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De Las Cuevas C, de Leon VC, Blasco-Fontecilla H, Baca-García E, Sagud M, Sanz EJ, de Leon J. Clozapine may consistently protect from suicidal behaviors while other antipsychotics may lack a specific protective effect: a comprehensive VigiBase study interpreted in the context of the prior literature. Expert Opin Drug Saf 2024:1-11. [PMID: 39223773 DOI: 10.1080/14740338.2024.2399094] [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: 06/02/2024] [Revised: 08/05/2024] [Accepted: 08/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND In the United States, clozapine was first approved for treatment-resistant schizophrenia and then for suicidality in schizophrenia psychoses. Systematic reviews support clozapine's anti-suicidal effect, but the forensic literature stresses its lethality during overdoses. RESEARCH DESIGN AND METHODS Clozapine reports to the international pharmacovigilance database (VigiBase) were analyzed for suicidal ideation, suicide attempts, intentional overdose, and completed suicides from introduction to 1 January 2024. VigiBase uses the information component (IC) as a disproportionality analysis. RESULTS The clozapine ICs (range: other antipsychotics) were: 1) suicidal ideation IC = 0.570 with IC025 = 0.454 to IC975 = 0.680 (IC = 3.568 for aripiprazole and 1.729 for risperidone), 2) suicide attempt IC = 1.428 with IC025 = 1.323 to IC975 = 1.529 (IC = 4.150 for quetiapine and 2.968 for risperidone), 3) intentional overdose: IC = 0.995 with IC025 = 0.864 to IC975 = 1.120 (IC = 4.080 for quetiapine and 1.957 for aripiprazole), and 4) completed suicide IC = 1.133 with IC025 = 1.026 to IC975 = 1.235 (IC = 4.648 for quetiapine and 2.160 for risperidone). In summary, all clozapine ICs were significantly lower. We found 2391 clozapine-treated patients on the suicidality spectrum (627 cases with suicidal ideation, 752 with suicide attempt, 488 with intentional overdose, and 731 with completed suicide) but many were taking other antipsychotics. The most frequent reporting countries were the United States, the United Kingdom, and Croatia. CONCLUSION This pharmacovigilance study, with all its inherent limitations, provides independent proof, not overlapping with prior literature, that clozapine may have specific strong anti-suicidal effects that do not appear to be present in other antipsychotics. Further VigiBase studies are needed to compare the lethality of an intentional overdose of clozapine (14.3%) with other antipsychotics.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology, and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Spain
| | - Victoria C de Leon
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Hilario Blasco-Fontecilla
- Instituto de Investigación, Transferencia e Innovación, Ciencias de la Saludy Escuela de Doctorado, Universidad Internacional de La Rioja, Logroño, Spain
- Emooti, Madrid, Spain
- Center of Biomedical Network Research on Mental Health (CIBERSAM), Carlos III Institute of Health, Madrid, Spain
| | - Enrique Baca-García
- Center of Biomedical Network Research on Mental Health (CIBERSAM), Carlos III Institute of Health, Madrid, Spain
- Department of Psychiatry, Hospital Fundación Jiménez Díaz, Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
- Universidad Católica del Maule, Talca, Chile
- Department of Psychiatry, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Marina Sagud
- School of Medicine, University of Zagreb, Zagreb, Croatia
- University Hospital Centre Zagreb, Zagreb, Croatia
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Spain
- Hospital Universitario de Canarias, Tenerife, Spain
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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Ștefan CS, Nechita A, Dragostin OM, Fulga A, Lisă EL, Vatcu R, Dragostin I, Velicescu C, Fulga I. Drugs Associated with Adverse Effects in Vulnerable Groups of Patients. Clin Pract 2024; 14:1010-1020. [PMID: 38921258 PMCID: PMC11203099 DOI: 10.3390/clinpract14030080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 05/11/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
In recent years, a series of recommendations have been issued regarding the administration of drugs because of awareness of the serious side effects associated with certain classes of drugs, especially in vulnerable patients. Taking into account the obligation of the continuous improvement of professionals in the medical fields and the fact that we are in the midst of a "malpractice accusations pandemic", through this work, we propose to carry out a "radiography" of the scientific literature regarding adverse effects that may occur as a result of the interaction of drugs with the physiopathological particularities of patients. The literature reports various cases regarding different classes of drugs administration associated with adverse effects in the elderly people, such as fluoroquinolones, which can cause torsade de pointes or tendinopathy, or diuretics, which can cause hypokalemia followed by torsade de pointes and cardiorespiratory arrest. Also, children are more prone to the development of adverse reactions due to their physiological particularities, while for pregnant women, some drugs can interfere with the normal development of the fetus, and for psychiatric patients, the use of neuroleptics can cause agranulocytosis. Considering the physiopathological particularities of each patient, the drug doses must be adjusted or even completely removed from the treatment scheme, thus requiring the mandatory active participation both of clinician pharmacists and specialists in the activity of medical-pharmaceutical analysis laboratories within the structure of hospitals.
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Affiliation(s)
- Claudia Simona Ștefan
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Aurel Nechita
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Oana-Maria Dragostin
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Ana Fulga
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Elena-Lăcrămioara Lisă
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Rodica Vatcu
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Ionut Dragostin
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
| | - Cristian Velicescu
- Faculty of Medicine, “Grigore T Popa” University of Medicine and Pharmacy Iasi, 16 University Street, 700115 Iaşi, Romania;
| | - Iuliu Fulga
- Research Centre in the Medical-Pharmaceutical Field, Faculty of Medicine and Pharmacy, “Dunarea de Jos” University of Galati, 35 AL Cuza st, 800010 Galati, Romania; (C.S.Ș.); (A.F.); (E.-L.L.); (R.V.); (I.D.); (I.F.)
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El-Gharbawy DM, Kabbash IA, Ghonem MM. A nomogram proposal for early prediction of intensive care unit admission in patients with acute antipsychotic poisoning. Toxicol Res (Camb) 2023; 12:873-883. [PMID: 37915484 PMCID: PMC10615807 DOI: 10.1093/toxres/tfad078] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 07/26/2023] [Accepted: 08/30/2023] [Indexed: 11/03/2023] Open
Abstract
Background Early identification of antipsychotic poisoned patients who may have a potential risk for intensive care unit (ICU) admission is crucial especially when resources are limited. Nomograms were previously used as a practical tool to predict prognosis and planning the treatment of some diseases including some poisoning conditions. However, they were not previously investigated in antipsychotic poisoning. Aim The current study aimed to construct a nomogram to predict the need for ICU admission in acute antipsychotic poisoning. Patients and methods: This 2-year study included 140 patients acutely intoxicated with antipsychotics and admitted at Tanta University Poison Control Centre throughout July 2019 to June 2021. Personal and toxicological data, findings of clinical examination and electrocardiography, as well as, results of laboratory investigations at time of admission were recorded. According to the outcome, patients were divided into ICU-admitted and ICU-not admitted groups. Results The results of this study provided a proposed nomogram that included five significant independent predictors for ICU admission in acute antipsychotic intoxications; the presence of seizures (OR: 31132.26[108.97-Inf]), corrected QT interval (OR: 1.04[1.01-1.09]), mean arterial blood pressure (OR: 0.83[0.70-0.92]), oxygen saturation (OR: 0.62[0.40 to 0.83)], and Glasgow Coma Scale (OR: 0.25 [0.06-0.56]). Conclusion It could be concluded that the developed nomogram is a promising tool for easy and rapid decision making to predict the need for ICU admission in acute antipsychotic poisoning.
