1
|
Kahn L, Kriikku P, Jönsson A. Loperamide positive deaths in Sweden 2012-2022 and Finland 2017-2022: Fatal loperamide intoxication exclusively for Sweden. Forensic Sci Int 2024; 361:112130. [PMID: 38986227 DOI: 10.1016/j.forsciint.2024.112130] [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: 03/11/2024] [Revised: 06/27/2024] [Accepted: 06/29/2024] [Indexed: 07/12/2024]
Abstract
Loperamide, a potent μ-opioid receptor agonist used as an antidiarrheal drug, exhibits increased bioavailability at supratherapeutic doses, causing potential central nervous system effects. Its misuse for opioid withdrawal relief and euphoria can lead to dangerously elevated blood levels, causing severe cardiac dysrhythmias and death. This study aimed to compare loperamide positive autopsy cases in Sweden and Finland after the introduction of postmortem toxicological analysis of loperamide, focusing on loperamide's role in fatalities and identifying common characteristics among those affected. All cases with detected loperamide in femoral blood at forensic autopsies in Sweden (2012-2022) and Finland (2017-2022) were included. In Sweden, loperamide was detected in 126 individuals, and in Finland, in 111 individuals. The incidence of individuals positive for loperamide in postmortem femoral blood increased steadily over the study duration in both Sweden and Finland. Loperamide related fatalities were observed exclusively in Sweden (n=80), predominantly involving younger males with histories of substance abuse, typically classified as accidental deaths. The group of loperamide nonrelated deaths in Sweden mirrored the entirety of cases in Finland. The concentration of loperamide in postmortem femoral blood was significantly higher in cases where loperamide was considered the cause of death (median 0.140 μg/g) compared to cases where loperamide contributed (median 0.080 μg/g), as well as in deaths unrelated to loperamide in both countries (Sweden: median 0.029 μg/g; Finland: median 0.010 μg/ml). The high limit of quantification for loperamide in Sweden may underestimate therapeutic users in epidemiological assessments. This study underscores the absence of loperamide misuse in Finland and indicates a rising trend of loperamide abuse in Sweden.
Collapse
Affiliation(s)
- Lydia Kahn
- Department of Forensic Medicine, National Board of Forensic Medicine, Stockholm 171 25, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm 171 77, Sweden.
| | - Pirkko Kriikku
- Forensic Chemistry Unit, Finnish Institute for Health and Welfare, Helsinki, Finland; Department of Forensic Medicine, University of Helsinki, Finland
| | - Anna Jönsson
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping 587 58, Sweden; Division of Clinical Chemistry and Pharmacology, Department of Biomedical and Clinical Sciences, Linköping University, Linköping 581 83, Sweden
| |
Collapse
|
2
|
Agnihotri A, Ramasubbu SK, Bandyopadhyay A, Bidarolli M, Nath UK, Das B. Prevalence, Attributes, and Risk Factors of QT-Interval-Prolonging Drugs and Potential Drug-Drug Interactions in Cancer Patients: A Prospective Study in a Tertiary Care Hospital. Cureus 2024; 16:e60492. [PMID: 38882995 PMCID: PMC11180424 DOI: 10.7759/cureus.60492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Cancer chemotherapy regimens include multiple classes of adjuvant drugs as supportive therapy. Because of the concurrent intake of other drugs (like antiemetics, antidepressants, analgesics, and antimicrobials), there is a heightened risk for possible QT interval prolongation. There is a dearth of evidence in the literature regarding the usage of QT-prolonging anticancer drugs and associated risk factors that have the propensity to prolong QT interval. The purpose was to explore the extent of the use of QT-interval-prolonging drugs and potential QT-prolonging drug-drug interactions (QT-DDIs) in cancer patients attending OPD in a tertiary-care hospital. Methods This was a hospital-based, cross-sectional, observational study. Risk stratification of QT-prolonging drugs for torsades de pointes (TdP) was done by the Arizona Center for Education and Research on Therapeutics (AzCERT)/CredibleMeds-lists, and potential QT-DDIs were determined with four online DDI-checker-software. Results In 1331 cancer patients, the overall prevalence of potential QT-prolonging drug utilization was 97.3%. Ondansetron, pantoprazole, domperidone, and olanzapine were the most frequent QT-prolonging drugs in cancer patients. The top six antineoplastics with potential QT-prolonging and torsadogenic actions were capecitabine, oxaliplatin, imatinib, bortezomib, 5-fluorouracil, and bendamustine. Evidence-based pragmatic QTc interval prolongation risk assessment tools are imperative for cancer patients. Conclusion This study revealed a high prevalence of QT-prolonging drugs and QT-DDIs among cancer patients who are treated with anticancer and non-anticancer drugs. As a result, it's critical to take precautions, stay vigilant, and avoid QT-prolonging in clinical situations. Evidence-based pragmatic QTc interval prolongation risk assessment tools are needed for cancer patients.
Collapse
Affiliation(s)
- Akash Agnihotri
- Department of Pharmacology, Amrita School of Medicine, Faridabad, IND
| | - Saravana Kumar Ramasubbu
- Department of Pharmacology, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, IND
| | - Arkapal Bandyopadhyay
- Department of Pharmacology, All India Institute of Medical Sciences, Kalyani, Kalyani, IND
| | - Manjunath Bidarolli
- Department of Pharmacology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Uttam Kumar Nath
- Department of Medical Oncology and Hematology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Biswadeep Das
- Department of Pharmacology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| |
Collapse
|
3
|
Garrido G, Garrido-Suárez BB, Martínez-Tapia N, Valdés-González M, Ortega-Mardones A. Antidiarrheal effect of Psidium guajava L. extract in acute diarrhea: a systematic review. JOURNAL OF THE SCIENCE OF FOOD AND AGRICULTURE 2024. [PMID: 38578668 DOI: 10.1002/jsfa.13515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 01/21/2024] [Accepted: 04/03/2024] [Indexed: 04/06/2024]
Abstract
Acute diarrheal diseases are a leading cause of childhood mortality and morbidity worldwide. Psidium guajava has been globally used for its antidiarrheal potential. We conducted a systematic review of scientific articles published up to the year 2021, which included in vivo pre-clinical tests and clinical trials involving patients with acute infectious diarrhea to verify the antidiarrheal, antibacterial and antispasmodic effects of galenic preparations or phytopharmaceuticals from P. guajava. PRISMA and Rayyan were used as tools for the selection of studies collected in four databases (Pubmed, Scopus, Web of Science and Science Direct). The keywords used to carry out the search were: 'Psidium guajava', 'guava', 'antidiarrhe*' and 'diarrhe*', joined by Boolean operators 'OR' or 'AND'. The characteristics of studies in animal models of acute diarrhea induction, as well as in vivo and in vitro motility and microbiological tests linked with its main pathophysiological mechanisms, were collected. Twenty-three articles were included. Twenty (87%) of these reported heterogenic preclinical studies, predominating pharmacological studies of efficacy against conventional antidiarrheal agents, which utilized relevant outcomes and models of infectious diarrhea from the top pathogens in the clinic along with classical castor oil-induced diarrhea associated with motility tests. Only three articles (13%) corresponded to clinical trials investigating the efficacy, dose and safety of these preparations. Most studies reported positive results and significant mechanistic evidence from antibacterial, anti-motility, anti-secretory and protective/anti-inflammatory perspectives. However, further studies are needed to define the clinical significance and safety treatment with P. guajava extracts. © 2024 Society of Chemical Industry.
