMR-S 1178 Santé Mentale et Santé Publique, Université Paris-Sud, Fac Pharmacie, Université Paris Saclay, Châtenay-Malabry, France
| | - C Sanchez
- Lundbeck Research USA, Inc., 215 College Road, 07652 Paramus, NJ, United States
| | - R Gaillard
- Service Hospitalo-Universitaire - Addictologie, Centre Hospitalier Sainte Anne, 1, rue Cabanis, 75674 Paris cedex 14, France.
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Abstract
Although newer cyclic antidepressants have been introduced over the past several years, the tricyclic antidepressants (TCAs) continue to be the leading cause of morbidity from drug overdose in the United States. Overdose features depend on the particular cyclic antidepressant ingested and its pharmacological properties, and can include CNS depression, cardiac arrhythmias, hypotension, seizures, and anticholinergic symptomatology. Life-threatening symptomatology almost always begins within 2 hours, and certainly within 6 hours, after arrival to the emergency department. Plasma TCA levels are unreliable predictors of TCA toxicity and are not recommended. An ECG with a prolonged QRS complex more than 100 msec seems to be the best indicator of serious sequelae with TCAs. Management consists of stabilization of vital signs, gastrointestinal decontamination, intravenous sodium bicarbonate, and supportive care. Agents once thought to be useful for the treatment of cardiac dysrhythmias and seizures such as phenytoin and physostigmine should be avoided. The future of TCA antibody fragments in the treatment of TCA overdose seems promising. Newer and, to some degree, safer antidepressants in overdose have recently been introduced, and they include fluoxetine, trazodone, and sertraline. Amoxapine, bupropion, and maprotiline seem to be as toxic as the TCAs. A significant interaction between cyclic antidepressants and monoamine-oxidase inhibitors exists. Management includes supportive care and basic poison management. Prevention of poisoning seems to be the most logical and effective method of maintaining patient safety. TCAs should be avoided in children younger than 6 years old. All adults with suicidal ideations should receive no more than a 1-week supply (about 1 g) of drug. Finally consideration should be given to using one of the newer, safer antidepressants in all patients with suicidal ideations.
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Affiliation(s)
- Henry Cohen
- Arnold and Marie Schwartz College of Pharmacy, Long Island University, Bellevue Hospital Center
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17
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Abstract
PURPOSE OF REVIEW Human and experimental research has identified cardioautonomic and respiratory dysfunction as a frequent accompaniment in human and animal model events of sudden unexpected death in epilepsy (SUDEP). This review aims to provide an overview of the scientific evidence behind the currently accepted risk factors and working hypotheses regarding SUDEP pathophysiology. RECENT FINDINGS Epidemiological analysis of public health burden of SUDEP has shown that it rates second only to stroke in the years of potential life lost. Clinical and experimental studies uncovered the dynamic cardiorespiratory dysfunction interictally and imminently to SUDEP, and model systems have facilitated discoveries in SUDEP mechanistic understanding and application of pilot therapeutic interventions. Pilot molecular profiling of human SUDEP has uncovered complex genomic structure in the candidate gene network. SUMMARY Extensive clinical and experimental work has established a rationale for the conceptual thinking about SUDEP mechanisms. The application of the global molecular profiling will be invaluable in unraveling the individually unique genomic complexities and interactions that underlie the physiological signature of each patient. At the same time, sophisticated model systems will be critical in the iterative translation of human genetics, physiology, pharmacological interventions, and in testing preventive interventions.
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Affiliation(s)
- Alica M Goldman
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
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18
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Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California. Am J Cardiovasc Drugs 2015; 15:43-50. [PMID: 25567789 DOI: 10.1007/s40256-014-0104-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented. OBJECTIVE The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes. METHODS We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP). RESULTS Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs. CONCLUSIONS Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.
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19
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Poisoning. Fam Med 2015. [DOI: 10.1007/978-1-4939-0779-3_55-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Sanaei-Zadeh H. Can theophylline be an alternative antidote for amitriptyline toxicity? Drug Chem Toxicol 2012; 36:133. [PMID: 22320422 DOI: 10.3109/01480545.2011.650794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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21
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Rozec B, Cinotti R, Blanloeil Y. [Perioperative adverse events related to antidepressive agents use]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2011; 30:828-840. [PMID: 22019304 DOI: 10.1016/j.annfar.2011.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 07/30/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Depression is the most common psychiatric disease, which is treated by the use of antidepressive agents possessing various mechanisms of action. Thus, the use in preoperative period of antidepressive agents is frequent (7% of patients scheduled for surgery). The objective of this review was to update the knowledge on the drug interactions between antidepressive agents and drugs used in perioperative period. METHODS (i) Medline and Ovid databases using combination of antidepressive agent and perioperative period as keywords; (ii) national and European epidemiologic database; (iii) expert recommendation and official French health agency; (iv) reference book chapters. RESULTS The clinical practice showed a limited risk of adverse event related to antidepressant agents interaction with perioperative used drugs. In the two past decades, few relevant observations of adverse event related with imipramine and monoamine oxidase inhibitors use was reported. The most recent antidepressive agents had no serious adverse interaction. Nevertheless, the serotonin syndrome has to be known as far as it is more and more reported. In case of hypotension, the use of vasopressive agent has to be careful because of excessive response.