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Affiliation(s)
- Doaa M El-Gharbawy
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ibrahim Ali Kabbash
- Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona M Ghonem
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta, Egypt
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Warstadt N, Mohan S, Furlano E, Shenker J, Gibbs E, Smith S. Abilifright: A Case Report of Massive Aripiprazole Overdose in a Toddler. Clin Pract Cases Emerg Med 2022; 6:32-36. [PMID: 35226844 PMCID: PMC8885235 DOI: 10.5811/cpcem.2021.10.54520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 10/15/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Aripiprazole is an atypical antipsychotic with unique receptor-binding
properties that has a favorable safety profile in therapeutic doses compared
to other antipsychotics. Massive aripiprazole overdose in children, however,
presents with profound lethargy and may have neurologic, hemodynamic, and
cardiac effects, often requiring admission to a high level of care. Case Report We describe a case of a 21-month-old male with a reported 52-milligram
aripiprazole ingestion. Initial vital signs were remarkable for tachycardia
and hypertension, which rapidly resolved. The patient did not develop
hypotension throughout hospitalization. He experienced 60 hours of lethargy.
Irritability associated with upper extremity spasms and tremors occurred
from 36–72 hours post ingestion, which resolved without
intervention. The initial electrocardiogram demonstrated ST-segment
depressions in the anteroseptal leads; further cardiac workup was normal.
Concurrent medical workup was unrevealing. Aripiprazole and
dehydro-aripiprazole serum concentrations sent 46 hours after reported
exposure were 266.5 nanograms per milliliter (ng/mL) and 138.6 ng/mL,
respectively. He returned to neurologic baseline and was discharged 72 hours
after ingestion. Conclusion Antipsychotics, including aripiprazole, should be considered as a potential
toxicological cause of persistent central nervous system depression;
ingestion of a single dose has the potential to cause significant
toxicity.
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Affiliation(s)
- Nicholus Warstadt
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, New York, New York
| | - Sanjay Mohan
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology, New York, New York
| | - Emma Furlano
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology, New York, New York
| | - Jennifer Shenker
- New York University Grossman School of Medicine, Department of Pediatrics, New York, New York
| | - Eric Gibbs
- New York University Grossman School of Medicine, Department of Pediatrics, New York, New York
| | - Silas Smith
- New York University Grossman School of Medicine, Ronald O. Perelman Department of Emergency Medicine, Division of Medical Toxicology, New York, New York; New York University Grossman School of Medicine, Institute for Innovations in Medical Education, New York, New York
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Affiliation(s)
- David C Sheridan
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - Adrienne Hughes
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
| | - B Zane Horowitz
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR.,Oregon Poison Center, Portland, OR
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Cortés-Beringola A, Vicent L, Martín-Asenjo R, Puerto E, Domínguez-Pérez L, Maruri R, Moreno G, Vidán MT, Bueno H. Diagnosis, prevention, and management of delirium in the intensive cardiac care unit. Am Heart J 2021; 232:164-176. [PMID: 33253676 DOI: 10.1016/j.ahj.2020.11.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/16/2020] [Indexed: 12/01/2022]
Abstract
Delirium is a frequent complication in patients admitted to intensive cardiac care units (ICCU) with potentially severe consequences including increased risks of mortality, cognitive impairment and dependence at discharge, and longer times on mechanical ventilation and hospital stay. Delirium has been widely documented and studied in general intensive care units and in patients after cardiac surgery, but it has barely been studied in acute nonsurgical cardiac patients. Moreover, delirium (especially in its hypoactive form) is commonly misdiagnosed. We propose a protocol for delirium prevention and management in ICCUs. A daily comprehensive assessment to improve detection should be done using validated scales (ie, confusion assessment method). Preventive measures are particularly relevance and constitute the basis of treatment as well, acting on reversible risk factors, including environmental interventions, such as quiet time, sleep promotion, family support, communication, and adequate treatment of pain and dyspnea. Pharmacological prophylaxis is not indicated with the exception of patients at risk of withdrawal syndrome but should only be used in patients with confirmed delirium. Dexmedetomidine is the drug of choice in patients with severe agitation, and those weaning from invasive mechanical ventilation. As the complexity of ICCUs increases, clinical scenarios posing challenges for the management of delirium become more frequent. Efforts should be done to improve the identification of patients at risk during admission in order to establish preventive interventions to avoid this complication. Patient-centered protocols will increase the awareness of the healthcare professionals for better prevention and earlier diagnosis and will positively impact on prognosis.
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Affiliation(s)
- Alejandro Cortés-Beringola
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Cardiology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Lourdes Vicent
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Roberto Martín-Asenjo
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Elena Puerto
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Laura Domínguez-Pérez
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Ramón Maruri
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | - Guillermo Moreno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - María T Vidán
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Department of Geriatric Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain; CIBER de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Héctor Bueno
- Intensive Cardiac Care Unit, Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
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Elgazzar FM, Elgohary MS, Basiouny SM, Lashin HI. Intravenous lipid emulsion as an adjuvant therapy of acute clozapine poisoning. Hum Exp Toxicol 2021; 40:1053-1063. [DOI: 10.1177/0960327120983873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Clozapine is a frequently prescribed atypical antipsychotic drug. Various case reports documented the successful recovery of acute antipsychotics toxicity in association with the administration of intralipid emulsion (ILE). Aim: This study aimed to assess the adjuvant therapeutic role of SMOF Lipid administration on the outcomes of acute clozapine poisoning. Methods: Forty patients with acute clozapine poisoning were randomly allocated into two equal groups. The control group received the standard supportive treatment only, whereas the intervention group received the standard supportive treatment plus SMOF Lipid 20% infusion. All patients were subjected to history taking, full clinical examination, and laboratory investigations. The study outcomes were evaluated. Results: The mean Glasgow Coma Scale (GCS) at 6 hours (13.1 ± 2.3 vs 9.2 ± 2, p < 0.001) and 12 hours (14.3 ± 1.5 vs 9.6 ± 2, p < 0.001) after admission was significantly higher in the intervention group compared to the control group. The intervention group showed a significantly lower frequency of prolonged QTc interval 12 hours after admission (p = 0.003), as well as a significantly shorter hospital stay (p < 0.001). Conclusions: SMOF Lipid infusion seemed to have improved GCS, the prolonged QTc interval, and shortened the length of hospital stay. Furthermore, there were no adverse effects related to its administration.
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Affiliation(s)
- Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona S Elgohary
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sara M Basiouny
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Abstract
PURPOSE/BACKGROUND Quetiapine is a relatively new atypical antipsychotic with fewer adverse effects. It is increasingly prescribed to patients. The purpose of this study was to describe the cases of poisoning observed at the western France Poison Control Centre and identify potential risk factors that increase the severity of the cases. METHODS This was a retrospective study of self-poisoning with quetiapine as reported by the western France Poison Control Centre between 2007 and 2017. RESULTS There were 372 cases of quetiapine poisoning. Circumstances are known in 367 of 372 cases. There were 75 cases of null severity (grade 0), 133 cases of mild severity (grade 1), 85 cases of moderate severity (grade 2), and 79 cases of high severity (grade 3). Five deaths were listed in this series. The most commonly observed symptoms were neurological and cardiovascular in nature (drowsiness, coma, tachycardia, hypotension). Of these cases, 79.8% included voluntary ingestions. Among 302 cases with coagents, the most common coagents were benzodiazepines (56%), other psychotropic drugs (41%), and antidepressants (37%). An evaluated ingested dose 1500 mg or greater and 2 or more coagents increase the risk of severe poisoning. In particular, concomitant ingestion of benzodiazepines and antidepressants with quetiapine was associated with high severity (odds ratio, 2.478 [confidence interval, 1.3-4.723]; odds ratio, 1.820 [confidence interval, 1.010-3.316]). CONCLUSIONS Quetiapine may lead to severe poisoning for which there is currently no specific treatment. Patients and practitioners should be aware of this when quetiapine is prescribed, particularly when used in combination with other medications, and in order to deal with cases of poisoning.