Collapse
Affiliation(s)
- Gabino Garrido
- Departamento de Ciencias Farmacéuticas, Facultad de Ciencias, Universidad Católica del Norte, Antofagasta, Chile
| | | | - Nicolás Martínez-Tapia
- Departamento de Ciencias Farmacéuticas, Facultad de Ciencias, Universidad Católica del Norte, Antofagasta, Chile
| | - Marisela Valdés-González
- Departamento de Ciencias Farmacéuticas, Facultad de Ciencias, Universidad Católica del Norte, Antofagasta, Chile
| | - Andrea Ortega-Mardones
- Departamento Procesos de Diagnóstico y Evaluación, Facultad Ciencias de la Salud, Universidad Católica de Temuco, Temuco, Chile
| |
Collapse
|
4
|
Fan YM, Zhao QY, Wei YY, Wang HR, Ga Y, Zhang YN, Hao ZH. Qingjie decoction attenuated E.coli-induced diarrhea by regulating energy metabolism and alleviating inflammation based on network analysis and metabolomics. JOURNAL OF ETHNOPHARMACOLOGY 2024; 318:116806. [PMID: 37460028 DOI: 10.1016/j.jep.2023.116806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/08/2023] [Accepted: 06/15/2023] [Indexed: 08/02/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Diarrhea is a frequently encountered gastrointestinal complication in clinical practice, and E. coli is one of the main causative agents. Although Qingjie decoction (QJD) has been shown to be highly effective in treating diarrhea by eliminating heat-toxin, the underlying molecular mechanisms and pathways of QJD remain unclear. AIM OF REVIEW The aim of this research was to explore the effects and fundamental mechanism of QJD on diarrhea induced by E.coli in rats. MATERIALS AND METHODS Initially, we used UHPLC-MS/MS analysis to identify the chemical composition of QJD. Then, we constructed a visualization network using network pharmacology. Next, we utilized metabolomics to identify differentially expressed metabolites of QJD that are effective in treating diarrhea. RESULTS The chemical composition of QJD was analyzed using UHPLC-MS/MS, which identified a total of 292 components. Using a network pharmacology approach, 127 bioactive compounds of QJD were screened, targeting 171 potential diarrhea treatment targets. TNF-α, IL-6, IL-1β, and CAT were identified as important targets through visualizing the PPI network. Enrichment analysis demonstrated significant enrichment in the TNF signaling pathway, IL-17 signaling pathway, and PI3K-Akt signaling pathway. QJD showed beneficial effects, such as increased body weight, decreased fecal water content, and reduced inflammatory cell infiltration in the duodenum and colon, as well as maintaining the structure of the duodenum and colon. Metabolomic analysis revealed 32 differentially expressed metabolites in the control, model and QJD-H groups, including glucose, valine, and cysteine. Functional analysis indicated that differential metabolites were related to energy metabolism, including glucose metabolism, TCA cycle, and amino acid metabolism. CONCLUSION QJD significantly increased body weight, decreased water content in feces, relieved inflammatory cell infiltration, maintained the structure of duodenum and colon. Combining network analysis and metabolomics, QJD exerted therapeutic effects by inhibiting inflammation and oxidative stress, regulating glucose metabolism, tricarboxylic acid metabolism, and amino acid metabolism.
Collapse
Affiliation(s)
- Yi-Meng Fan
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China
| | - Qing-Yu Zhao
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China
| | - Yuan-Yuan Wei
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China
| | - Hui-Ru Wang
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China
| | - Yu Ga
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China
| | - Yan-Nan Zhang
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China
| | - Zhi-Hui Hao
- Key Biology Laboratory of Chinese Veterinary Medicine, Ministry of Agriculture and Rural Affairs, Beijing 100193, PR China; National Center of Technology Innovation for Medicinal Function of Food, National Food and Strategic Reserves Administration, Beijing 100193, China.
| |
Collapse
|
5
|
Graven-Nielsen CS, Knoph CS, Okdahl T, Høyer KL, Krogh K, Hellström PM, Drewes AM. Opioids in the Treatment of Chronic Idiopathic Diarrhea in Humans—A Systematic Review and Treatment Guideline. J Clin Med 2023; 12:jcm12072488. [PMID: 37048572 PMCID: PMC10094889 DOI: 10.3390/jcm12072488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/14/2023] [Accepted: 03/20/2023] [Indexed: 03/29/2023] Open
Abstract
In patients with chronic idiopathic diarrhea resistant to standard treatment, opioids are often used as rescue therapy. This systematic review investigated opioid effects on gut function in chronic diarrhea. PubMed and Embase were searched regarding effects of opioid agonists on the gastrointestinal tract in humans with chronic or experimentally induced diarrhea. A total of 1472 relevant articles were identified and, after thorough evaluation, 11 clinical trials were included. Generally, studies reported a reduction in stool frequency and an increase in transit time during treatment with the opioid receptor agonists loperamide, asimadoline, casokefamide, and codeine compared with placebo. Loperamide and diphenoxylate significantly improved stool consistency compared with placebo, whereas asimadoline showed no such effects. Compared with placebo, loperamide treatment caused less abdominal pain and urgency. Asimadoline showed no significant subjective improvements, but fedotozine was superior to placebo in reducing abdominal pain and bloating in selected patients. Only two relevant studies were published within the last 20 years, and standardized endpoint measures are lacking. Most trials included few participants, and further evidence is needed from larger, prospective studies. Likewise, consensus is needed to standardize endpoints for stool frequency, transit time, and consistency to conduct future meta-analyses on opioids in management of chronic idiopathic diarrhea.
Collapse
|
6
|
Geno KA, Badea A, Lynch KL, Jannetto P, Hubbard JA, Nerenz RD, Cervinski MA. An Opioid Hiding in Plain Sight: Loperamide-Induced False-Positive Fentanyl and Buprenorphine Immunoassay Results. J Appl Lab Med 2022; 7:1318-1328. [PMID: 36036092 DOI: 10.1093/jalm/jfac065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/21/2022] [Indexed: 11/09/2023]
Abstract
BACKGROUND Loperamide (Imodium®), a commonly used anti-diarrheal, is a mu opioid receptor agonist that, like all opioids, reduces gastrointestinal tract peristalsis. Loperamide is considered to have low abuse potential as it does not produce an analgesic or euphoric effect due to low bioavailability and first-pass metabolism. However, reports of individuals misusing loperamide through the use of super-therapeutic doses, alone or in combination with P-glycoprotein and/or CYP450 enzyme inhibitors, is increasing. We hypothesized that loperamide could potentially cross-react with laboratory immunoassay drug screens. METHODS Drug-free urine was spiked with loperamide or its principal metabolite, N-desmethyl loperamide (dLop), and assayed on multiple fentanyl and buprenorphine assays. Fentanyl immunoassay screen-positive results at one institution were examined by high-resolution mass spectrometry (MS) for the presence of loperamide and quantified by liquid chromatography- tandem MS when positive. RESULTS Loperamide produced positive results on the Thermo DRI Fentanyl and Immunalysis Fentanyl assays at concentrations greater than 5.72 mg/L and 23.7 mg/L. dLop generated positive results for the Thermo DRI and Immunalysis fentanyl assays at concentrations exceeding 6.9 mg/L and 35.7 mg/L. dLop also produced positive buprenorphine results on the Thermo CEDIA buprenorphine assay at concentrations exceeding 12.2 mg/L. High-resolution MS analysis of 225 fentanyl immunoassay positives (Thermo DRI) yielded 5 specimens containing loperamide and/or dLop, 4 of which contained measurable quantities of fentanyl in addition to loperamide/dLop. CONCLUSIONS Laboratories using these assays should be aware of the potential for false-positive screening results due to the presence of high concentrations of loperamide and its metabolite dLop.
Collapse
Affiliation(s)
- K Aaron Geno
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Adina Badea
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kara L Lynch
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Paul Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jacqueline A Hubbard
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Mark A Cervinski
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| |
Collapse
|
7
|
Kowalchuk A, Gonzalez SJ, Mejia MC, Zoorob RJ. Substance Use Disorders. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
8
|
Isang E, Shali L, Morris CB, Mahlow J. Loperamide-Induced Torsades de Pointes. Cureus 2021; 13:e20299. [PMID: 35028205 PMCID: PMC8747988 DOI: 10.7759/cureus.20299] [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] [Accepted: 12/08/2021] [Indexed: 11/18/2022] Open
Abstract
Loperamide, an over-the-counter antidiarrheal, works on the µ opioid receptor with minimal opioid activity if taken as directed. Recently, it has gained popularity as the “poor man's methadone” at supratherapeutic dosing. Opioid antagonism with naloxone is beneficial in reversing respiratory depression but has no effect on cardiotoxicity due to the human ether-a-go-go-related gene (hERG). We present the case of a 34-year-old female who presented for syncope after taking 48 tablets of 2 mg loperamide. On arrival, she was obtunded with variable heart block and a QTc of 560 ms. Subsequently, due to further QT prolongation from loperamide to 656 ms, she developed Torsades de Pointes requiring defibrillation at 120 J twice. Ultimately, she was discharged home with psychiatric and substance abuse outpatient follow-up. Patients and healthcare providers face new challenges with the increase in loperamide misuse due to easy access and delayed identification. It is important for clinicians to recognize and be familiar with loperamide overdose given the potential for multiorgan failure and increased mortality.