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Affiliation(s)
- B Rozec
- Service d'anesthésie et de réanimation chirurgicale, hôpital G.-et-R.-Laënnec, CHU de Nantes, boulevard Jacques-Monod, 44093 Nantes cedex 1, France
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22
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Lee MY, Kim SJ, Kim JS, Kang HS. Imipramine-Induced Cardiac Depression Is Responsible for the Increase in Intracellular Magnesium and the Activation of ERK 1/2 in Rats. J Cardiovasc Pharmacol Ther 2010; 15:303-10. [DOI: 10.1177/1074248410366853] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Imipramine, an antidepressant drug, can cause potentially lethal cardiotoxic side effects including hypotension, ventricular tachycardia, and decreased cardiac output. This study investigated the mechanism responsible for imipramine-induced cardiac depression in rats. The left ventricular developed pressure (LVDP), velocity of the change in pressure (dP/dt), and heart rate (HR) accompanied with the total magnesium efflux ([Mg]e) were measured in Langendorff-perfused intact rats hearts. Intracellular ionized magnesium concentrations ([Mg2+] i) were measured using Mag-fura 2 AM in a single H9c2 cell. The activation of the extracellular signal-regulated kinases 1/2 (ERK 1/2) was analyzed by Western blot. Imipramine induced reversible decreases in LVDP, dP/dt, and HR, which were accompanied by increases in [Mg]e. Imipramine also induced activation of ERK 1/2 and increase in the [Mg2+] i, which was inhibited PD98059, ERK 1/2 inhibitor. These results suggest that imipramine-induced cardiac depression may be partly due to increases of [Mg2+]i that are accompanied by the activation of ERK 1/2 in rats.
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Affiliation(s)
- Mun-Young Lee
- Department of Pharmacology and Toxicology, College of Veterinary Medicine, Chonbuk National University, Jeonju, Republic of Korea
| | - Shang-Jin Kim
- Department of Pharmacology and Toxicology, College of Veterinary Medicine, Chonbuk National University, Jeonju, Republic of Korea
| | - Jin-Shang Kim
- Department of Pharmacology and Toxicology, College of Veterinary Medicine, Chonbuk National University, Jeonju, Republic of Korea, Korean Zoonoses Research Institute, Chonbuk National University, Jeonju, Jeonbuk, Republic of Korea
| | - Hyung-Sub Kang
- Department of Pharmacology and Toxicology, College of Veterinary Medicine, Chonbuk National University, Jeonju, Republic of Korea, , Center for the Healthcare Technology Development, Chonbuk National University, Jeonju, Republic of Korea
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QTc intervals in drug poisoning patients with tricyclic antidepressants and selective serotonin reuptake inhibitors. Am J Ther 2010; 17:30-3. [PMID: 19417591 DOI: 10.1097/mjt.0b013e318197eec6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Commonly used agents of drug poisoning among patients who come to the emergency services are tricyclic antidepressants (TCAs). These drugs may cause defect in cardiac conduction due to the slowdown in the cardiac depolarization and expansions in the QT interval. Selective serotonin reuptake inhibitors (SSRIs) are less expansion of the QT period and lower cardio toxic side effects. The aim of this study was to investigate QTc intervals and prognosis of the patients who come to the emergency service due to TCA and SSRI group antidepressant drug poisoning. In a study of 96 patients, 75 of whom were diagnosed to be poisoned by TCAs (TCA group) and 21 by SSRIs (SSRI group) were examined. Electrocardiographic alterations and QTc intervals all of patients were evaluated. QTc intervals of patients in TCA group were determined to be slightly more than those in SSRI group and it was not statistically significant. In the SSRI group, only one patient had QTc period more than 500 milliseconds (520 milliseconds); however, TCA overdose showed 9 (12%) patients with QTc interval over 500 milliseconds, and QTc values of 2 patients were over 600 milliseconds. In our study, it was determined that SSRI group drugs caused similar expansion of the QTc period as TCA drugs but they did not reach high values like TCA drugs, and their OTc intervals stayed in more innocent levels.
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Zima AV, Qin J, Fill M, Blatter LA. Tricyclic antidepressant amitriptyline alters sarcoplasmic reticulum calcium handling in ventricular myocytes. Am J Physiol Heart Circ Physiol 2008; 295:H2008-16. [PMID: 18790837 DOI: 10.1152/ajpheart.00523.2008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Tricyclic antidepressants such as amitriptyline (AMT) have been reported to have adverse side effects on cardiac performance. AMT effects on Ca handling in ventricular myocytes, however, are not well understood. Therefore, we investigated AMT action on sarcoplasmic reticulum (SR) Ca release in ventricular myocytes, ryanodine receptor (RyR) activity, and Ca uptake by SR microsomes. In permeabilized myocytes, AMT transiently increased free luminal Ca concentration ([Ca]) followed by marked depletion. AMT (10 microM) caused a rapid and a transient increase of Ca spark frequency, followed by a significant suppression of spark activity. The latter was associated with a decrease of Ca spark amplitude and SR Ca load to 87 and 60%, respectively. AMT (10 microM) completely abolished propagation of spontaneous Ca waves. Higher concentrations of AMT (0.1-1 mM) evoked SR Ca release reminiscent of the effect of caffeine (20 mM) and caused almost complete depletion of SR Ca content. Studies on single calsequestrin-free RyR channels revealed that AMT increased the mean open time and open probability (Po) in a dose-dependent fashion (dissociation constant = 4.2 microM). High concentrations of AMT (> 25 microM) evoked frequent long openings with Po reaching very high levels (> 0.70). In studies with cardiac SR microsomes, AMT slowed the rate of ATP-dependent Ca uptake. We conclude that AMT affects SR Ca handling in ventricular myocytes by multiple mechanisms, including direct stimulation of RyRs and inhibition of SR Ca uptake. These effects could contribute to AMT cardiotoxicity.