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Abstract
BACKGROUND Aripiprazole is an atypical antipsychotic with a long half-life. Overdose can result in protracted somnolence and cardiac disturbances, particularly QT interval prolongation. METHODS This is a single case report of a 14-year-old boy who took an overdose of aripiprazole and developed QRS widening. CASE A 14-year-old boy intentionally ingested 20 tablets of aripiprazole (5 mg). He was brought to the emergency department when his ingestion was discovered. The patient's vital signs were as follows: temperature, 37.7°C; heart rate, 108 beats/min; blood pressure, 138/98 mm Hg; and respirations, 16 breaths/min. Activated charcoal was administered within 90 minutes of ingestion. Initial electrocardiogram (EKG) showed sinus tachycardia, with a QRS of 138 ms and QT interval of 444 ms. QRS duration was 90 ms on an EKG performed 3 months earlier. A bolus of sodium bicarbonate was administered, and the patient was transferred to the pediatric intensive care unit. Repeat EKG demonstrated a QRS of 156 ms, and a sodium bicarbonate infusion was initiated. The patient continued to have QRS prolongation for the next 8 days, reaching a peak of 172 ms 3 days postingestion. Despite aggressive treatment with sodium bicarbonate, there was persistent QRS prolongation; however, the patient did not have any dysrhythmias and remained hemodynamically stable. The patient was discharged 9 days postingestion when the QRS duration normalized to 82 ms. Genetic testing revealed that the patient was a CYP2D6 poor metabolizer. CONCLUSIONS This case suggests that aripiprazole toxicity may possibly be associated with QRS prolongation without associated dysrhythmias or cardiovascular compromise. In addition, toxicity may be prolonged in patients who are CYP2D6 poor metabolizers.
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Maignan M, Viglino D, Collomb Muret R, Vejux N, Wiel E, Jacquin L, Laribi S, N-Gueye P, Joly LM, Dumas F, Beaune S. Intensity of care delivered by prehospital emergency medical service physicians to patients with deliberate self-poisoning: results from a 2-day cross-sectional study in France. Intern Emerg Med 2019; 14:981-988. [PMID: 31104303 DOI: 10.1007/s11739-019-02108-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
Emergency management of deliberate self-poisoning (DSP) by drug overdose is common in emergency medicine. There is a paucity of data about the prehospital care of these patients. The principal aim was to describe the intensity of care received by patients with DSP who were managed by prehospital emergency medical service (EMS) physicians. A 48-h cross-sectional study was conducted in 319 EMS and emergency units in France. Patient and poisoning characteristics and treatments administered were recorded. Complications of poisoning, hospitalization, intensive care unit admission and death were recorded until day 30. The primary endpoint was the probability of receiving prehospital intensive care, including fluid resuscitation, vasopressor therapy, invasive ventilation, or antidotal treatments, depending whether prehospital treatment was carried out by an EMS physician or not. Data from 703 patients (median age was 43 [30-52] years, 288 (40%) men) were analyzed. One hundred and fifteen (16%) patients were attended by an EMS physician. Patients attended by EMS physicians were more likely to receive intensive treatment in the prehospital setting [odds ratio (OR) 7.4, 95% confidence interval 4.3-12.9]. These patients had more severe poisoning as suggested mainly by a lower Glasgow Coma Score (13 [8-15] vs. 15 [15-15]; p < 0.001) and a higher rate of admission to an intensive care unit [29 (25%) vs. 15 (2%), p < 0.001]. Patients with DSP attended by prehospital EMS physicians frequently received intensive care. The level of care seemed appropriate for the severity of the poisoning.
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Affiliation(s)
- Maxime Maignan
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France.
| | - Damien Viglino
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Roselyne Collomb Muret
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Nathan Vejux
- Emergency Department, CHU Grenoble Alpes University Hospital, HP2 INSERM U1042, CS 10217, 38043, Grenoble cedex 9, France
| | - Eric Wiel
- Emergency Department and SAMU 59, Lille University Hospital, Inserm UMR1011 and UDSL, Institut Pasteur de Lille, EGID, Lille, France
| | - Laurent Jacquin
- Emergency Department, Hospices Civiles de Lyon, Lyon, France
| | - Said Laribi
- Emergency Department, Tours University Hospital, 37044, Tours, France
- INSERM, U942, BIOmarkers in CArdioNeuroVAScular Diseases, Paris, France
| | - Papa N-Gueye
- Emergency Department, APHP Hôpital Lariboisière, Paris, France
| | - Luc-Marie Joly
- Emergency Department, Charles Nicolle Hospital, Rouen, France
| | - Florence Dumas
- Emergency Department, APHP Hôpital Cochin, Sudden Death Expertise Center, Paris Cardiovascular Research Center, INSERM Unit 970, Paris, France
| | - Sebastien Beaune
- Department of Emergency Medicine, Ambroise Paré Hospital, APHP, University Paris Diderot, INSERM UMR-S 1144, Paris, France
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12
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Manolis TA, Manolis AA, Manolis AS. Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale. Angiology 2018; 70:103-129. [PMID: 29874922 DOI: 10.1177/0003319718780145] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.
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Affiliation(s)
| | | | - Antonis S Manolis
- 3 Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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13
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Pourmand A, Mazer-Amirshahi M, Chistov S, Sabha Y, Vukomanovic D, Almulhim M. Emergency department approach to QTc prolongation. Am J Emerg Med 2017; 35:1928-1933. [PMID: 28855066 DOI: 10.1016/j.ajem.2017.08.044] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 08/13/2017] [Accepted: 08/19/2017] [Indexed: 01/08/2023] Open
Abstract
QTc prolongation has been associated with increased risk of developing ventricular tachydysrhythmias, particularly Torsades de Pointes (TdP). QTc prolongation is influenced by many factors including congenital causes, heart rate, metabolic imbalances, and pharmacotherapy. Several commonly used medications in the emergency department (ED), such as antipsychotics and antiemetics, are known to prolong the QT interval. In addition, ED patients may present with conditions that may predispose them to QTc prolongation, such as drug overdose or hypokalemia, which can further complicate management. ED providers should not only be aware of which medications have these effects, but must also thoroughly investigate any pertinent patient history that may contribute to QTc prolongation. This review discusses commonly encountered medications that are associated with QTc prolongation, the mechanisms by which they prolong the QTc interval, and other factors that may influence ED medication administration and management.
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Affiliation(s)
- Ali Pourmand
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Georgetown University School of Medicine, Washington, DC, United States
| | - Sonya Chistov
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Youssef Sabha
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Damir Vukomanovic
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Mohammed Almulhim
- Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
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Guilbert O, Pélissier F, Franchitto N, Delcourt N. Les intoxications aiguës à la quétiapine : étude rétrospective (2012–2015) à partir des données du centre antipoison et de toxicovigilance (CAPTV) de Toulouse. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2017.03.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
The most important diagnostic factor in uncovering a toxic etiology for delirium or critical illness is the clinician's openness to the possibility of its existence. Therefore, a consulting psychiatrist, already prepared to perform the detail-oriented work of sorting out behavioral manifestations of disease, can be a vital asset at the bedside if also attuned to the role of purposeful, accidental, and iatrogenic exposures in the intensive care unit. This article summarizes the presentation, evaluation, and treatment of toxidromes relevant to the work of acute psychosomatic medicine.
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Rapid determination of some psychotropic drugs in complex matrices by tandem dispersive liquid-liquid microextraction followed by high performance liquid chromatography. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1052:51-59. [PMID: 28355580 DOI: 10.1016/j.jchromb.2017.03.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 02/22/2017] [Accepted: 03/12/2017] [Indexed: 11/22/2022]
Abstract
Simple and rapid determinations of some psychotropic drugs in some pharmaceutical wastewater and human plasma samples were successfully accomplished via the tandem dispersive liquid-liquid microextraction combined with high performance liquid chromatography-ultraviolet detection (TDLLME-HPLC-UV). TDLLME of the three psychotropic drugs clozapine, chlorpromazine, and thioridazine was easily performed through two consecutive dispersive liquid-liquid microextractions. By performing this convenient method, proper sample preconcentrations and clean-ups were achieved in just about 7min. In order to achieve the best extraction efficiency, the effective parameters involved were optimized. The optimal experimental conditions consisted of 100μL of CCl4 (as the extraction organic solvent), and the pH values of 13 and 2 for the donor and acceptor phases, respectively. Under these optimum experimental conditions, the proposed TDLLME-HPLC-UV technique provided a good linearity in the range of 5-3000ngmL-1 for the three psychotropic drugs with the correlation of determinations (R2s) higher than 0.996. The limits of quantification (LOQs) and limits of detection (LODs) obtained were 5.0ngmL-1 and 1.0-1.5ngmL-1, respectively. Also the proper enrichment factors (EFs) of 96, 99, and 88 for clozapine, chlorpromazine, and thioridazine, respectively, and good extraction repeatabilities (relative standard deviations below 9.3%, n=5) were obtained.
