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Hirayama I, Kamijo Y, Abe H, Nonaka M, Yano T, Ishii M, Tominaga Y. Guanfacine poisoning resulting in transient ST-segment elevation: a case report. Int J Emerg Med 2024; 17:60. [PMID: 38671356 PMCID: PMC11046827 DOI: 10.1186/s12245-024-00634-0] [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: 02/02/2024] [Accepted: 04/21/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Guanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of guanfacine poisoning have also risen. CASE PRESENTATION A 15-year-old male (height: 170 cm, weight: 48 kg), who was taking 2 mg/day of guanfacine for ADHD, was brought to our emergency department after ingesting 40 tablets of guanfacine due to poor exam results. He presented with impaired consciousness and sinus bradycardia on an electrocardiogram (ECG), leading to diagnosis of guanfacine poisoning. Gastric lavage (5 L) was performed, and activated charcoal was administered. Although his consciousness gradually recovered, he developed ST-segment elevation on the ECG. Despite the absence of chest pain and elevated myocardial enzymes, coronary artery stenosis was not observed on coronary artery computed tomography. As his blood guanfacine level decreased, his ECG returned to normal. CONCLUSIONS This case highlights the need for careful monitoring of guanfacine poisoning patients due to the potential for various cardiovascular events.
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Affiliation(s)
- Ichiro Hirayama
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan.
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan.
| | - Yoshito Kamijo
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Hiroko Abe
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
- Biodesign Inc, Tokyo, Japan
| | - Minaho Nonaka
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Tetsuhiro Yano
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Mitsuru Ishii
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Yoshiteru Tominaga
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
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Inoue F, Okazaki Y, Kashiwa K, Ichiba T, Namera A. QT-Interval Prolongation Associated with Supratherapeutic Guanfacine Concentration: A Case Report. J Med Toxicol 2024; 20:218-221. [PMID: 38231419 PMCID: PMC10959869 DOI: 10.1007/s13181-023-00986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/09/2023] [Accepted: 12/17/2023] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Guanfacine, an alpha-2 adrenergic agonist, is used to treat attention deficit hyperactivity disorder (ADHD). Although cardiovascular effects including hypotension and bradycardia are common adverse effects of guanfacine, the effect of guanfacine on QT intervals remains unclear. The association between the serum concentration of guanfacine and its toxicity has also not been fully investigated. CASE REPORT This is a case of a 21-year-old woman with ADHD who developed repeated presyncope 1 day before admission. She was taking 3 mg of extended-release guanfacine and 50 mg of sertraline. On admission, she had bradycardia and hypotension. An electrocardiogram (ECG) showed a QT interval of 0.68 s and a QTcF interval of 0.648 s. The QT intervals were manually measured and corrected by the Fridericia formula (QTcF = QT/RR1/3). Although she denied taking an overdose of guanfacine and other drugs, we suspected guanfacine toxicity. The serum guanfacine concentration was 13.0 ng/mL on admission and decreased to 3.2 ng/mL on day 1 and 0.4 ng/mL on day 2. Changes in QTcF intervals and her vital signs correlated with serum guanfacine concentrations. CONCLUSION Supratherapeutic serum guanfacine concentrations may induce QT prolongation.
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Affiliation(s)
- Fumiya Inoue
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan.
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan
| | - Akira Namera
- Department of Forensic Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, 734-8553, Japan
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Ayata R, Fujita M, Harada K, Esaki Y, Koga Y, Hisamoto Y, Asami-Noyama M, Takeda S, Harada K, Tsuruta R. A case of pulmonary edema due to guanfacine intoxication with measurement of serum guanfacine concentrations. J Toxicol Sci 2023; 48:641-644. [PMID: 38044125 DOI: 10.2131/jts.48.641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Guanfacine hydrochloride extended-release (GXR) is used to treat attention deficit hyperactivity disorder. It is a selective α2A-adrenorecepor agonist that was reported to cause QT prolongation and hypotension in the event of overdosing. We report the case of a 17-year-old man who took 226 tablets of GXR 3 mg for attempted suicide. He was found complaining of dyspnea, and emergency medical services were called. When the patient was transferred to our hospital, his Glasgow coma scale was 12 (E4V3M5). He was agitated and hypoxemic. He was intubated for invasive mechanical ventilation under sedation. His chest X-ray and computed tomography scan showed pulmonary edema. Transthoracic echocardiography showed markedly reduced cardiac function. His serum guanfacine concentration peaked on day 3 after admission. His pulmonary edema improved quickly after a decrease in serum guanfacine concentration, but cardiac decompensation persisted for about 1 month. This case reveals that the decline in cardiac function after guanfacine intoxication is prolonged even after its serum concentration has decreased.
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Affiliation(s)
- Ryo Ayata
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital
| | - Motoki Fujita
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine
| | - Kayoko Harada
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital
| | - Yusuke Esaki
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital
| | - Yasutaka Koga
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital
| | - Yukari Hisamoto
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital
| | - Maki Asami-Noyama
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University Hospital
| | - Saki Takeda
- Department of Forensic Medicine, Fukushima Medical University School of Medicine
| | - Kazuki Harada
- Department of Forensic Medicine, Fukushima Medical University School of Medicine
| | - Ryosuke Tsuruta
- Advanced Medical Emergency and Critical Care Center, Yamaguchi University Hospital
- Acute and General Medicine, Yamaguchi University Graduate School of Medicine
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Shimozato A, Ohashi K, Saitoh S. Two case reports of extended-release guanfacine overdose in children. Pediatr Int 2023; 65:e15424. [PMID: 36412228 DOI: 10.1111/ped.15424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 10/21/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Asuka Shimozato
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Kei Ohashi
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | - Shinji Saitoh
- Department of Pediatrics and Neonatology, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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Pettitt RM, Brown EA, Delashmitt JC, Pizzo MN. The Management of Anxiety and Depression in Pediatrics. Cureus 2022; 14:e30231. [DOI: 10.7759/cureus.30231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
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Delayed Signs and Symptoms of Extended Release Guanfacine Overdose in Two Adolescent Patients: Implications of Monitoring on the Psychiatry Unit. Case Rep Psychiatry 2022; 2022:2149301. [PMID: 35371580 PMCID: PMC8975677 DOI: 10.1155/2022/2149301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
Guanfacine is a selective alpha-2a adrenoreceptor agonist that with overdose can cause symptoms ranging from mild sedation to coma, respiratory depression, hyporeflexia, hypotonia, bradycardia, and hypotension. Despite a well-defined and predictable toxidrome, variations can be seen based on multiple factors including age, quantity ingested, organ functions, coingestions, time since ingestion, and specific dosage form. Here, we describe two cases of delayed presentation of extended release guanfacine toxicity and highlight the variations encountered in the toxidrome presentation. These cases bring to attention the importance of maintaining a high suspicion for such atypical presentations, keeping in mind the limitations of managing these complications on an inpatient psychiatric unit.
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