Collapse
|
9
|
Malinky CA, Lindsley CW, Han C. DARK Classics in Chemical Neuroscience: Loperamide. ACS Chem Neurosci 2021; 12:2964-2973. [PMID: 34346690 DOI: 10.1021/acschemneuro.1c00382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Loperamide, a popular and inexpensive over-the-counter antidiarrheal medicine, is a potent μ-opioid receptor agonist approved by the U.S. Food and Drug Administration (FDA). It has been on the market since 1976 and is relatively safe with no central nervous system-related side effects when used for a short period of time at the recommended therapeutic dose (2-8 mg/day). In recent years, loperamide has become notoriously known as the "poor man's methadone" for people with substance dependence due to the increase in loperamide overdoses from self-administered medication to treat opioid withdrawal symptoms. As a result, in 2018, the FDA decided to limit the available packaged dose of loperamide to stop prominent abuse. This review provides the synthesis and chemical properties of loperamide as well as the pharmacology and adverse effects of its use and the social effects of such abuse.
Collapse
Affiliation(s)
- Cori A. Malinky
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Craig W. Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Changho Han
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| |
Collapse
|
10
|
Vearrier D, Grundmann O. Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids. J Clin Pharmacol 2021; 61 Suppl 2:S70-S88. [PMID: 34396552 DOI: 10.1002/jcph.1923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022]
Abstract
Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.
Collapse
Affiliation(s)
- David Vearrier
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| |
Collapse
|
11
|
Iqbal S, Fayyaz SM, Saeed Y, Aqeel M. Loperamide-induced cardiotoxicity: a case overlooked? BMJ Case Rep 2021; 14:14/7/e243325. [PMID: 34290024 DOI: 10.1136/bcr-2021-243325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A young man presented to the emergency department with seizures and recurrent episodes of polymorphic ventricular tachycardia (PMVT)/torsades de pointes (TdP) requiring cardioversion and administration of intravenous magnesium. A battery of tests performed to identify a cause for his arrhythmias and seizures were all normal. A revisit of history with family revealed he had consumed over 100 tablets/day of loperamide for the past 1 year. A prolonged QT interval on his ECG raised concerns for long QT syndrome (LQTS) (congenital or acquired). Our patient was suspected to have loperamide-induced cardiotoxicity. TdP is a specific PMVT that occurs with a prolonged QT interval and is usually drug-induced. Less frequently, congenital LQTS may be implicated. With supportive care, including mechanical ventilation, vasopressors and temporary transvenous overdrive pacing, our patient recovered completely. We describe the importance of a systematic and time-sensitive approach to diagnosing critical illness. Loperamide overdose may cause QT prolongation, life-threatening arrhythmias/cardiogenic shock, or cardiac arrest. Seizures/epilepsy may also be a manifestation in young patients. There is a substantial need to revisit the safety of over-the-counter medications and increasing awareness of manifestations of drug overdose.
Collapse
Affiliation(s)
- Sameen Iqbal
- Section of Cardiology, Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Sidra Malik Fayyaz
- Section of Pulmonology & Critical Care Medicine, Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Yawer Saeed
- Section of Cardiology, Department of Medicine, The Aga Khan University, Karachi, Pakistan
| | - Masooma Aqeel
- Section of Pulmonology & Critical Care Medicine, Department of Medicine, The Aga Khan University, Karachi, Pakistan
| |
Collapse
|
12
|
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
| |
Collapse
|
13
|
Song YQ, He RJ, Pu D, Guan XQ, Shi JH, Li YG, Hou J, Jia SN, Qin WW, Fang SQ, Ge GB. Discovery and Characterization of the Biflavones From Ginkgo biloba as Highly Specific and Potent Inhibitors Against Human Carboxylesterase 2. Front Pharmacol 2021; 12:655659. [PMID: 34084136 PMCID: PMC8167799 DOI: 10.3389/fphar.2021.655659] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 04/08/2021] [Indexed: 11/13/2022] Open
Abstract
Human carboxylesterase 2 (CES2), one of the most abundant hydrolases distributed in the small intestine, has been validated as a key therapeutic target to ameliorate the intestinal toxicity caused by irinotecan. This study aims to discover efficacious CES2 inhibitors from natural products and to characterize the inhibition potentials and inhibitory mechanisms of the newly identified CES2 inhibitors. Following high-throughput screening and evaluation of the inhibition potency of more than 100 natural products against CES2, it was found that the biflavones isolated from Ginkgo biloba displayed extremely potent CES2 inhibition activities and high specificity over CES1 (>1000-fold). Further investigation showed that ginkgetin, bilobetin, sciadopitysin and isoginkgetin potently inhibited CES2-catalyzed hydrolysis of various substrates, including the CES2 substrate-drug irinotecan. Notably, the inhibition potentials of four biflavones against CES2 were more potent than that of loperamide, a marketed anti-diarrhea agent used for alleviating irinotecan-induced intestinal toxicity. Inhibition kinetic analyses demonstrated that ginkgetin, bilobetin, sciadopitysin and isoginkgetin potently inhibited CES2-catalyzed fluorescein diacetate hydrolysis via a reversible and mixed inhibition manner, with K i values of less than 100 nM. Ensemble docking and molecular dynamics revealed that these biflavones could tightly and stably bind on the catalytic cavity of CES2 via hydrogen bonding and π-π stacking interactions, while the interactions with CES1 were awfully poor. Collectively, this study reports that the biflavones isolated from Ginkgo biloba are potent and highly specific CES2 inhibitors, which offers several promising lead compounds for developing novel anti-diarrhea agent to alleviate irinotecan-induced diarrhea.
Collapse
Affiliation(s)
- Yun-Qing Song
- Department of Gastroenterology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong-Jing He
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Dan Pu
- Department of Gastroenterology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Xiao-Qing Guan
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jin-Hui Shi
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yao-Guang Li
- Department of Biotechnology, College of Basic Medical Sciences, Dalian Medical University, Dalian, China
| | - Jie Hou
- Department of Biotechnology, College of Basic Medical Sciences, Dalian Medical University, Dalian, China
| | - Shou-Ning Jia
- Qinghai Hospital of Traditional Chinese Medicine, Xining, China
| | - Wei-Wei Qin
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Department of Pharmacy & Worldwide Medical Center, Huashan Hospital, Fudan University, Shanghai, China
| | - Sheng-Quan Fang
- Department of Gastroenterology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Guang-Bo Ge
- Department of Gastroenterology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| |
Collapse
|
14
|
Abstract
Loperamide is an over-the-counter medication which is commonly used to treat diarrhoea. In excessive doses, loperamide acts as an opioid on the central nervous system, which contributes to its increasing popularity as an alternative substance for opiate addictions. High doses for prolonged periods can cause prolonged QTc and provoke life-threatening arrhythmias, such as ventricular fibrillation. We report the case of a young female who developed dangerous arrhythmias as a result of chronic loperamide overdosing. Following syncopal episodes at rest, she was admitted for a period of monitored observation and later discharged with a plan to taper her loperamide in the community. Upon second presentation, her loperamide was replaced with buprenorphine patches, which were then weaned successfully in the community. Despite this, she passed away several months later, most likely from an underlying congenital cardiac arrhythmia which was unmasked by excessive use of loperamide.