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Affiliation(s)
- Aleksey V Zima
- Department of Molecular Biophysics and Physiology, Rush University Medical Center, 1750 W. Harrison Ave., Chicago, IL 60612, USA
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26
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Clomipramine block of the hERG K+ channel: Accessibility to F656 and Y652. Eur J Pharmacol 2008; 592:19-25. [DOI: 10.1016/j.ejphar.2008.06.094] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Revised: 06/19/2008] [Accepted: 06/27/2008] [Indexed: 11/23/2022]
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SALERNO DAVIDM. CLASS IA AND CLASS IB ANTIARRHYTHMIC DRUGS - A Review of Their Pharmacokinetics, Electrophysiology, Efficacy, and Toxicity. J Cardiovasc Electrophysiol 2008. [DOI: 10.1111/j.1540-8167.1990.tb01697.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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28
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Hancox JC, McPate MJ, El Harchi A, Zhang YH. The hERG potassium channel and hERG screening for drug-induced torsades de pointes. Pharmacol Ther 2008; 119:118-32. [PMID: 18616963 DOI: 10.1016/j.pharmthera.2008.05.009] [Citation(s) in RCA: 206] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 05/27/2008] [Indexed: 01/08/2023]
Abstract
Drug-induced torsades de pointes (TdP) arrhythmia is a major safety concern in the process of drug design and development. The incidence of TdP tends to be low, so early pre-clinical screens rely on surrogate markers of TdP to highlight potential problems with new drugs. hERG (human ether-à-go-go-related gene, alternative nomenclature KCNH2) is responsible for channels mediating the 'rapid' delayed rectifier K+ current (IKr) which plays an important role in ventricular repolarization. Pharmacological inhibition of native IKr and of recombinant hERG channels is a shared feature of diverse drugs associated with TdP. In vitro hERG assays therefore form a key element of an integrated assessment of TdP liability, with patch-clamp electrophysiology offering a 'gold standard'. However, whilst clearly necessary, hERG assays cannot be assumed automatically to provide sufficient information, when considered in isolation, to differentiate 'safe' from 'dangerous' drugs. Other relevant factors include therapeutic plasma concentration, drug metabolism and active metabolites, severity of target condition and drug effects on other cardiac ion channels that may mitigate or exacerbate effects of hERG blockade. Increased understanding of the nature of drug-hERG channel interactions may ultimately help eliminate potential hERG blockade early in the design and development process. Currently, for promising drug candidates integration of data from hERG assays with information from other pre-clinical safety screens remains essential.
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Affiliation(s)
- Jules C Hancox
- Department of Physiology and Pharmacology, Cardiovascular Research Laboratories, Bristol Heart Institute, School of Medical Sciences, The University of Bristol, University Walk, Bristol, BS8 1TD, United Kingdom.
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Jo SH, Hong HK, Chong SH, Choe H. Protriptyline block of the human ether-à-go-go-related gene (HERG) K+ channel. Life Sci 2008; 82:331-40. [PMID: 18191158 DOI: 10.1016/j.lfs.2007.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Revised: 11/30/2007] [Accepted: 12/04/2007] [Indexed: 11/18/2022]
Abstract
Protriptyline, a tricyclic antidepressant for psychiatric disorders, can induce prolonged QT, torsades de pointes, and sudden death. We studied the effects of protriptyline on human ether-à-go-go-related gene (HERG) channels expressed in Xenopus oocytes and HEK293 cells. Protriptyline induced a concentration-dependent decrease in current amplitudes at the end of the voltage steps and HERG tail currents. The IC(50) for protriptyline block of HERG current in Xenopus oocytes progressively decreased relative to the degree of depolarization, from 142.0 microM at -40 mV to 91.7 microM at 0 mV to 52.9 microM at +40 mV. The voltage dependence of the block could be fit with a monoexponential function, and the fractional electrical distance was estimated to be delta=0.93. The IC(50) for the protriptyline-induced blockade of HERG currents in HEK293 cells at 36 degrees C was 1.18 microM at +20 mV. Protriptyline affected channels in the activated and inactivated states, but not in the closed states. HERG blockade by protriptyline was use-dependent, exhibiting a more rapid onset and a greater steady-state block at higher frequencies of activation. Our findings suggest that inhibition of HERG currents may contribute to the arrhythmogenic side effects of protriptyline.
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Affiliation(s)
- Su-Hyun Jo
- Department of Physiology, Institute of Bioscience and Biotechnology, Kangwon National University College of Medicine, Chuncheon 200-701, South Korea.
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30
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Glancy DL, Glancy CF. Wide Qrs Tachycardia in a Young Woman with a Drug Overdose. Proc (Bayl Univ Med Cent) 2007; 20:305-6. [PMID: 17637887 PMCID: PMC1906582 DOI: 10.1080/08998280.2007.11928309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- D Luke Glancy
- Section of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA.