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Klein L, Bangh S, Cole JB. Intentional Recreational Abuse of Quetiapine Compared to Other Second-generation Antipsychotics. West J Emerg Med 2016; 18:243-250. [PMID: 28210359 PMCID: PMC5305132 DOI: 10.5811/westjem.2016.10.32322] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 09/30/2016] [Accepted: 10/15/2016] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Case reports and poison center data have demonstrated that the second-generation antipsychotic quetiapine is being obtained and used for recreational abuse. The purpose of this study was to describe the relative rates of single-substance abuse for different atypical antipsychotics and compare their demographic and clinical features. METHODS We conducted a 10-year retrospective analysis of the National Poison Data System (NPDS) database (2003 - 2013). Trained nurses and pharmacists with specialty training in toxicology prospectively collect all NPDS data at poison control centers around the United States. We queried the NPDS for all cases of single-substance second-generation antipsychotic exposures coded as "intentional abuse." The data provided by the NPDS regarding rates and clinical features of quetiapine abuse and the abuse of all other second-generation antipsychotics were compared and described descriptively. RESULTS During the study period, 2,118 cases of quetiapine abuse and 1,379 cases of other second-generation antipsychotic abuse were identified. Quetiapine abuse was more common than the abuse of other second-generation antipsychotics, compromising 60.6% of all abuse cases during the study period. After quetiapine, the next most frequently abused medications were risperidone (530 cases, 15.2%) and olanzapine (246 cases, 7.0%). For all second-generation antipsychotics including quetiapine, central nervous system clinical effects were most common, including drowsiness, confusion, and agitation. Other serious clinical effects observed with second-generation antipsychotic abuse included hypotension, respiratory depression, and seizures. CONCLUSION Quetiapine abuse is relatively common, and is abused far more often than any other second-generation antipsychotic. Emergency physicians should be aware of the clinical effects that may occur after second-generation antipsychotic abuse.
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Affiliation(s)
- Lauren Klein
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Stacey Bangh
- Minnesota Poison Control System, Minneapolis, Minnesota
| | - Jon B Cole
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota; Minnesota Poison Control System, Minneapolis, Minnesota
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Sengul MCB, Karadag F, Sengul C, Karakulah K, Kalkanci O, Herken H. Risk of Psychotropic Drug Interactions in Real World Settings: a Pilot Study in Patients with Schizophrenia and Schizoaffective Disorder. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140311041445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Filiz Karadag
- Gazi University School of Medicine, Department of Psychiatry, Ankara - Turkey
| | - Cem Sengul
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
| | - Kamuran Karakulah
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
| | - Ozgur Kalkanci
- Servergazi State Hospital, Psychiatry Clinic, Denizli - Turkey
| | - Hasan Herken
- Pamukkale University School of Medicine, Department of Psychiatry, Denizli - Turkey
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Abstract
Several classes of recreational and prescription drugs have been associated with an increased risk of cardiovascular disease and the occurrence of arrhythmias, which may be involved in sudden deaths in chronic users even at therapeutic doses. The study presented herein focuses on pathological changes involving the heart, which may be caused by selective serotonin reuptake inhibitor use and their possible role in the occurrence of sudden cardiac death. A total of 40 cases were included in the study and were divided evenly into 2 groups: 20 cases of patients treated with selective serotonin reuptake inhibitors and 20 cases of sudden deaths involving patients void of any drug treatment. The first group included 16 patients treated with citalopram and 4 with sertraline. Autopsies, histology, biochemistry, and toxicology were performed in all cases. Pathological changes in selective serotonin reuptake inhibitor users consisted of various degrees of interstitial and perivascular fibrosis as well as a small degree of perineural fibrosis within the myocardium of the left ventricle. Within the limits of the small number of investigated cases, the results of this study seem to confirm former observations on this topic, suggesting that selective serotonin reuptake inhibitors may play a potential, causative role in the pathogenesis of sudden deaths in chronic users even at therapeutic concentrations.
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Rybojad B, Lukasiewicz A. Neuroinfection or Suicide Attempt? Difficult Diagnosis If Lack of Anamnesis. JOURNAL OF CHILD & ADOLESCENT SUBSTANCE ABUSE 2016. [DOI: 10.1080/1067828x.2015.1081116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Beata Rybojad
- Department of Emergency Unit, Medical University of Lublin, Lublin, Poland
- Pediatric University Hospital of Lublin, Lublin, Poland
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Borg L, Julkunen A, Rørbaek Madsen K, Strøm T, Toft P. Antidepressant or Antipsychotic Overdose in the Intensive Care Unit - Identification of Patients at Risk. Basic Clin Pharmacol Toxicol 2015; 119:110-4. [PMID: 26663682 DOI: 10.1111/bcpt.12541] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 11/30/2015] [Indexed: 11/27/2022]
Abstract
It is often advised that patients who have ingested an overdose of antidepressants (AD) or antipsychotics (AP) are monitored with continuous ECG for minimum of 12-24 hr. These patients are often observed in an ICU. Our aim was to identify the number of patients with AD and/or AP overdose without adverse signs at hospital admission that turned out to need intensive care treatment. The effect of the antidepressants overdose risk assessment (ADORA) system was evaluated in patients with antidepressant as well as antipsychotic overdose. Our hypothesis was that patients with low ADORA do not need intensive care treatment. This retrospective study was conducted in adult patients admitted to the ICU at Odense University Hospital after an overdose with AP and/or AD between 1 January 2009 and 1 September 2014. Patients with predefined adverse signs in the emergency department were excluded due to obvious need of intensive care. Of the 157 patients included, 12 patients (8%) developed events during the ICU stay. Only 3 patients received intubation, vasoactive drugs and/or dialysis. None developed ventricular dysrhythmias. There were no fatalities. All the patients with low-risk assessment by ADORA within the first 6 hr did not develop events within the first 24 hr after hospital admission. The vast majority of patients with AD and/or AP overdose and no adverse signs at admission did not require intensive care treatment. Low-risk ADORA identified patients with antidepressant as well as antipsychotic overdose who would not require initial intensive care treatment. This is the first time the ADORA system has been evaluated in patients with antidepressant as well as antipsychotic overdose.
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Affiliation(s)
- Linda Borg
- Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Anna Julkunen
- Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Kristian Rørbaek Madsen
- Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Palle Toft
- Department of Anaesthesia and Intensive Care Medicine, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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Inferior ST-Elevation Acute Myocardial Infarction or an Inferior-Lead Brugada-like Electrocardiogram Pattern Associated With the Use of Pregabalin and Quetiapine? Am J Ther 2015; 23:e1057-9. [PMID: 26291591 DOI: 10.1097/mjt.0000000000000301] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Brugada electrocardiogram pattern is characterized by coved-type ST-elevation (>2 mm) in the right precordial leads. We report the case of a 62-year-old man, with bipolar disorder, admitted to the emergency department because of dyspnea and chest discomfort. The patient was on treatment with pregabalin and quetiapine. Unexpectedly, electrocardiogram at admission showed diffuse ST-elevation, more evident in inferior leads, where a Brugada-like pattern was present. The patient underwent coronary angiography with a diagnosis of suspected acute coronary syndrome. Coronary angiography, however, showed mild coronary artery disease not requiring coronary angioplasty. Echocardiography did not reveal left ventricular dysfunction or pericardial effusion. Troponin levels remained normal over serial controls. Eventually, chest radiography showed lung opacities and consolidation suggestive for pneumonia. To the best of our knowledge, this is one of the first cases showing a transient Brugada-like electrocardiogram pattern in inferior leads, probably amplified by the administration of pregabalin and quetiapine.