Collapse
|
15
|
Shi CC, Song YQ, He RJ, Guan XQ, Song LL, Chen ST, Sun MR, Ge GB, Zhang LR. Rapalogues as hCES2A Inhibitors: In Vitro and In Silico Investigations. Eur J Drug Metab Pharmacokinet 2020; 46:129-139. [PMID: 33140264 DOI: 10.1007/s13318-020-00659-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVE Rapamycin and its semi-synthetic analogues (rapalogues) are frequently used in combination with other prescribed medications in clinical settings. Although the inhibitory effects of rapalogues on cytochrome P450 enzymes (CYPs) have been well examined, the inhibition potentials of rapalogues on human esterases have not been investigated. Herein, the inhibition potentials and inhibitory mechanisms of six marketed rapalogues on human esterases are investigated. METHODS The inhibitory effects of six marketed rapalogues (rapamycin, zotarolimus, temsirolimus, everolimus, pimecrolimus and tacrolimus) on three major esterases, including human carboxylesterases 1 (hCES1A), human carboxylesterases 2 (hCES2A) and butyrylcholinesterase (BuChE), were assayed using isozyme-specific substrates. Inhibition kinetic analyses and docking simulations were performed to investigate the inhibitory mechanisms of the rapalogues with strong hCES2A inhibition potency. RESULTS Zotarolimus and pimecrolimus displayed strong inhibition of human hCES2A but these agents did not inhibit hCES1A or BuChE. Further investigation demonstrated that zotarolimus could strongly inhibit intracellular hCES2A in living HepG2 cells, with an estimated IC50 value of 4.09 µM. Inhibition kinetic analyses revealed that zotarolimus inhibited hCES2A-catalyzed fluorescein diacetate hydrolysis in a mixed manner, with the Ki value of 1.61 µM. Docking simulations showed that zotarolimus could tightly bind on hCES2A at two district ligand-binding sites, consistent with its mixed inhibition mode. CONCLUSION Our findings demonstrate that several marketed rapalogues are potent and specific hCES2A inhibitors, and these agents can serve as leading compounds for the development of more efficacious hCES2A inhibitors to modulate the pharmacokinetic profiles and toxicity of hCES2A-substrate drugs (such as the anticancer agent irinotecan).
Collapse
Affiliation(s)
- Cheng-Cheng Shi
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People's Republic of China. .,Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, People's Republic of China.
| | - Yun-Qing Song
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, People's Republic of China
| | - Rong-Jing He
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, People's Republic of China
| | - Xiao-Qing Guan
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, People's Republic of China
| | - Li-Lin Song
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, People's Republic of China
| | - Shi-Tong Chen
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, People's Republic of China
| | - Meng-Ru Sun
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, People's Republic of China
| | - Guang-Bo Ge
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, People's Republic of China.
| | - Li-Rong Zhang
- Department of Pharmacology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, Henan, People's Republic of China.
| |
Collapse
|
16
|
Wolfes J, Ellermann C, Burde S, Leitz P, Bögeholz N, Willy K, Fehr M, Reinke F, Eckardt L, Frommeyer G. Divergent Electrophysiological Effects of Loperamide and Naloxone in a Sensitive Whole-Heart Model. Cardiovasc Toxicol 2020; 21:248-254. [PMID: 33125619 DOI: 10.1007/s12012-020-09616-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 10/16/2020] [Indexed: 11/24/2022]
Abstract
Several case reports suggest QT prolongation leading to ventricular arrhythmias with fatal outcome after intoxication with the μ-opioid receptor agonist and anti-diarrheal agent loperamide. The number of cases of loperamide misuse are growing due to its potential stimulating effects. Loperamide intoxications can be treated by naloxone. However, previous reports described a further QT prolongation associated with naloxone administration. Therefore, the aim of this study was to investigate the effects of loperamide and naloxone on the cardiac electrophysiology in a sensitive whole-heart model. Twenty-six hearts of New Zealand White rabbits were retrogradely perfused in a modified Langendorff apparatus. Monophasic action potentials were recorded by endo- and epicardially positioned catheters. Hearts were stimulated at different cycle lengths, thereby obtaining action potential duration at 90% of repolarization (APD90) and QT intervals. Programmed ventricular stimulation was used to assess ventricular vulnerability. Fourteen hearts were perfused with ascending concentrations of loperamide (0.2 μM, 0.35 μM, and 0.5 μM) after obtaining baseline data. Another 12 hearts were treated with naloxone (0.1 μM, 0.5 μM, 2 μM). Loperamide led to a significant increase in QT interval, APD90, and ventricular tachycardia (VT) episodes. In contrast, naloxone led to a decrease in QT interval and APD90. Accordingly, the number of VT episodes was unaltered. To the best of our knowledge, this is the first experimental study that investigated the effects of loperamide and naloxone in a whole-heart model. Loperamide led to a significant increase in action potential duration and QT interval. Simultaneously, the number of ventricular tachycardias was significantly increased. In contrast, naloxone led to a shortening of the action potential duration without altering arrhythmia susceptibility.
Collapse
Affiliation(s)
- Julian Wolfes
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany.
| | - Christian Ellermann
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Sophie Burde
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Patrick Leitz
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Nils Bögeholz
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Kevin Willy
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Michael Fehr
- University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, 30559, Hannover, Germany
| | - Florian Reinke
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Lars Eckardt
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| | - Gerrit Frommeyer
- Department of Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Munster, Germany
| |
Collapse
|
17
|
Huo PC, Guan XQ, Liu P, Song YQ, Sun MR, He RJ, Zou LW, Xue LJ, Shi JH, Zhang N, Liu ZG, Ge GB. Design, synthesis and biological evaluation of indanone-chalcone hybrids as potent and selective hCES2A inhibitors. Eur J Med Chem 2020; 209:112856. [PMID: 33007602 DOI: 10.1016/j.ejmech.2020.112856] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 11/30/2022]
Abstract
Human carboxylesterase 2 (hCES2A), one of the major serine hydrolases distributed in the small intestine, plays a crucial role in hydrolysis of ester-bearing drugs. Accumulating evidence has indicated that hCES2A inhibitor therapy can modulate the pharmacokinetic and toxicological profiles of some important hCES2A-substrate drugs, such as the anticancer agent CPT-11. Herein, a series of indanone-chalcone hybrids are designed and synthesized to find potent and highly selective hCES2A inhibitors. Inhibition assays demonstrated that most indanone-chalcone hybrids displayed strong to moderate hCES2A inhibition activities. Structure-hCES2A inhibition activity relationship studies showed that introduction of a hydroxyl at the C4' site and introduction of an N-alkyl group at the C6 site were beneficial for hCES2A inhibition. Particularly, B7 (an N-alkylated 1-indanone-chalcone hybrid) exhibited the most potent inhibition on hCES2A and excellent specificity (this agent could not inhibit other human esterases including hCES1A and butyrylcholinesterase). Inhibition kinetic analyses demonstrated that B7 potently inhibited hCES2A-mediated FD hydrolysis in a mixed inhibition manner, with a calculated Ki value of 0.068 μM. Furthermore, B7 was capable of inhibiting intracellular hCES2A in living cells and displayed good metabolic stability. Collectively, our findings show that indanone-chalcone hybrids are good choices for the development of hCES2A inhibitors, while B7 is a promising candidate for the development of novel anti-diarrhea agents to ameliorate irinotecan-induced intestinal toxicity.
Collapse
Affiliation(s)
- Peng-Chao Huo
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China; School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, 450001, China
| | - Xiao-Qing Guan
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Peng Liu
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yun-Qing Song
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Meng-Ru Sun
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Rong-Jing He
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Li-Wei Zou
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Li-Juan Xue
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jin-Hui Shi
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Nan Zhang
- School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, 450001, China.
| | - Zhi-Guo Liu
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, Zhejiang, China.
| | - Guang-Bo Ge
- Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| |
Collapse
|
18
|
Pharmacological Aspects of Over-the-Counter Opioid Drugs Misuse. Molecules 2020; 25:molecules25173905. [PMID: 32867117 PMCID: PMC7504308 DOI: 10.3390/molecules25173905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
Several over-the-counter (OTC) drugs are known to be misused. Among them are opioids such as codeine, dihydrocodeine, and loperamide. This work elucidates their pharmacology, interactions, safety profiles, and how pharmacology is being manipulated to misuse these common medications, with the aim to expand on the subject outlined by the authors focusing on abuse prevention and prevalence rates. The reviewed literature was identified in several online databases through searches conducted with phrases created by combining the international non-proprietary names of the drugs with terms related to drug misuse. The results show that OTC opioids are misused as an alternative for illicit narcotics, or prescription-only opioids. The potency of codeine and loperamide is strongly dependent on the individual enzymatic activity of CYP2D6 and CYP3A4, as well as P-glycoprotein function. Codeine can also be utilized as a substrate for clandestine syntheses of more potent drugs of abuse, namely desomorphine (“Krokodil”), and morphine. The dangerous methods used to prepare these substances can result in poisoning from toxic chemicals and impurities originating from the synthesis procedure. OTC opioids are generally safe when consumed in accordance with medical guidelines. However, the intake of supratherapeutic amounts of these substances may reveal surprising traits of common medications.