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Duncan R, McPate M, Ridley J, Gao Z, James A, Leishman D, Leaney J, Witchel H, Hancox J. Inhibition of the HERG potassium channel by the tricyclic antidepressant doxepin. Biochem Pharmacol 2007; 74:425-37. [PMID: 17560554 PMCID: PMC1920586 DOI: 10.1016/j.bcp.2007.04.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Revised: 04/25/2007] [Accepted: 04/27/2007] [Indexed: 11/25/2022]
Abstract
HERG (human ether-à-go-go-related gene) encodes channels responsible for the cardiac rapid delayed rectifier potassium current, IKr. This study investigated the effects on HERG channels of doxepin, a tricyclic antidepressant linked to QT interval prolongation and cardiac arrhythmia. Whole-cell patch-clamp recordings were made at 37 °C of recombinant HERG channel current (IHERG), and of native IKr ‘tails’ from rabbit ventricular myocytes. Doxepin inhibited IHERG with an IC50 value of 6.5 ± 1.4 μM and native IKr with an IC50 of 4.4 ± 0.6 μM. The inhibitory effect on IHERG developed rapidly upon membrane depolarization, but with no significant dependence on voltage and with little alteration to the voltage-dependent kinetics of IHERG. Neither the S631A nor N588K inactivation-attenuating mutations (of residues located in the channel pore and external S5-Pore linker, respectively) significantly reduced the potency of inhibition. The S6 point mutation Y652A increased the IC50 for IHERG blockade by ∼4.2-fold; the F656A mutant also attenuated doxepin's action at some concentrations. HERG channel blockade is likely to underpin reported cases of QT interval prolongation with doxepin. Notably, this study also establishes doxepin as an effective inhibitor of mutant (N588K) HERG channels responsible for variant 1 of the short QT syndrome.
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Affiliation(s)
- R.S. Duncan
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
| | - M.J. McPate
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
| | - J.M. Ridley
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
| | - Z. Gao
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
| | - A.F. James
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
| | - D.J. Leishman
- Pfizer Global Research & Development, Sandwich Laboratories, Ramsgate Road, Sandwich, Kent CT13 9NJ, UK
- Lilly Research Laboratories, Greenfield Laboratories, PO Box 708, Greenfield IN, 46140, USA
| | - J.L. Leaney
- Pfizer Global Research & Development, Sandwich Laboratories, Ramsgate Road, Sandwich, Kent CT13 9NJ, UK
| | - H.J. Witchel
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
- Corresponding authors. Tel.: +117 928 9028; fax: +117 928 8923.
| | - J.C. Hancox
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, BS8 1TD, UK
- Corresponding authors. Tel.: +117 928 9028; fax: +117 928 8923.
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Lenkey N, Karoly R, Kiss JP, Szasz BK, Vizi ES, Mike A. The Mechanism of Activity-Dependent Sodium Channel Inhibition by the Antidepressants Fluoxetine and Desipramine. Mol Pharmacol 2006; 70:2052-63. [PMID: 16985186 DOI: 10.1124/mol.106.026419] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The effect of monoamine uptake inhibitor-type antidepressants on sodium channels of hippocampal neurons was investigated. Members of the tricyclic group of antidepressants are known to modify multiple targets, including sodium channels, whereas selective serotonin-reuptake inhibitors (SSRIs) are regarded as highly selective compounds, and their effect on sodium channels was not investigated in detail. In this study, a representative member of each group was chosen: the tricyclic antidepressant desipramine and the SSRI fluoxetine. The drugs were roughly equipotent use-dependent inhibitors of sodium channels, with IC(50) values approximately 100 microM at -150 mV holding potential, and approximately 1 microM at -60 mV. We suggest that therapeutic concentrations of antidepressants affect neuronal information processing partly by direct, activity-dependent inhibition of sodium channels. As for the mechanism of inhibition, use-dependent inhibition by antidepressants was believed to be due to a preferential affinity to the fast-inactivated state. Using a voltage and perfusion protocol by which relative affinities to fast-versus slow-inactivated states could be assessed, we challenged this view and found that the affinity of both drugs to slowinactivated state(s) was higher. We propose a different mechanism of action for these antidepressants, in which slow rather than fast inactivation plays the dominant role. This mechanism is similar but not equivalent with the novel mechanism of usedependent sodium channel inhibition previously described by our group (Neuroscience 125:1019-1028, 2004; Neuroreport 14:1945-1949, 2003). Our results suggest that different drugs can produce use-dependent sodium channel inhibition by different mechanisms.
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Affiliation(s)
- N Lenkey
- Department of Pharmacology, Institute of Experimental Medicine, Hungarian Academy of Sciences, Budapest, Hungary
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Kinoshita H, Taniguchi T, Kubota A, Nishiguchi M, Ouchi H, Minami T, Utsumi T, Motomura H, Nagasaki Y, Ameno K, Hishida S. An autopsy case of imipramine poisoning. Am J Forensic Med Pathol 2005; 26:271-4. [PMID: 16121085 DOI: 10.1097/01.paf.0000176279.67733.5d] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We present a fatal imipramine poisoning. Quantitative analysis of imipramine and its metabolite, desipramine, was performed by high-performance liquid chromatography. The concentrations of imipramine and desipramine were 18.67 microg/mL and 6.21 microg/mL in heart blood and 6.90 microg/mL and 1.77 microg/mL in the femoral venous blood, respectively. We concluded that the cause of death was due to imipramine poisoning.