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Mattson ME, Albright VA, Yoon J, Council CL. Emergency Department Visits Involving Misuse and Abuse of the Antipsychotic Quetiapine: Results from the Drug Abuse Warning Network (DAWN). SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2015; 9:39-46. [PMID: 26056465 PMCID: PMC4444129 DOI: 10.4137/sart.s22233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 12/03/2022]
Abstract
Case reports in medical literature suggest that the atypical antipsychotic quetiapine, a medication not previously considered to have abuse potential, is now being subject to misuse and abuse (MUA; ie, taken when not prescribed for them or used in a way other than instructed by their health professional). Here we present systematic, nationally representative data from the 2005 to 2011 Drug Abuse Warning Network (DAWN) for prevalence of emergency department (ED) visits among the U.S. general population involving quetiapine and related to MUA, suicide attempts, and adverse reactions. Nationally, quetiapine-related ED visits increased 90% between 2005 and 2011, from 35,581 ED visits to 67,497. DAWN data indicate that when used without medical supervision for recreational/self-medication purposes, quetiapine poses health risks for its users, especially among polydrug users and women. These findings suggest that the medical and public health communities should increase vigilance concerning this drug and its potential for MUA.
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Affiliation(s)
- Margaret E Mattson
- Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
| | | | - Joanna Yoon
- Health Resources and Services Administration, Rockville, MD, USA
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Coma After Quetiapine Fumarate Intentional Overdose in a 71-year-old Man: A Case Report. DRUG SAFETY - CASE REPORTS 2015; 2:3. [PMID: 27747715 PMCID: PMC4982457 DOI: 10.1007/s40800-015-0005-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 71-year-old man developed coma with severe respiratory failure, hypotension, and tachycardia induced by the intentional ingestion of quetiapine fumarate extended release (XR) 20 g. At the time, he had been treated for bipolar depression with venlafaxine 75 mg/day, lamotrigine 100 mg/day, pregabalin 75 mg/day, and quetiapine XR 400 mg/day for approximately 1 year. Comorbidities were hypertension treated with metoprolol, diabetes mellitus type 2 treated with metformin, and benign prostatic hyperplasia treated with silodosin. In the emergency room, about 4 h after ingestion of quetiapine fumarate XR, the presenting symptomatology was characterized by coma (Glasgow Coma Scale score 3), hypotension (blood pressure [BP] 90/60 mmHg), tachycardia (electrocardiogram [ECG] showed sinus tachycardia with heart rate 120 beats per minute and a QTc of 499 ms). A gastric lavage was performed and activated charcoal 50 g and magnesium sulfate 30 g was administered. About 6 h after ingestion, he developed marked desaturation and underwent mechanical ventilation; 13 h after ingestion, a severe hypotensive episode followed (BP 70/40), which was treated with an infusion of ringer lactate 500 cc. On the 3rd day after intentional overdose, an episode of agitation occurred; 4 days after ingestion, the quetiapine plasma level was found to be 42 ng/ml (within therapeutic range). At 5 days after ingestion, the patient developed septicemia caused by staphylococci (probably originating from the central vein catheter), which was treated with antibiotic therapy. On days 10 and 18 after the suicide attempt, two episodes of paroxysmal supraventricular tachycardia (PSVT) occurred and were successfully treated with intravenous adenosine triphosphate. The patient recovered completely without residual symptoms. In line with literature data, in this case report, symptoms of quetiapine overdose were tachycardia, agitation, hypotension, QT interval prolongation, and coma. A causal relationship between PSVT and quetiapine intoxication seems quite unlikely due to the drug level.
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Miura N, Saito T, Taira T, Umebachi R, Inokuchi S. Risk factors for QT prolongation associated with acute psychotropic drug overdose. Am J Emerg Med 2014; 33:142-9. [PMID: 25445869 DOI: 10.1016/j.ajem.2014.09.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 09/01/2014] [Accepted: 09/29/2014] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Antipsychotic/Antidepressant use is a risk factor for QT interval (QT) prolongation and sudden cardiac death. However, it is unclear which drugs are risk factors for QT prolongation and torsades de pointes in cases of psychotropic drug overdose. METHODS After correction of QT data by Bazett formula (QTc), QTc was classified into 3 categories (QTc<440 milliseconds, 440 milliseconds≤QTc<500 milliseconds, and QTc≥500 milliseconds), and the blood concentration of each drug was classified as not detected, therapeutic range, or toxic range. The association of the blood concentration of each drug with QTc was analyzed using the ordinal logistic regression model. Drugs that induced QT-heart rate pairs higher than the at-risk line of Isbister's QT-heart rate nomogram (QT nomogram) were further analyzed using the binomial logistic regression model. RESULTS A total of 649 patients were enrolled in the study. The independent risk factors for QTc prolongation were therapeutic and toxic range of phenotiazine antipsychotic drug (therapeutic range: odds ratio [OR], 1.56 [P=.039]; toxic range: OR, 3.85 [P<.001]), and toxic range of cyclic antidepressants (OR, 2.39; P=.018). In addition, toxic range of phenotiazine antipsychotic drug (OR, 3.87; P=.012) and tricyclic antidepressants (OR, 4.94; P<.001) were risk factors for QT higher than the at-risk line of the QT nomogram. CONCLUSIONS The possibility of QT prolongation and torsades de pointes due to overdose of phenotiazine antipsychotic drug or tricyclic antidepressants requires particular consideration.
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Affiliation(s)
- Naoya Miura
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
| | - Takeshi Saito
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1143, Japan
| | - Takayuki Taira
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1143, Japan
| | - Rimako Umebachi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1143, Japan
| | - Sadaki Inokuchi
- Department of Emergency and Critical Care Medicine, Tokai University School of Medicine, Isehara, Kanagawa 259-1143, Japan
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Meli M, Rauber-Lüthy C, Hoffmann-Walbeck P, Reinecke HJ, Prasa D, Stedtler U, Färber E, Genser D, Kupferschmidt H, Kullak-Ublick GA, Ceschi A. Atypical antipsychotic poisoning in young children: a multicentre analysis of poisons centres data. Eur J Pediatr 2014; 173:743-50. [PMID: 24370666 DOI: 10.1007/s00431-013-2241-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 12/05/2013] [Accepted: 12/09/2013] [Indexed: 11/24/2022]
Abstract
UNLABELLED Although paediatric patients frequently suffer from intoxications with atypical antipsychotics, the number of studies in young children, which have assessed the effects of acute exposure to this class of drugs, is very limited. The aim of this study was to achieve a better characterization of the acute toxicity profile in young children of the atypical antipsychotics clozapine, olanzapine, quetiapine, and risperidone. We performed a multicentre retrospective analysis of cases with atypical antipsychotics intoxication in children younger than 6 years, reported by physicians to German, Austrian, and Swiss Poisons Centres for the 9-year period between January 1, 2001 and December 31, 2009. One hundred and six cases (31 clozapine, 29 olanzapine, 12 quetiapine, and 34 risperidone) were available for analysis. Forty-seven of the children showed minor, 28 moderate, and 2 severe symptoms. Twenty-nine cases were asymptomatic. No fatalities were recorded. Symptoms predominantly involved the central nervous and cardiovascular systems. Minor reduction in vigilance (Glasgow Coma Scale score >9) (62 %) was the most frequently reported symptom, followed by miosis (12 %) and mild tachycardia (10 %). Extrapyramidal motor symptoms were observed in one case (1 %) after ingestion of risperidone. In most cases, surveillance and supportive care were sufficient to achieve a good outcome, and all children made full recovery. CONCLUSIONS Paediatric antipsychotic exposure can result in significant poisoning; however, in most cases only minor or moderate symptoms occurred and were followed by complete recovery. Symptomatic patients should be monitored for central nervous system depression and an electrocardiogram should be obtained.