Collapse
|
19
|
Abstract
PURPOSE This article presents updated information on kratom (Mitragyna speciosa), a natural opioid with stimulant properties that is currently sold in the United States without a prescription. SUMMARY Kratom exerts opioid and alpha-2 agonistic effects, as well as anti-inflammatory and mild stimulant effects. Respiratory depression has not been commonly reported, but kratom does cause a host of adverse effects. While kratom may have a role in patients who are in chronic pain or dependent on opioid painkillers or heroin, this needs to be established in clinical trials. Kratom may have drug interactions as both a cytochrome P-450 system substrate and inhibitor. Kratom does not appear in normal drug screens and, especially when ingested with other substances of abuse, may not be recognized as an agent of harm. There are numerous cases of death in kratom users, but many involved polypharmaceutical ingestions. There are assessments where people have been unable to stop using kratom therapy and withdrawal signs/symptoms occurred in patients or their newborn babies after kratom cessation. Both banning and failure to ban kratom places people at risk; a middle-ground alternative, placing it behind the pharmacy counter, might be useful. CONCLUSION Kratom has a unique pharmacologic profile that might offer advantages over other opioids, but its high abuse liability, potential for drug interactions and adverse events, and inadequate research into the balance of benefits to harm are concerning. There is mounting information on the adverse events associated with kratom use and potential treatments that can be useful to clinicians.
Collapse
Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, CT, and Department of Pharmacy, Hartford Hospital, Hartford, CT
| |
Collapse
|
20
|
|
21
|
Webb NE, Wood DM, Black JC, Amioka E, Dart RC, Dargan PI. Non-medical use of loperamide in the UK and the USA. QJM 2020; 113:25-30. [PMID: 31424512 DOI: 10.1093/qjmed/hcz215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/07/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Loperamide is a mu-opioid receptor agonist that is available as an over-the-counter anti-motility agent in the US and UK; recommended maximum doses of 12-16 mg/day. Anecdotal reports of non-medical use (NMU) have increased over the past decade with supra-therapeutic doses (70-800 mg/day) associated with cardiotoxicity. Little data exists on the prevalence of loperamide NMU. AIM The aim of this study was to determine the prevalence of loperamide NMU in the UK and US and to describe characteristics of non-medical loperamide users. DESIGN The Researched, Abuse, Diversion and Addiction Related Surveillance (RADARS® ) Survey of Nonmedical Use of Prescription Drugs (NMURx) was utilized to study NMU of loperamide among the adult population in the UK and US in 2017. The RADARS® NMURx is anonymous and self-administered online. METHODS A total of 40,029 completed surveys were included (10,019 from the UK and 30,010 from the US). Respondents were asked questions about medical and NMU of loperamide, frequency of and reasons for NMU, route of use problematic drug use markers, and demographics. RESULTS Prevalence of lifetime loperamide use (95% CI) and lifetime NMU of loperamide were: UK 28.5% (27.67-29.4), and 0.66% (0.5-0.8), respectively; US 33.7% (33.1-34.2), and 5.19% (4.9-5.5), respectively. Problematic drug use markers were elevated in those who reported NMU of loperamide in both the UK and US, however high-risk use was more prevalent in the UK than in the US. CONCLUSION NMU of loperamide is common. In the current international environment of opioid addiction involving both therapeutic and illicit opioids, awareness of the NMU of loperamide is important.
Collapse
Affiliation(s)
- N E Webb
- Clinical Toxicology Department, St Thomas' Hospital, Westminster Bridge Road London, London, UK
| | - D M Wood
- Clinical Toxicology Department, St Thomas' Hospital, Westminster Bridge Road London, London, UK
- Faculty of Life Sciences and Medicine, King's College London, Strand, London, London, UK
| | - J C Black
- Rocky Mountain Poison and Drug Center, 1391 Speer Boulevard, Suite 600, Denver, CO, USA
| | - E Amioka
- Rocky Mountain Poison and Drug Center, 1391 Speer Boulevard, Suite 600, Denver, CO, USA
| | - R C Dart
- Rocky Mountain Poison and Drug Center, 1391 Speer Boulevard, Suite 600, Denver, CO, USA
| | - P I Dargan
- Clinical Toxicology Department, St Thomas' Hospital, Westminster Bridge Road London, London, UK
- Faculty of Life Sciences and Medicine, King's College London, Strand, London, London, UK
| |
Collapse
|
22
|
Kowalchuk A, Gonzalez SJ, Mejia MC, Zoorob RJ. Substance Use Disorders. Fam Med 2020. [DOI: 10.1007/978-1-4939-0779-3_174-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
23
|
Eggleston W, Palmer R, Dubé PA, Thornton S, Stolbach A, Calello DP, Marraffa JM. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila) 2019; 58:355-359. [DOI: 10.1080/15563650.2019.1681443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY, USA
- Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA
| | | | - Pierre-André Dubé
- Department of Environmental Health and Toxicology, Institut National de Santé Publique du Québec, Quebec, Canada
| | - Stephen Thornton
- Emergency Medicine, University of Kansas Medical Center, Kansas City, KS, USA
- Poison Control Center, University of Kansas Health System, Kansas City, KS, USA
| | - Andrew Stolbach
- Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Diane P Calello
- Rutgers New Jersey Medical School, Department of Emergency Medicine, New Jersey Poison Information and Education System, Newark, NJ, USA
| | - Jeanna M Marraffa
- Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA
| |
Collapse
|
24
|
Lin QM, Li YH, Liu Q, Pang NH, Xu RA, Cai JP, Hu GX. Functional characteristics of CYP3A4 allelic variants on the metabolism of loperamide in vitro. Infect Drug Resist 2019; 12:2809-2817. [PMID: 31571937 PMCID: PMC6750855 DOI: 10.2147/idr.s215129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/08/2019] [Indexed: 11/23/2022] Open
Abstract
Background Cytochrome P450 3A4 (CYP3A4) appears to be genetically polymorphic, which in turn contributes to interindividual variability in response to therapeutic drugs. Loperamide, identified as a CYP3A4 substrate, is prone to misuse and abuse and has high risks of life-threatening cardiotoxicity. Methods Thus, this study is designed to evaluate the enzymatic characteristics of 29 CYP3A4 alleles toward loperamide in vitro, including the 7 novel CYP3A4 variants (*28-*34). The incubation system (containing CYP3A4 enzyme, cytochrome b5, 0.5-20 μM loperamide, potassium phosphate buffer and nicotinamide adenine dinucleotide phosphate) was subject to 40-mins incubation at 37°C and the concentrations of N-demethylated loperamide were quantified by UPLC-MS/MS. Results As a result, CYP3A4.6, .17, .20 and .30 showed extremely low activity or no activity and the rest of CYP3A4 variants presented varying degrees of decrements in catalytical activities when compared with CYP3A4.1. Conclusion As the first study to identify the properties of these CYP3A4 variants toward loperamide metabolism, our investigation may establish the genotype-phenotype relationship for loperamide, predict an individual's capability in response to loperamide, and provide some guidance of clinical medication and treatment for loperamide.