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Affiliation(s)
- Hiroshi Kinoshita
- Department of Legal Medicine, Hyogo College of Medicine, Hyogo, Japan.
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Lee DW, Flint J, Morey T, Dennis D, Partch R, Baney R. Aromatic-aromatic interaction of amitriptyline: implication of overdosed drug detoxification. J Pharm Sci 2005; 94:373-81. [PMID: 15614810 DOI: 10.1002/jps.20256] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The objectives of this work are to explore the pi-pi complexation of amitriptyline with pi electron-deficient aromatic rings and demonstrate the feasibility of pi-pi complexation for overdosed drug detoxification. Water-soluble oligochitosan was chemically modified with dinitrobenzenesulfonyl groups to induce selective binding toward amitriptyline through pi-pi complexation. NMR studies showed that benzenesulfonyl and dinitrobenzenesulfonyl protons were upfield shifted by the addition of amitriptyline, indicating the formation of pi-pi complexes. The pi-pi complexation of amitriptyline is driven primarily by a desolvation driving force, whereas the magnitude of interaction is dictated by the complementrary electrostatic interaction. Isolated rat heart tests revealed that dinitrobenzenesulfonyl oligochitosan prevented the amitriptyline-induced cardiotoxicity and was itself not cardiotoxic.
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Affiliation(s)
- Dong-Won Lee
- Department of Materials Science and Engineering, Gainesville, Florida 32611, USA
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Michael JB, Sztajnkrycer MD. Deadly pediatric poisons: nine common agents that kill at low doses. Emerg Med Clin North Am 2004; 22:1019-50. [PMID: 15474780 DOI: 10.1016/j.emc.2004.05.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
More than 97% of pediatric exposures reported to the AAPCC in 2001 had either no effect or mild clinical effects. Despite the large number of exposures, only 26 of the 1074 reported fatalities occurred in children younger than age 6. These findings reflect the fact that, in contrast to adolescent or adult ingestions, pediatric ingestions are unintentional events secondary to development of exploration behaviors and the tendency to place objects in the mouth. Ingested substances typically are nontoxic or ingested in such small quantities that toxicity would not be expected. As a result, it commonly is believed that ingestion of one or two tablets by a toddler is a benign act and not expected to produce any consequential toxicity. Select agents have the potential to produce profound toxicity and death, however, despite the ingestion of only one or two tablets or sips. Although proven antidotes are a valuable resource, their value is diminished if risk after ingestion is not adequately appreciated and assessed. Future research into low-dose, high-risk exposures should be directed toward further clarification of risk, improvements in overall management strategies,and, perhaps most importantly, prevention of toxic exposure through parental education and appropriate safety legislation.
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Affiliation(s)
- Joshua B Michael
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Sadanaga T, Sadanaga F, Yao H, Fujishima M. Abnormal QT prolongation and psychotropic drug therapy in psychiatric patients: Significance of bradycardia-dependent QT prolongation. J Electrocardiol 2004; 37:267-73. [PMID: 15484154 DOI: 10.1016/j.jelectrocard.2004.07.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Because many psychotropic drugs have electrophysiological properties similar to antiarrhythmic drugs, they might lengthen QT interval and cause torsades de pointes. Electrocardiograms were obtained in 688 psychiatric patients receiving psychotropic drugs. A QTc interval >460 ms was observed in 96 (14%) patients. To elucidate the heart rate dependence of QT prolongation, we measured QT intervals and the preceding R-R intervals at various heart rates by 24-hour Holter electrocardiogram in 97 patients. We estimated the QT intervals at the heart rates of 80 beats/min and 50 beats/min by the regression curve. A QT interval at the heart rate of 80 beats/min exceeded 400 ms in 14 (15%) patients and that at the heart rate of 50 beats/min exceeded 480 ms in additional 12 (12%) patients. Therefore, additional attention is needed for bradycardia-dependent QT prolongation even when the QT interval was not prolonged at usual heart rates.
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Affiliation(s)
- Tsuneaki Sadanaga
- Department of Medicine and Clinical Science, Graduate School fo Medical Sciences, Kyushu University, Japan.
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37
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Arya B, Hirudayaraj P, Willmer K. Myocardial infarction: a rare complication of dothiepin overdose. Int J Cardiol 2004; 96:493-4. [PMID: 15301910 DOI: 10.1016/j.ijcard.2003.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2003] [Revised: 06/21/2003] [Accepted: 06/21/2003] [Indexed: 10/26/2022]
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Cheeta S, Schifano F, Oyefeso A, Webb L, Ghodse AH. Antidepressant-related deaths and antidepressant prescriptions in England and Wales, 1998-2000. Br J Psychiatry 2004; 184:41-7. [PMID: 14702226 DOI: 10.1192/bjp.184.1.41] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Deaths from antidepressants continue to account for a substantial proportion of drug-related deaths. AIMS To investigate the relative toxicity of the major classes of antidepressant drugs, with the specific objective of assessing this in relation to the cause of death; and to analyse the deaths where there were multiple mentions of antidepressant drugs or other psychoactive drugs with antidepressants. METHOD Mortality data were collected from the National Programme of Substance Abuse Deaths, and antidepressant prescription data were collected. RESULTS Most deaths from antidepressant drugs were suicides (80%). Tricyclic antidepressants (TCAs) accounted for more drug mentions than did other antidepressant drugs (12 per million prescriptions). Selective serotonin reuptake inhibitors (SSRIs) were associated with a significantly lower risk of toxicity, but 93% of deaths from SSRIs occurred in combination with other drugs, especially TCAs (24.5%). In 'combination' deaths patients were significantly more likely to have had a history of drug misuse. CONCLUSIONS The efficacy and safety of augmentation therapy with TCAs in SSRI-resistant patients should be monitored carefully, and patients prescribed antidepressants should be screened for drug use/misuse.