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Affiliation(s)
- Marianne Meli
- Division of Science, Swiss Toxicological Information Centre, Associated Institute of the University of Zurich, Freiestrasse 16, Zurich, CH-8032, Switzerland
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Selective action of an atypical neuroleptic on the mechanisms related to the development of cocaine addiction: a pre-clinical behavioural study. Int J Neuropsychopharmacol 2014; 17:613-23. [PMID: 24345415 DOI: 10.1017/s1461145713001430] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
An increased function in the mesolimbic dopaminergic system has been extensively associated with the rewarding effects of both natural stimuli and drugs of abuse. Thus, dopamine receptor blockers, such as neuroleptic drugs, can be proposed as candidates for potential therapeutic approaches to treat drug dependence. Notwithstanding, this therapeutic potential of neuroleptics critically depends on a selective action on the specific mechanisms related to the development of addiction. We compared the effects of different doses of haloperidol, ziprasidone and aripiprazole (first-, second- and third-generation neuroleptics, respectively) on spontaneous locomotor activity of mice in a novel environment, hyperlocomotion induced by acute cocaine administration and cocaine-induced locomotor sensitization by a two-injection protocol. Whereas high doses of haloperidol abolished the three behavioural paradigms without selectivity, low doses of ziprasidone selectively abolished the development of the behavioural sensitization phenomenon. Finally, low doses of aripiprazole inhibited acute cocaine-induced hyperlocomotion and behavioural sensitization without modifying spontaneous locomotor activity. Thus, aripiprazole at lower doses was the most selective antipsychotic drug concerning the inhibition of the development of behavioural sensitization to cocaine. Because locomotor sensitization in rodents has been proposed to share plastic mechanisms with drug addiction in humans, our data provide relevant suggestions to the clinical practice.
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Richard A, Debaty G, Pommier P, Koch FX, Briot R, Loizzo F, Carpentier F, Danel V, Maignan M. Fréquence et facteurs de risque des Smur de seconde intention dans les intoxications médicamenteuses volontaires. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-013-0388-9] [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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Lung DD, Wu AH, Gerona RR. Cardiotoxicity in a Citalopram and Olanzapine Overdose. J Emerg Med 2013; 45:554-8. [DOI: 10.1016/j.jemermed.2013.04.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 03/29/2013] [Accepted: 04/30/2013] [Indexed: 11/26/2022]
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Bartos M, Knudsen K. Use of intravenous lipid emulsion in the resuscitation of a patient with cardiovascular collapse after a severe overdose of quetiapine. Clin Toxicol (Phila) 2013; 51:501-4. [DOI: 10.3109/15563650.2013.803229] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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XXXIII International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 28–31 May 2013, Copenhagen, Denmark. Clin Toxicol (Phila) 2013. [DOI: 10.3109/15563650.2013.785188] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Sayyah M, Majzoob S, Sayyah M. Metabolic and toxicological considerations for obsessive-compulsive disorder drug therapy. Expert Opin Drug Metab Toxicol 2013; 9:657-73. [PMID: 23521155 DOI: 10.1517/17425255.2013.783011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Obsessive-compulsive disorder (OCD) affects the daily life of the patients. Chronic nature of this disease and the need for long-term high-dose drug therapy for its maintenance increase the risk of metabolic and toxicological complications. AREAS COVERED In this concise article, the metabolic and toxicological aspects of major medication categories prescribed in OCD, such as serotonin-specific reuptake inhibitors, tricyclic antidepressant (clomipramine), serotonin-norepinephrine reuptake inhibitors, and atypical antipsychotics indicated in OCD (both Food and Drug Administration-approved and off-label) are discussed. EXPERT OPINION The most critical point in pharmacotherapy of OCD is the need for the high-dose and long-term use of drugs. In OCD, generally the higher doses of applicable drugs than those used in depression are required, often exceeding the recommended maximum dose. Moreover, such high doses should be given for at least 10 - 12 weeks to ensure the adequate treatment duration for the clinical effects to emerge. This long-term high-dose maintenance therapy increases the risk of drug toxicity and adverse effects. Physicians should take extra care in periodical assessment of signs and symptoms of metabolic and toxicological complications in patients. Subjective symptoms reported by patients should be carefully assessed and not attributed to obsessive nature of the patients.
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Affiliation(s)
- Mohammad Sayyah
- Pasteur Institute of Iran, Department of Physiology and Pharmacology, Tehran, Iran
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Nelson S, Leung JG. Torsades De Pointes after Administration of Low-Dose Aripiprazole. Ann Pharmacother 2013; 47:e11. [DOI: 10.1345/aph.1r387] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE: To describe a case of torsades de pointes (TdP) in a patient treated with aripiprazole. CASE SUMMARY: A 42-year-old white male with schizophrenia, diabetes, hypertension, and a history of stroke was admitted to the intensive care unit following 2 days of fever, diarrhea, and altered mental status. Following the resolution of his acute illness, previous therapy with quetiapine 400 mg orally at bedtime was resumed for schizophrenia and presumed delirium. Quetiapine was discontinued after 1 dose because of QTc interval prolongation. Twenty-three days later, with a baseline Q Tc interval of 414 milliseconds, aripiprazole 2.5 mg orally once daily was initiated. Following 5 days of aripiprazole therapy, the patient had a cardiac arrest due to TdP. Normal sinus rhythm was restored after 30 seconds of cardiopulmonary resuscitation, 1 shock of 200 Joules, and 4 g of intravenous magnesium sulfate. Serial electrocardiographs obtained after aripiprazole discontinuation revealed resolution of QTc interval prolongation. DISCUSSION: Aripiprazole is a second-generation antipsychotic that may be selected for patients with prolonged QTc intervals and at risk for TdP. Data from trials indicate that aripiprazole has minimal effects on the QTc interval. However, in this case, aripiprazole was associated with TdP in a patient with minimal risk factors. The Naranjo probability scale was used to determine a probable association between aripiprazole and the development of TdP. To our knowledge, this is the first reported case of TdP associated with the use of aripiprazole. CONCLUSIONS: Five days of low-dose aripiprazole therapy was associated with the development of TdP in a man with minimal risk factors. Clinicians should be aware of this potential adverse drug event with aripiprazole.
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Affiliation(s)
- Sarah Nelson
- Sarah Nelson PharmD BCPS, Critical Care Clinical Pharmacist, Mayo Clinic, Rochester, MN
| | - Jonathan G Leung
- Jonathan G Leung PharmD BCPS BCPP, Psychiatric Clinical Pharmacist, Mayo Clinic, Rochester
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Gardner DM, Murphy AL, Kutcher S, Beaulieu S, Carandang C, Labelle A, Lalonde P, Malla A, Milliken H, O’Donovan C, Schaffer A, Soni J, Taylor VH, Williams R. Evidence review and clinical guidance for the use of ziprasidone in Canada. Ann Gen Psychiatry 2013; 12:1. [PMID: 23347694 PMCID: PMC3564821 DOI: 10.1186/1744-859x-12-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 01/14/2013] [Indexed: 12/17/2022] Open
Abstract
While indicated for schizophrenia and acute mania, ziprasidone's evidence base and use in clinical practice extends beyond these regulatory approvals. We, an invited panel of experts led by a working group of 3, critically examined the evidence and our collective experience regarding the effectiveness, tolerability and safety of ziprasidone across its clinical uses. There was no opportunity for manufacturer input into the content of the review. As anticipated, ziprasidone was found to be effective for its indicated uses, although its utility in mania and mixed states lacked comparative data. Beyond these uses, the available data were either unimpressive or were lacking. An attractive characteristic is its neutral effect on weight thereby providing patients with a non-obesogenic long-term treatment option. Key challenges in practice include the need for dosing on a full stomach and managing its early onset adverse effect of restlessness. Addressing these issues are critical to its long-term success.