Collapse
Affiliation(s)
- Qian-Meng Lin
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Ying-Hui Li
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Qian Liu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Ni-Hong Pang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Ren-Ai Xu
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Jian-Ping Cai
- The Ministry of Health (MOH) Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing 100730, People's Republic of China
| | - Guo-Xin Hu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| |
Collapse
|
25
|
Teigeler T, Stahura H, Alimohammad R, Kalahasty G, Koneru JN, Ellenbogen M, Ellenbogen KA, Padala SK. Electrocardiographic changes in loperamide toxicity: Case report and review of literature. J Cardiovasc Electrophysiol 2019; 30:2618-2626. [DOI: 10.1111/jce.14129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/16/2019] [Accepted: 08/08/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Todd Teigeler
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Heather Stahura
- Capital Cardiology Associates Albany Medical Center Albany New York
| | | | - Gautham Kalahasty
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Jayanthi N. Koneru
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Michael Ellenbogen
- Division of General Internal Medicine Johns Hopkins University School of Medicine Baltimore Maryland
| | - Kenneth A. Ellenbogen
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Santosh K. Padala
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
- Capital Cardiology Associates Albany Medical Center Albany New York
| |
Collapse
|
26
|
Kim S. The unsuspected threat of three opioid-like substitutes. Arch Psychiatr Nurs 2019; 33:325-328. [PMID: 31280775 DOI: 10.1016/j.apnu.2019.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/16/2019] [Accepted: 01/19/2019] [Indexed: 12/24/2022]
Abstract
The opioid epidemic has left its toll on the United States with millions suffering from an opioid use disorder and tens of thousands dying from overdoses each year. With intentions to combat the crisis, health providers have been prescribing less opioids, which resulted in an unintentional increase in the abuse of other opioid-like substances. Three emerging drugs of abuse have been noted in the literature as having increased abuse potential in light of recent trends. Kratom, an herbal supplement, gabapentin, a prescription nerve pain and anticonvulsant medication, and loperamide, an over-the-counter antidiarrheal medication. These have all displayed opioid-like properties at high doses and used to alleviate opioid withdrawal. Healthcare clinicians and patients might not be aware of the potential risks involved with misusing or abusing these opioid substitutes. This article discusses the increased usage of kratom, gabapentin, and loperamide, the abuse potential, adverse effects and withdrawal symptoms of each drug, and nursing implications that impact inpatient safety and management.
Collapse
Affiliation(s)
- Sarah Kim
- Pacific Lutheran University, School of Nursing, Tacoma, WA, 98447, United States of America.
| |
Collapse
|
27
|
Vera G, Girón R, Martín-Fontelles MI, Abalo R. Radiographic dose-dependency study of loperamide effects on gastrointestinal motor function in the rat. Temporal relationship with nausea-like behavior. Neurogastroenterol Motil 2019; 31:e13621. [PMID: 31117152 DOI: 10.1111/nmo.13621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/09/2019] [Accepted: 04/24/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Loperamide is a potent mu opioid receptor agonist available over the counter to treat diarrhea. Although at therapeutic doses loperamide is devoid of central effects, it may exert them if used at high doses or combined with drugs that increase its systemic and/or central bioavailability. Recently, public health and scientific interest on loperamide has increased due to a growing trend of misuse and abuse, and consequent reports on its toxicity. Our aim was to evaluate in the rat the effects of increasing loperamide doses, with increasing likelihood to induce central effects, on gastrointestinal motor function (including gastric dysmotility and nausea-like behavior). METHODS Male Wistar rats received an intraperitoneal injection of vehicle or loperamide (0.1, 1, or 10 mg kg-1 ). Three sets of experiments were performed to evaluate: (a) central effects (somatic nociceptive thresholds, immobility time, core temperature, spontaneous locomotor activity); (b) general gastrointestinal motility (serial X-rays were taken 0-8 hours after intragastric barium administration and analyzed semiquantitatively, morphometrically, and densitometrically); and (c) bedding intake (a rodent indirect marker of nausea). Animals from sets 1 and 3 were used to evaluate gastric dysmotility ex vivo at 2 and 4 hours after administration, respectively. KEY RESULTS Loperamide significantly induced antinociception, hypothermia, and hypolocomotion (but not catalepsy) at high doses and dose-dependently reduced gastrointestinal motor function, with the intestine exhibiting higher sensitivity than the stomach. Whereas bedding intake occurred early and transiently, gastric dysmotility was much more persistent. CONCLUSIONS AND INFERENCES Our results suggest that loperamide-induced nausea and gastric dysmotility might be temporally dissociated.
Collapse
Affiliation(s)
- Gema Vera
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Alcorcón, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica (IQM), Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Rocío Girón
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Alcorcón, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica (IQM), Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - María Isabel Martín-Fontelles
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Alcorcón, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica (IQM), Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| | - Raquel Abalo
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Alcorcón, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica (IQM), Centro Superior de Investigaciones Científicas (CSIC), Madrid, Spain
| |
Collapse
|
28
|
Lin QM, Pang NH, Li YH, Huang HL, Zhang XD, Hu GX, Wang ZS. Investigation of the effects of axitinib on the pharmacokinetics of loperamide and its main metabolite N-demethylated loperamide in rats by UPLC-MS/MS. Chem Biol Interact 2019; 310:108744. [PMID: 31299239 DOI: 10.1016/j.cbi.2019.108744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 01/10/2023]
Abstract
The epidemic of loperamide abuse and misuse in the patients for the alternative to opioids has become an increasing worldwide concern and has led to considerations about the potential for drug-drug interactions between loperamide and other combined drugs, especially inhibitors of cytochrome P450 (CYP450) enzymes, such as axitinib. This study assessed the effects of axitinib on the metabolism of loperamide and its main metabolite N-demethylated loperamide in rats and in rat liver microsomes (RLM), human liver microsomes (HLM) and recombinant human CYP3A4*1. The concentrations of both compounds were determined by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The exposures (AUC(0-t), AUC(0-∞) and Cmax) of loperamide and N-demethylated loperamide showed a conspicuous increase when loperamide was co-administered with axitinib. The Tmax of loperamide increased while CLz/F decreased under the influence of axitinib. In vitro, axitinib inhibited loperamide metabolism with the IC50 of 18.34 μM for RLM, 1.705 μM for HLM and 1.604 μM for CYP3A4*1, and it was confirmed as a non-competitive inhibitor in all enzymes. Taken together, the results indicated that axitinib had an obvious inhibitory impact on loperamide metabolism both in vivo and in vitro. Thus, more attention should be paid to the concurrent use of loperamide and axitinib to reduce the risk of unexpected clinical outcomes.
Collapse
Affiliation(s)
- Qian-Meng Lin
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Ni-Hong Pang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Ying-Hui Li
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Huan-le Huang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Xiao-Dan Zhang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Guo-Xin Hu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China.
| | - Zeng-Shou Wang
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China.
| |
Collapse
|
29
|
Powell JW, Presnell SE. Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina. J Forensic Sci 2019; 64:1726-1730. [DOI: 10.1111/1556-4029.14115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 01/10/2023]
Affiliation(s)
- John W. Powell
- The Medical University of South Carolina Charleston SC29415
| | - Susan Erin Presnell
- Department of Pathology and Laboratory Medicine The Medical University of South Carolina Charleston SC29425-9080
| |
Collapse
|
30
|
White CM. Loperamide: A Readily Available but Dangerous Opioid Substitute. J Clin Pharmacol 2019; 59:1165-1169. [DOI: 10.1002/jcph.1449] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/09/2019] [Indexed: 11/10/2022]
Affiliation(s)
- C. Michael White
- University of Connecticut School of Pharmacy and Hartford Hospital Hartford CT USA
| |
Collapse
|
31
|
Loperamide-Associated Opioid Use Disorder and Proposal of an Alternative Treatment with Buprenorphine. J Addict Med 2019; 13:245-247. [DOI: 10.1097/adm.0000000000000472] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
Kohli U, Altujjar M, Sharma R, Hassan S. Wide interindividual variability in cardiovascular toxicity of loperamide: A case report and review of literature. HeartRhythm Case Rep 2019; 5:221-224. [PMID: 30997339 PMCID: PMC6453448 DOI: 10.1016/j.hrcr.2019.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
|
33
|
Abstract
Novel drugs of abuse are synthetic illicit drugs, or analogues of known illicit drugs, that can be more potent. Novel drugs of abuse are often labeled as designer drugs, research chemicals, legal highs, or psychoactive substances. They are often sold as designated legal or nondrug products, such as incense, plant food, or bath salts, with labeling such as "Not for Human Consumption" or "For Use in Research Only." The prevalence of use of novel drugs of abuse is difficult to determine because specific drugs, compounds, and availability of these drugs are constantly evolving. Changes in chemical structures lead to heterogeneity in physiologic response and clinical symptoms, even within the same category of drug. Pediatricians and emergency medicine physicians should be knowledgeable about novel drugs of abuse and their resulting symptoms for prevention and identification of their use.