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Affiliation(s)
- Survjit Cheeta
- Department of Addictive Behaviour and Psychological Medicine, St George's Hospital Medical School, London, UK.
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39
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Mohr WK, Petti TA, Mohr BD. Adverse effects associated with physical restraint. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2003; 48:330-7. [PMID: 12866339 DOI: 10.1177/070674370304800509] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint. METHOD Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine. CONCLUSIONS Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.
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Affiliation(s)
- Wanda K Mohr
- Rutgers University, College of Nursing, Newark, New Jersey, USA.
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40
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Poisoning. Fam Med 2003. [DOI: 10.1007/978-0-387-21744-4_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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41
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Buckley NA, Chevalier S, Leditschke IA, O'Connell DL, Leitch J, Pond SM. The limited utility of electrocardiography variables used to predict arrhythmia in psychotropic drug overdose. Crit Care 2003; 7:R101-7. [PMID: 12974977 PMCID: PMC270716 DOI: 10.1186/cc2345] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2003] [Revised: 06/06/2003] [Accepted: 06/11/2003] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The aim of the present study was to examine the relationship between serious arrhythmias in patients with psychotropic drug overdose and electrocardiography (ECG) findings that have been suggested previously to predict this complication. METHODS Thirty-nine patients with serious arrhythmias (ventricular tachycardia, supraventricular tachycardia or cardiac arrest) after tricyclic antidepressant overdose or thioridazine overdose were compared with 117 controls with clinically significant overdose matched to each case for the drug ingested. These patients with psychotropic drug overdose had presented for treatment to the Department of Clinical Toxicology, Newcastle and to the Princess Alexandra Hospital, Brisbane. The heart rate, the QRS width, the QTc and QT intervals, the QT dispersion, and the R wave and R/S ratios in aVR on the initial ECGs were compared in cases and controls. RESULTS The cases had taken dothiepin (16 patients), doxepin (six patients), thioridazine (five patients), amitriptyline (five patients), nortriptyline (three patients), imipramine (one patient) and a combination of dothiepin and thioridazine (three patients). In 20 of the 39 patients with arrhythmias, the arrhythmia had been a presumed ventricular tachycardia. Of the other 19 patients, 15 patients had a supraventricular tachycardia, two patients had cardiac arrests (one asystole, one without ECG monitoring) and two patients had insufficient data recorded to make classification of the arrhythmias possible. The QRS was >/= 100 ms in 82% of cases but also in 76% of controls. QRS >/= 160 ms had a sensitivity of only 13% and occurred in 2% of controls. QRS > 120 ms, QTc > 500 and the R/S ratio in aVR appeared to have a stronger association with the occurrence of arrhythmia: QRS > 120 ms (odds ratio [OR], 3.56; 95% confidence interval [CI], 1.46-8.68), QTc > 500 (OR, 3.07; 95% CI, 1.33-7.07), and R/S ratio in aVR > 0.7 (OR, 16; 95% CI, 3.47-74). Excluding thioridazine overdoses and performing the analysis for tricyclic antidepressant overdoses alone gave increased odds ratios for QRS > 120 ms (OR, 4.83; 95% CI, 1.73-13.5) and QTc > 500 (OR, 4.5; 95% CI, 1.56-13) but had little effect on that for the R/S ratio in aVR > 0.7 (OR, 14.5; 95% CI, 3.10-68). CONCLUSION ECG measurements were generally weakly related to the occurrence of arrhythmia and should not be used as the sole criteria for risk assessment in tricyclic antidepressant overdose. The frequently recommended practice of using either QRS >/= 100 ms or QRS >/= 160 ms to predict arrhythmias is not supported by our study. R/S ratio in aVR > 0.7 was most strongly related to arrhythmia but had estimated positive and negative predictive values of only 41% and 95%, respectively. The use of these specific predictors in other drug overdoses is not recommended without specific studies.
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43
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Casis O, Gallego M, Sánchez-Chapula JA. Imipramine, mianserine and maprotiline block delayed rectifier potassium current in ventricular myocytes. Pharmacol Res 2002; 45:141-6. [PMID: 11846627 DOI: 10.1006/phrs.2002.0941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Imipramine, mianserine and maprotiline are three widely used antidepressant drugs with different chemical structure. In the present work we have studied the effects of these drugs on the delayed rectifier potassium current (I(K)) in myocytes isolated from rat ventricle. The delayed rectifier potassium current, responsible for action potential termination, is blocked by all of the three drugs I(K)studied in a state-independent manner. Imipramine and mianserine block I(K)in a 1 : 1 drug-receptor interaction, whereas maprotiline shows a negative cooperativity in the interaction between the channel complex and drug molecules.