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Affiliation(s)
- David M Gardner
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Andrea L Murphy
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Stan Kutcher
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Serge Beaulieu
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Carlo Carandang
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Alain Labelle
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
| | - Pierre Lalonde
- Centre de recherche Fernand-Seguin de l’Hôpital Louis-H. Lafontaine, Montreal, QC, Canada
| | - Ashok Malla
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Heather Milliken
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Claire O’Donovan
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Ayal Schaffer
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jorge Soni
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Richard Williams
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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Pacciardi B, Mauri M, Cargioli C, Belli S, Cotugno B, Di Paolo L, Pini S. Issues in the management of acute agitation: how much current guidelines consider safety? Front Psychiatry 2013; 4:26. [PMID: 23675355 PMCID: PMC3646256 DOI: 10.3389/fpsyt.2013.00026] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 04/09/2013] [Indexed: 11/29/2022] Open
Abstract
Agitated behavior constitutes up to 10% of emergency psychiatric interventions. Pharmacological tranquilization is often used as a valid treatment for agitation but a strong evidence base does not underpin it. Available literature shows different recommendations, supported by research data, theoretical considerations, or clinical experience. Rapid tranquilization (RT) is mainly based on parenteral drug treatment and the few existing guidelines on this topic, when suggesting the use of first generation antipsychotics and benzodiazepines, include drugs with questionable tolerability profile such as chlorpromazine, haloperidol, midazolam, and lorazepam. In order to systematically evaluate safety concerns related to the adoption of such guidelines, we reviewed them independently from principal diagnosis while examining tolerability data for suggested treatments. There is a growing evidence about safety profile of second generation antipsychotics for RT but further controlled studies providing definitive data in this area are urgently needed.
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Affiliation(s)
- Bruno Pacciardi
- Psychiatry Division, Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa Pisa, Italy
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Rasimas JJ, Liebelt EL. Adverse Effects and Toxicity of the Atypical Antipsychotics: What is Important for the Pediatric Emergency Medicine Practitioner. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012; 13:300-310. [PMID: 23471213 DOI: 10.1016/j.cpem.2012.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Medications are being used with greater frequency to address pediatric mental health problems, and in recent years atypical antipsychotic (AAP) prescriptions have increased more than any other class. Acute care practitioners must be aware of the pharmacology of AAPs and the conditions, on- and off-label, for which they are prescribed. This involves identifying and managing side effects that manifest both mentally and physically. Although "atypicality" confers a lower risk of movement side effects compared to conventional agents, children are more sensitive than adults to extrapyramidal reactions. Like adults, they also may present with toxic sedation, confusion, cardiovascular dysfunction, and metabolic derangements. Evaluation and management of these toxicities requires an index of suspicion, a careful symptom and medication history, physical examination, and targeted interventions. This review is designed to orient the emergency practitioner to the challenging task of recognizing and treating adverse effects related to acute and chronic atypical antipsychotic exposure in children.
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Affiliation(s)
- J J Rasimas
- Staff Clinician, National Institutes of Health; National Institutes of Mental Health Experimental Therapeutics and Pathophysiology Branch; Bethesda, MD, Associate Professor of Psychiatry & Emergency Medicine; Penn State College of Medicine; Pinnacle Health Toxicology Center; Harrisburg, PA
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Abstract
The topic of central nervous system intoxicants encompasses a multitude of agents. This article focuses on three classes of therapeutic drugs, with specific examples in which overdoses require admission to the intensive care unit. Included are some of the newer antidepressants, the atypical neuroleptic agents, and selected anticonvulsant drugs. The importance of understanding pertinent physiology and applicable supportive care is emphasized.
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Affiliation(s)
- Matthew W Hedge
- Department of Emergency Medicine, Detroit Receiving Hospital, Children's Hospital of Michigan Regional Poison Control Center, Wayne State University, Hutzel Building, 4707 Street Antoine, Suite 302, Detroit, MI 48201, USA.
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Witsil JC, Zell-Kanter M, Mycyk MB. Single-dose ziprasidone associated with QT interval prolongation. Am J Emerg Med 2012; 30:837.e1-2. [PMID: 21641143 DOI: 10.1016/j.ajem.2011.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 03/26/2011] [Indexed: 10/18/2022] Open
Abstract
Ziprasidone has been rarely associated with QT prolongation especially in patients (1) with no underlying cardiac or metabolic disorders, (2) who are receiving no concomitant medications known to prolong the QT interval, and (3) whom therapy is being initiated at a low dose. We report a 47-year-old patient who was agitated with suicidal ideation. He had a history of cocaine use, the last time being 72 hours before emergency department (ED) presentation. His electrocardiogram (ECG) on arrival in the ED showed a QT of 484 milliseconds and a QTc of 475 milliseconds with a pulse of 58 beats per minute. The patient was given 20 mg intramuscular (IM) ziprasidone for agitation. He reported feeling palpitations and weakness 45 minutes after receiving ziprasidone. His QT interval was prolonged on ECG and returned to baseline after 72 hours. Clinicians should consider obtaining an ECG before ziprasidone administration.
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Affiliation(s)
- Joanne C Witsil
- Department of Pharmacy, Cook County Hospital (Stroger), TOXIKON Consortium, Chicago, Ill 60612, USA.
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Farzad G. Comment on “Lipid 20% emulsion ameliorates the symptoms of olanzapine toxicity in a 4-year-old”. Am J Emerg Med 2012; 30:1003-4. [PMID: 22633735 DOI: 10.1016/j.ajem.2012.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 03/19/2012] [Indexed: 02/08/2023] Open
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Levine M, Ruha AM. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management. CNS Drugs 2012; 26:601-11. [PMID: 22668123 DOI: 10.2165/11631640-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Historically, treatment for schizophrenia focused on sedation. The advent of the typical antipsychotics resulted in treatment aimed specifically at the underlying disease, but these agents were associated with numerous adverse effects, and were not particularly effective at treatment of the negative symptoms of schizophrenia. As a result, numerous atypical agents have been developed over the past 2 decades, including several agents within the past 5 years. Overdose of antipsychotics remains quite common in Western society. In 2010, poison control centres in the US received nearly 43,000 calls related to atypical antipsychotics alone. Due to underreporting, the true incidence of overdose with atypical antipsychotics is likely much greater. Following overdose of an atypical antipsychotic, the clinical effects observed, such as CNS depression, tachycardia and orthostasis are largely predictable based on the unique receptor binding profile of the agent. This article, which focuses on the atypical antipsychotics commonly used in the treatment of schizophrenia, discusses the features commonly encountered in overdose. Specifically, agents that result in QT prolongation and the corresponding potential for torsades de pointes, as well as unique features encountered with the various medications are discussed. The diagnosis of this overdose is largely based on history. Routine use of drug screens is unlikely to be beneficial. The primary goal of management is aggressive supportive care. Patients with significant CNS depression with associated loss of airway reflexes and respiratory failure need advanced airway management. Hypotension should be treated first with intravenous fluids, with the use of direct acting vasopressors reserved for persistent hypotension. Benzodiazepines should be used for seizures, with barbiturates used for refractory seizures. Intravenous magnesium can be administered for patients with a corrected QT interval exceeding 500 milliseconds.
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Affiliation(s)
- Michael Levine
- Section of Medical Toxicology, Department of Emergency Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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McAllister RK, Tutt CD, Colvin CS. Lipid 20% emulsion ameliorates the symptoms of olanzapine toxicity in a 4-year-old. Am J Emerg Med 2012; 30:1012.e1-2. [DOI: 10.1016/j.ajem.2011.03.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 03/27/2011] [Indexed: 10/18/2022] Open
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Minns AB, Clark RF. Toxicology and overdose of atypical antipsychotics. J Emerg Med 2012; 43:906-13. [PMID: 22555052 DOI: 10.1016/j.jemermed.2012.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 02/27/2012] [Accepted: 03/09/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Second-generation antipsychotic medications, or "atypical antipsychotics," are now first-line therapy in the treatment of schizophrenia and other psychotic disorders, and are additionally being used in a wide array of other psychiatric and non-psychiatric conditions in both adults and children. Overdose is frequently reported to poison control centers. OBJECTIVES We review the toxicology and general management of poisonings involving the atypical antipsychotic medications. DISCUSSION The most serious toxicity involves the cardiovascular system and the central nervous system. All typical and atypical antipsychotics cause sedation, which is pronounced in overdose. The most common cardiovascular effects that occur after atypical antipsychotic overdose are tachycardia, mild hypotension, and prolongation of the QTc interval. Other clinical syndromes in overdose include neuroleptic malignant syndrome (NMS) and antimuscarinic delirium. Seizures may be observed. No antidotes exist for these poisonings, but they most often do well with supportive care. CONCLUSION Antipsychotic overdose produces a gamut of manifestations that affect multiple organ systems. Treatment is primarily supportive. Specific therapies for NMS, hypotension, and seizures are discussed.