Collapse
Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
| |
Collapse
|
34
|
Cardiac Dysrhythmias Associated With Substitutive Use of Loperamide: A Systematic Review. Am J Ther 2019; 26:e170-e182. [DOI: 10.1097/mjt.0000000000000585] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Lee VR, Vera A, Alexander A, Ruck B, Nelson LS, Wax P, Campleman S, Brent J, Calello DP. Loperamide misuse to avoid opioid withdrawal and to achieve a euphoric effect: high doses and high risk. Clin Toxicol (Phila) 2018; 57:175-180. [DOI: 10.1080/15563650.2018.1510128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Vincent R. Lee
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Ariel Vera
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Andreia Alexander
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bruce Ruck
- Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Lewis S. Nelson
- Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Paul Wax
- UT Southwestern Medical School, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | | | - Jeffrey Brent
- American College of Medical Toxicology, Phoenix, AZ, USA
- School of Medicine, University of Colorado, Aurora, CO, USA
| | - Diane P. Calello
- Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
| |
Collapse
|
36
|
Toce MS, Chai PR, Burns MM, Boyer EW. Pharmacologic Treatment of Opioid Use Disorder: a Review of Pharmacotherapy, Adjuncts, and Toxicity. J Med Toxicol 2018; 14:306-322. [PMID: 30377951 PMCID: PMC6242798 DOI: 10.1007/s13181-018-0685-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 12/27/2022] Open
Abstract
Opioid use disorder continues to be a significant source of morbidity and mortality in the USA and the world. Pharmacologic treatment with methadone and buprenorphine has been shown to be effective at retaining people in treatment programs, decreasing illicit opioid use, decreasing rates of hepatitis B, and reducing all cause and overdose mortality. Unfortunately, barriers exist in accessing these lifesaving medications: users wishing to start buprenorphine therapy require a waivered provider to prescribe the medication, while some states have no methadone clinics. As such, users looking to wean themselves from opioids or treat their opioid dependence will turn to alternative agents. These agents include using prescription medications, like clonidine or gabapentin, off-label, or over the counter drugs, like loperamide, in supratherapeutic doses. This review provides information on the pharmacology and the toxic effects of pharmacologic agents that are used to treat opioid use disorder. The xenobiotics reviewed in depth include buprenorphine, clonidine, kratom, loperamide, and methadone, with additional information provided on lofexidine, akuamma seeds, kava, and gabapentin.
Collapse
Affiliation(s)
- Michael S Toce
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Peter R Chai
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Edward W Boyer
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
37
|
Gauvin DV, Zimmermann ZJ, Baird TJ. In further defense of nonclinical abuse liability testing of biologics. Regul Toxicol Pharmacol 2018; 101:103-120. [PMID: 30465804 DOI: 10.1016/j.yrtph.2018.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/13/2018] [Accepted: 11/15/2018] [Indexed: 01/12/2023]
Abstract
Risk assessment is not a choice. Drug Abuse Liability (DAL) is mandated under international and national drug control statutes for all drugs targeting the CNS. Once administered to humans many biologics may have long-lived or permanent physiological effects that make DAL testing arduous. We respond to premises of a recently published position on DAL testing of biologics by de Zafra et al. (2018). We propose that, at a minimum, Sponsors submitting a Biologics Licensure Application (BLA) must think "outside the box" and include differential study designs for the same three core small NME assays detailed in the current DAL guidelines (self-administration, drug discrimination, and dependence liability). Abuse liability testing for drug scheduling decisions for marketing approval are not excluded or limited from risk assessment analysis simply because the entity is a biologic. In fact, more robust study designs may be necessary to address alterations in the reinforcing and discriminative stimulus effects of common drugs of abuse, as well as the dependence liability of the biologic, itself.
Collapse
|
38
|
|
39
|
Schifano F, Chiappini S. Is there such a thing as a 'lope' dope? Analysis of loperamide-related European Medicines Agency (EMA) pharmacovigilance database reports. PLoS One 2018; 13:e0204443. [PMID: 30286103 PMCID: PMC6171858 DOI: 10.1371/journal.pone.0204443] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 09/07/2018] [Indexed: 12/02/2022] Open
Abstract
Background Among over-the-counter (OTC) drugs, loperamide has recently emerged for its potential of misuse and cardiotoxicity issues. Hence, we aimed here at assessing the loperamide-related cases being reported to the EMA's EudraVigilance (EV) database. Methods All spontaneous EV reports relating to loperamide misuse/abuse/dependence/withdrawal and cardiotoxicity issues were here retrieved, performing a descriptive analysis. Findings During the years 2005–2017, EV collected a number of 1,983 (out of a total of 7,895; 25.11%) loperamide-related misuse/abuse/dependence/withdrawal adverse drug reaction (ADR) reports, with a progressively increasing trend since 2014. Most cases were classified as drug use disorder (37.4%) or intentional overdose (25.4%). Loperamide was used on its own in 41.9% of cases; remaining, polydrug, cases included antidepressants; benzodiazepines; and other OTCs. Some 1,085 (1,085/7,895 = 13.7%) cardiovascular ADRs were reported, being conduction abnormalities and EKG alterations the most frequently identified. Conclusions EV data may support the levels of concern relating to loperamide potential of abuse and associated cardiotoxicity issues.
Collapse
Affiliation(s)
- Fabrizio Schifano
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, United Kingdom
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Herts, United Kingdom
- Casa di Cura Villa Rosa, Viterbo (VT), Italy
- * E-mail:
| |
Collapse
|
40
|
Methadone Management of Withdrawal Associated With Loperamide-related Opioid Use Disorder. J Addict Med 2018; 11:402-404. [PMID: 28574864 DOI: 10.1097/adm.0000000000000325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Loperamide hydrochloride is an over-the-counter anti-diarrheal agent, acting via mu-opioid receptor agonist effects in the intestinal myenteric plexus. Although preclinical investigations suggested that abuse liability associated with loperamide use is low, there are increasing numbers of cases reported to the US Food and Drug Administration, of abuse, dependence, and withdrawal associated with loperamide use. A case of a patient with opioid use disorder, that is, in the form of protracted loperamide excess use, requiring management of withdrawal with methadone is presented. Management of withdrawal from abrupt loperamide discontinuation has not been discussed in the literature. Long-term treatment issues are also described.
Collapse
|
41
|
Marraffa JM, Stork CM, Hoffman RS, Su MK. Poison control center experience with tianeptine: an unregulated pharmaceutical product with potential for abuse. Clin Toxicol (Phila) 2018; 56:1155-1158. [DOI: 10.1080/15563650.2018.1476694] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Jeanna M. Marraffa
- Department of Emergency Medicine, Upstate Medical University, Upstate NY Poison Center, Syracuse, NY, USA
| | - Christine M. Stork
- Department of Emergency Medicine, Upstate Medical University, Upstate NY Poison Center, Syracuse, NY, USA
| | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
| | - Mark K. Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA
- New York City Poison Control Center, New York, NY, USA
| |
Collapse
|
42
|
Schifano F, Chiappini S, Corkery JM, Guirguis A. Abuse of Prescription Drugs in the Context of Novel Psychoactive Substances (NPS): A Systematic Review. Brain Sci 2018; 8:E73. [PMID: 29690558 PMCID: PMC5924409 DOI: 10.3390/brainsci8040073] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 04/11/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023] Open
Abstract
Recently, a range of prescription and over-the-counter drugs have been reportedly used as Novel Psychoactive Substances (NPS), due to their potential for abuse resulting from their high dosage/idiosyncratic methods of self-administration. This paper provides a systematic review of the topic, focusing on a range of medications which have emerged as being used recreationally, either on their own or in combination with NPS. Among gabapentinoids, pregabalin may present with higher addictive liability levels than gabapentin, with pregabalin being mostly identified in the context of opioid, polydrug intake. For antidepressants, their dopaminergic, stimulant-like, bupropion activities may explain their recreational value and diversion from the therapeutic intended use. In some vulnerable clients, a high dosage of venlafaxine (‘baby ecstasy’) is ingested for recreational purposes, whilst the occurrence of a clinically-relevant withdrawal syndrome may be a significant issue for all venlafaxine-treated patients. Considering second generation antipsychotics, olanzapine appears to be ingested at very large dosages as an ‘ideal trip terminator’, whilst the immediate-release quetiapine formulation may possess proper abuse liability levels. Within the image- and performance- enhancing drugs (IPEDs) group, the beta-2 agonist clenbuterol (‘size zero pill’) is reported to be self-administered for aggressive slimming purposes. Finally, high/very high dosage ingestion of the antidiarrhoeal loperamide has shown recent increasing levels of popularity due to its central recreational, anti-withdrawal, opiatergic effects. The emerging abuse of prescription drugs within the context of a rapidly modifying drug scenario represents a challenge for psychiatry, public health and drug-control policies.