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Affiliation(s)
- Oscar Casis
- Department of Physiology, School of Pharmacy, University of the Basque Country, Bilbao, Spain.
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44
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Ash SR, Levy H, Akmal M, Mankus RA, Sutton JM, Emery DR, Scanlon JC, Blake DE, Carr DJ. Treatment of severe tricyclic antidepressant overdose with extracorporeal sorbent detoxification. ADVANCES IN RENAL REPLACEMENT THERAPY 2002; 9:31-41. [PMID: 11927905 DOI: 10.1053/jarr.2001.30475] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tricyclic overdose can be a medical emergency, and therapy with intravenous bicarbonate is not always successful in preventing cardiac toxicity or coma. Mortality in patients developing these complications is from 1% to 15%. Extracorporeal detoxification with sorbents has been used in treatment of patients with very high drug levels and declining clinical condition. Ten patients with serious drug overdose caused by tricyclics failed to respond quickly to standard therapy and were in stage 3-4 encephalopathy. Nine of these patients were on respirator support, 5 had hypotension, and 6 had QRS widening. Average level was 1,423 microg/L at presentation. Enteral activated charcoal and intravenous (IV) bicarbonate were initiated in the emergency room. The patients were treated for 3 to 4 hours with the Liver Dialysis Unit, a hemodiabsorption device using a cellulosic plate dialyzer and sorbent suspension as dialysate. Inflow and outflow blood levels indicated that the hemodetoxifier removed modest amounts of the tricyclics, metabolites, and other consumed drugs. The clinical improvement of the patients was dramatic, with patients reaching stage 0 or 1 encephalopathy during the treatment. Ventilator support was removed at the end of treatment for 3 patients who had not already developed pneumonia, and for others was prolonged up to 48 hours because of pneumonia, rather than mental status. Average length of stay in the intensive care unit (ICU) was 4.8 days (range 1 to 7 days). None of the patients died despite their high risk for ventricular arrhythmias, seizures, and death. Clinical improvement may have been attributable to removal of free drug from the blood or to removal of drug metabolites.
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Affiliation(s)
- Stephen R Ash
- Arnett Clinic, Greater Lafayette Health Services, West Lafayette, IN 47906, USA.
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45
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Abstract
Overdoses of tricyclic antidepressants are among the commonest causes of drug poisoning seen in accident and emergency departments. This review discusses the pharmacokinetics, clinical presentation and treatment of tricyclic overdose.
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Affiliation(s)
- G W Kerr
- Accident and Emergency Department, Ayr Hospital, Dalmellington Road, Ayr, Scotland.
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46
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Lappa A, Castagna A, Imperiale C, Fenga M. Near fatal case of atrio-ventricular block induced by amitriptyline at therapeutic dose. Intensive Care Med 2000; 26:1399. [PMID: 11089775 DOI: 10.1007/s001340000581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Affiliation(s)
- L H Opie
- Heart Research Unit, University of Cape Town, South Africa
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48
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Abstract
Cisapride, a prokinetic agent, has been used for the treatment of a number of gastrointestinal disorders, particularly gastro-oesophageal reflux disease in adults and children. Since 1993, 341 cases of ventricular arrhythmias, including 80 deaths, have been reported to the US Food and Drug Administration. Marketing of the drug has now been discontinued in the US; however, it is still available under a limited-access protocol. Knowledge of the risk factors for cisapride-associated arrhythmias will be essential for its continued use in those patients who meet the eligibility criteria. This review summarises the published literature on the pharmacokinetic and pharmacodynamic interactions of cisapride with concomitantly administered drugs, providing clinicians with practical recommendations for avoiding these potentially fatal events. Pharmacokinetic interactions with cisapride involve inhibition of cytochrome P450 (CYP) 3A4, the primary mode of elimination of cisapride, thereby increasing plasma concentrations of the drug. The macrolide antibacterials clarithromycin, erythromycin and troleandomycin are inhibitors of CYP3A4 and should not be used in conjunction with cisapride. Azithromycin is an alternative. Similarly, azole antifungal agents such as fluconazole, itraconazole and ketoconazole are CYP3A4 inhibitors and their concomitant use with cisapride should be avoided. Of the antidepressants nefazodone and fluvoxamine should be avoided with cisapride. Data with fluoxetine is controversial, we favour the avoidance of its use. Citalopram, paroxetine and sertraline are alternatives. The HIV protease inhibitors amprenavir, indinavir, nelfinavir, ritonavir and saquinavir inhibit CYP3A4. Clinical experience with cisapride is lacking but avoidance with all protease inhibitors is recommended, although saquinavir is thought to have clinically insignificant effects on CYP3A4. Delavirdine is also a CYP3A4 inhibitor and should be avoided with cisapride. We also recommend avoiding coadministration of cisapride with amiodarone, cimetidine (alternatives are famotidine, nizatidine, ranitidine or one of the proton pump inhibitors), diltiazem and verapamil (the dihydropyridine calcium antagonists are alternatives), grapefruit juice, isoniazid, metronidazole, quinine, quinupristin/dalfopristin and zileuton (montelukast is an alternative). Pharmacodynamic interactions with cisapride involve drugs that have the potential to have additive effects on the QT interval. We do not recommend use of cisapride with class Ia and III antiarrhythmic drugs or with adenosine, bepridil, cyclobenzaprine, droperidol, haloperidol, nifedipine (immediate release), phenothiazine antipsychotics, tricyclic and tetracyclic antidepressants or vasopressin. Vigilance is advised if anthracyclines, cotrimoxazole (trimethoprim-sulfamethoxazole), enflurane, halothane, isoflurane, pentamidine or probucol are used with cisapride. In addition, uncorrected electrolyte disturbances induced by diuretics may increase the risk of torsade de pointes. Patients receiving cisapride should be promptly treated for electrolyte disturbances.