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Affiliation(s)
- Alicia B Minns
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, San Diego, California 92103, USA
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Lannemyr L, Knudsen K. Severe overdose of quetiapine treated successfully with extracorporeal life support. Clin Toxicol (Phila) 2012; 50:258-61. [DOI: 10.3109/15563650.2012.665456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Eyer F, Pfab R, Felgenhauer N, Strubel T, Saugel B, Zilker T. Clinical and analytical features of severe suicidal quetiapine overdoses – a retrospective cohort study. Clin Toxicol (Phila) 2011; 49:846-53. [DOI: 10.3109/15563650.2011.624100] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Florian Eyer
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Rudolf Pfab
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Norbert Felgenhauer
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Tim Strubel
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
| | - Bernd Saugel
- Medical Intensive Care Unit, Klinikum rechts der Isar, II. Medizinische Klinik,
Ismaninger Strasse 22, Munich, Germany
| | - Thomas Zilker
- Toxicological Department, Klinikum rechts der Isar,
Ismaninger Strasse 22, Munich, Germany
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Togar B, Turkez H, Tatar A, Kırkpınar I, Hacımuftuoglu A, Geyikoglu F, Keles MS, Dirican E. The genotoxic potentials of some atypical antipsychotic drugs on human lymphocytes. Toxicol Ind Health 2011; 28:327-33. [DOI: 10.1177/0748233711410919] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Olanzapine (OLZ), risperidone (RPD) and quetiapine (QTP) are atypical antipsychotic drugs and are commonly used for the treatments of schizophrenia and bipolar disorders. However, recent reports indicated that these drugs could exhibit toxic effects on nervous and cardiovascular systems. To our best knowledge, there are scarce data considering the genotoxic damage potentials of OLZ, RPD and QTP on human lymphocyte culture system. Therefore, in this study, the genotoxic potentials of OLZ, RPD and QTP (0–400 mg/L) have been evaluated in human whole blood cultures (WBCs; n = 4). The single cell gel electrophoresis (SCGE) and micronucleus (MN) assays were applied to estimate the DNA damage. The results of the present study indicated that the tested antipsychotic drug did not induce genotoxicity. In fact, the mean values of the total scores of cells showing DNA damage (for SCGE assay) and MN/1000 cell were not found significantly different from the control values ( p > 0.05). However, the application of the highest drug concentrations (250 mg/L and above) caused the sterility in lymphocyte cultures. It is concluded that the tested three different atypical antipsychotic drugs can be used safely, but it is necessary to consider the cytotoxic effects that are likely to appear depending on the doses exposed.
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Affiliation(s)
- Başak Togar
- Faculty of Science, Biology Department, Atatürk University, Erzurum, Turkey
| | - Hasan Turkez
- Faculty of Science, Biology Department, Atatürk University, Erzurum, Turkey
| | - Abdulgani Tatar
- Medical Faculty, Medical Genetics Department, Atatürk University, Erzurum, Turkey
| | - Ismet Kırkpınar
- Medical Faculty, Psychiatry Department, Atatürk University, Erzurum, Turkey
| | - Ahmet Hacımuftuoglu
- Medical Faculty, Medical Pharmacology Department, Atatürk University, Erzurum, Turkey
| | - Fatime Geyikoglu
- Faculty of Science, Biology Department, Atatürk University, Erzurum, Turkey
| | - M Sait Keles
- Medical Faculty, Biochemistry Department, Atatürk University, Erzurum, Turkey
| | - Ebubekir Dirican
- Faculty of Science, Biology Department, Atatürk University, Erzurum, Turkey
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Farooq H, Reith R, Roskilly A, Solomon A. Acutely admitted patients who have taken an overdose: a practical update. Br J Hosp Med (Lond) 2011; 72:M104-8. [PMID: 21841602 DOI: 10.12968/hmed.2011.72.sup7.m104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hadia Farooq
- Department of Emergency Medicine, Princess Alexandra Hospital, Harlow
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Aung GL, O'Brien JG, Tien PG, Kawamoto LS. Increased aripiprazole concentrations in an HIV-positive male concurrently taking duloxetine, darunavir, and ritonavir. Ann Pharmacother 2010; 44:1850-4. [PMID: 20978219 DOI: 10.1345/aph.1p139] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To report a case of increased aripiprazole concentrations during coadministration with darunavir, ritonavir, and duloxetine. CASE SUMMARY A 43-year-old HIV-positive Hispanic man received darunavir/ritonavir-based antiretroviral therapy (ART) in addition to aripiprazole and duloxetine for depression and anxiety. A month after the aripiprazole dosage was increased to 50 mg daily, the patient developed confusion and loss of coordination. Weeks later, he presented to the emergency department with fever, cough, headache, neck stiffness, back pain, and blurred vision and was admitted for possible meningitis. Because symptoms improved with pain control and intravenous fluids during hospitalization, he was discharged within a couple days after admission. One month later he was readmitted for worsening symptoms, and the resulting diagnostic workup showed unremarkable findings except for lymphadenopathy (LAD). This finding was attributed to discontinuing ARTs after his first admission. He was discharged on aripiprazole 50 mg daily, darunavir 800 mg daily, ritonavir 100 mg daily, and duloxetine 60 mg daily. A random steady-state concentration of aripiprazole was 1100 ng/mL (therapeutic concentration 100-200 ng/mL) obtained 49 days after discharge. DISCUSSION The Horn Drug Interaction Probability Scale demonstrated a possible relationship between the increased aripiprazole concentration and coadministration of darunavir/ritonavir and duloxetine, which inhibit CYP3A4 and 2D6. Potential confounders to the increased concentration include duloxetine inhibition of CYP2D6 polymorphism, possible 2D6 polymorphism, and exceeding aripiprazole's maximum dose. The initial presentation of confusion and loss of coordination may have been early signs of aripiprazole toxicity, which relapsed as shown by his symptoms prior to admission. CONCLUSIONS The interaction between aripiprazole and darunavir, ritonavir, and duloxetine may be significant. Clinicians should be cognizant of increased risk of aripiprazole toxicity in HIV-positive patients concurrently taking ritonavir-boosted ART and other cytochrome P450 inhibitors like duloxetine. Dose adjustments or monitoring parameters should be an area of research and discussion.
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Affiliation(s)
- Gregory L Aung
- Santa Clara Valley Medical Center, PACE Clinic, San Jose, CA, USA
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Türkez H, Toğar B. The genotoxic and oxidative damage potential of olanzapine in vitro. Toxicol Ind Health 2010; 26:583-8. [PMID: 20542924 DOI: 10.1177/0748233710373090] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Olanzapine (OLZ) is an atypical antipsychotic drug and is commonly used for the treatment of schizophrenia and bipolar disorder (BD). However, recent reports indicated that this drug could exhibit cytotoxic effects on nervous and immune systems. To our knowledge, there is scarce data considering the genotoxic or oxidative damage potentials of OLZ on human lymphocyte culture system. Therefore, in this study, the genotoxic potential of OLZ (0 to 160 µM) have been evaluated in human whole blood cultures (WBCs) related to oxidative status. Sister-chromatid exchange (SCE) test was applied to estimate the DNA damage, and biochemical parameters (total antioxidant capacity [TAC] and total oxidative stress [TOS]) were examined to determine oxidative stress. Our results indicated that the tested antipsychotic drug did not induce SCEs in lymphocytes of treated cultures. However, the application of the highest OLZ concentration caused oxidative stress. It is concluded that the OLZ can be used safely, but it is necessary to consider the tissue damages that are likely to appear depending on the oxidative stress.
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Affiliation(s)
- Hasan Türkez
- Biology Department, Science Faculty, Atatürk University, Erzurum, Turkey
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Bharadwaj RS, Slade TB. Sustained hypotension with initial low dose of quetiapine in a middle-aged man receiving an antihypertensive agent. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2010; 12. [PMID: 21494344 DOI: 10.4088/pcc.10l00981yel] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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