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Affiliation(s)
- E L Michalets
- Mission + St Joseph's Health System, Department of Pharmacy, Asheville, North Carolina 28801, USA.
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49
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Reich MR, Ohad DG, Overall KL, Dunham AE. Electrocardiographic assessment of antianxiety medication in dogs and correlation with serum drug concentration. J Am Vet Med Assoc 2000; 216:1571-5. [PMID: 10825942 DOI: 10.2460/javma.2000.216.1571] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine effects of tricyclic antidepressants (TCA) on the ECG of dogs treated for behavioral conditions and to examine correlations between ECG findings and serum concentrations of these medications. DESIGN Repeated-measures study. ANIMALS 39 client-owned dogs with behavioral problems. PROCEDURE Two groups of dogs with behavioral problems were evaluated. In group 1 (n = 20), ECG tracings were recorded before starting treatment with TCA and again after treatment for > or = 1 month. Dogs in group 2 were already on long-term maintenance amounts of antianxiety medication when ECG tracings were recorded and serum concentrations of medications were obtained. RESULTS Significant differences were not detected for dogs in group 1 between ECG values measured before and after TCA administration. The ECG values for dogs in group 2 did not differ significantly from the mean of group-1 dogs before receiving medication or from the reference range used at our facility. Duration of the P wave had a significant positive correlation with serum concentrations of clomipramine but significant negative correlation with serum concentrations of amitriptyline. The QT interval corrected for heart rate had a significant negative correlation with serum concentrations of amitriptyline. CONCLUSIONS AND CLINICAL RELEVANCE Amitriptyline and clomipramine administered at standard dosages apparently do not cause ECG abnormalities in healthy dogs with behavioral problems. These medications should be used cautiously in dogs with conduction abnormalities, and clinicians should periodically monitor ECG and use good clinical judgment to weigh risks and benefits of medications for the safety of each dog.
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Affiliation(s)
- M R Reich
- Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania, Philadelphia 19104-6010, USA
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50
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Jo SH, Youm JB, Lee CO, Earm YE, Ho WK. Blockade of the HERG human cardiac K(+) channel by the antidepressant drug amitriptyline. Br J Pharmacol 2000; 129:1474-80. [PMID: 10742304 PMCID: PMC1571977 DOI: 10.1038/sj.bjp.0703222] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
1. Amitriptyline has been known to induce QT prolongation and torsades de pointes which causes sudden death. We studied the effects of amitriptyline on the human ether-a-go-go-related gene (HERG) channel expressed in Xenopus oocytes and on the rapidly activating delayed rectifier K(+) current (I(Kr)) in rat atrial myocytes. 2. The amplitudes of steady-state currents and tail currents of HERG were decreased by amitriptyline dose-dependently. The decrease became more pronounced at more positive potential, suggesting that the block of HERG by amitriptyline is voltage dependent. IC(50) for amitriptyline block of HERG current was progressively decreased according to depolarization: IC(50) values at -30, -10, +10 and +30 mV were 23.0, 8.71, 5.96 and 4.66 microM, respectively. 3. Block of HERG by amitriptyline was use dependent: exhibiting a much faster block at higher activation frequency. Subsequent decrease in frequency after high activation frequency resulted in a partial relief of HERG blockade. 4. Steady-state block by amitriptyline was obtained while depolarization to +20 mV for 0.5 s was applied at 0.5 Hz: IC(50) was 3.26 microM in 2 mM [K(+)](o). It was increased to 4. 78 microM in 4 mM [K(+)](o), suggesting that the affinity of amitriptyline on HERG was decreased by external K(+). 5. In rat atrial myocytes bathed in 35 degrees C, 5 microM amitriptyline blocked I(Kr) by 55%. However, transient outward K(+) current (I(to)) was not significantly affected. 6. In summary, the data suggest that the block of HERG currents may contribute to arrhythmogenic side effects of amitriptyline.
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Affiliation(s)
- Su-Hyun Jo
- Department of Life Science, Pohang University of Science and Technology, Pohang 790–784, South Korea
| | - Jae Boum Youm
- Department of Physiology, Seoul National University College of Medicine, Yonkeun-Dong, Chongno-Ku, Seoul 110–799, South Korea
| | - Chin O Lee
- Department of Life Science, Pohang University of Science and Technology, Pohang 790–784, South Korea
| | - Yung E Earm
- Department of Physiology, Seoul National University College of Medicine, Yonkeun-Dong, Chongno-Ku, Seoul 110–799, South Korea
| | - Won-Kyung Ho
- Department of Physiology, Seoul National University College of Medicine, Yonkeun-Dong, Chongno-Ku, Seoul 110–799, South Korea
- Author for correspondence:
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