Collapse
Affiliation(s)
- Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire AL10 9AB, UK.
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire AL10 9AB, UK.
| | - John M Corkery
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire AL10 9AB, UK.
| | - Amira Guirguis
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire AL10 9AB, UK.
| |
Collapse
|
43
|
Abstract
This chapter describes how new psychoactive substances (NPS) have been involved in fatal intoxications from 2010 and onwards. It summarizes the circumstances, antemortem symptoms, and adverse effects that have led to death after ingestion of one or more NPS and tabulates concentrations, and postmortem findings from these intoxications.Consumption of NPS exerts health problems and unknown risks for the users. Data on toxicity of many NPS are scarce or nonexistent and long-term toxicity and risks are still largely unknown. In addition, purity and composition of products containing NPS are often inconsistent or not known, which places users at high risk as evidenced by hospital emergency admissions and deaths.The most serious threat to drug users are the synthetic opioids that with strong central nervous depressant effects have caused numerous accidental deaths spread over the entire globe. The synthetic cannabinoids seem to be the most unpredictable with no clear toxidrome and unknown or poorly understood mechanisms of toxicity, but with adverse effects pointing toward the cardiovascular system. The toxidromes commonly encountered after ingestion of cathinones and phenethylamines are of sympathomimetic and hallucinogenic character, which includes risk of developing a serotonin syndrome, excited delirium, and life-threatening cardiovascular effects. In comparison to their conventional "parent" drug, i.e., heroin, cannabis, and amphetamine, most NPS appear to exhibit more severe adverse effects. The deaths attributed to NPS have dramatically increased in the last years. In our opinion, this is because of the shift from synthetic cannabinoids and cathinones to the even more toxic and dangerously potent fentanyl analogues.
Collapse
|
44
|
Characterization of loperamide-mediated block of hERG channels at physiological temperature and its proarrhythmia propensity. J Pharmacol Toxicol Methods 2017; 88:109-122. [DOI: 10.1016/j.vascn.2017.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/14/2017] [Accepted: 08/18/2017] [Indexed: 02/05/2023]
|
45
|
Eggleston W, Marraffa JM, Nacca N. In response to: “Loperamide metabolite-induced cardiomyopathy and QTc prolongation”. Clin Toxicol (Phila) 2017; 55:1023. [DOI: 10.1080/15563650.2017.1334917] [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]
Affiliation(s)
- William Eggleston
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Nicholas Nacca
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| |
Collapse
|
46
|
Yéléhé-Okouma M, Martini H, Lemarié J, Labroca P, Petitpain N, Gibaja V, Paille F, Gillet P. Opioid substitution therapy or hidden opioids are a minefield for nalmefene: an atypical case series of 11 patients in Lorraine. Fundam Clin Pharmacol 2017; 31:574-579. [DOI: 10.1111/fcp.12286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/07/2017] [Accepted: 03/16/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Melissa Yéléhé-Okouma
- Centre Régional de Pharmacovigilance de Lorraine; Laboratoire de Pharmacologie Clinique et de Toxicologie; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| | - Hervé Martini
- Service de Médecine L / Addictologie CHRU de Nancy; Hôpitaux de Brabois - Bâtiment Philippe Canton; Rue du Morvan 54500 Vandœuvre-lès-Nancy France
| | - Jérémie Lemarié
- Service de Réanimation Médicale; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| | - Pierre Labroca
- Service de Réanimation Médicale; Hôpital de Mercy; CHR Metz-Thionville; 1, allée du château, CS 45001 57085 Metz cedex 03 France
| | - Nadine Petitpain
- Centre Régional de Pharmacovigilance de Lorraine; Laboratoire de Pharmacologie Clinique et de Toxicologie; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| | - Valérie Gibaja
- Centre d'Addictovigilance de Nancy; Hôpital Central; Pavillon Bruillatre-Balbatre, 29, avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 NANCY Cedex France
| | - François Paille
- Service de Médecine L / Addictologie CHRU de Nancy; Hôpitaux de Brabois - Bâtiment Philippe Canton; Rue du Morvan 54500 Vandœuvre-lès-Nancy France
| | - Pierre Gillet
- Centre Régional de Pharmacovigilance de Lorraine; Laboratoire de Pharmacologie Clinique et de Toxicologie; CHRU de Nancy; Hôpital Central; 29 avenue du Maréchal de Lattre de Tassigny, CO 60034 54035 Nancy cedex France
| |
Collapse
|
47
|
Loperamide-Induced Torsades de Pointes: A Case Series. J Emerg Med 2017; 53:339-344. [DOI: 10.1016/j.jemermed.2017.04.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/29/2017] [Accepted: 04/25/2017] [Indexed: 11/24/2022]
|
48
|
Chhabra N, Aks SE. Current Opiate and Opioid Hazards in Children and Adolescents. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
49
|
Beck R, Atherton DS, Kloda S, Dye DW, Robinson CA. Quantification of Loperamide by Gas Chromatography Mass Spectrometry. J Anal Toxicol 2017; 41:729-734. [DOI: 10.1093/jat/bkx069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 01/06/2023] Open
|
50
|
Hua S, Dias TH, Pepperall DG, Yang Y. Topical Loperamide-Encapsulated Liposomal Gel Increases the Severity of Inflammation and Accelerates Disease Progression in the Adjuvant-Induced Model of Experimental Rheumatoid Arthritis. Front Pharmacol 2017; 8:503. [PMID: 28824428 PMCID: PMC5539122 DOI: 10.3389/fphar.2017.00503] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 07/17/2017] [Indexed: 12/14/2022] Open
Abstract
This study evaluates the prophylactic effect of the peripherally-selective mu-opioid receptor agonist, loperamide, administered topically in a liposomal gel formulation on pain, inflammation, and disease progression in the adjuvant-induced model of experimental rheumatoid arthritis in female Lewis rats. In a randomized, blinded and controlled animal trial, AIA rats were divided into six groups consisting of eleven rats per group based on the following treatments: loperamide liposomal gel, free loperamide gel, empty liposomal gel, diclofenac gel (Voltaren®), no treatment, and naive control. Topical formulations were applied daily for a maximum of 17 days-starting from day 0 at the same time as immunization. The time course of the effect of the treatments on antinocieption and inflammation was assessed using a paw pressure analgesiometer and plethysmometer, respectively. Arthritis progression was scored daily using an established scoring protocol. At the end of the study, hind paws were processed for histological analysis. Administration of loperamide liposomal gel daily across the duration of the study produced significant peripheral antinociception as expected; however, increased the severity of inflammation and accelerated arthritis progression. This was indicated by an increase in paw volume, behavioral and observational scoring, and histological analysis compared to the control groups. In particular, histology results showed an increase in pannus formation and synovial inflammation, as well as an upregulation of markers of inflammation and angiogenesis. These findings may have implications for the use of loperamide and other opioids in arthritis and potentially other chronic inflammatory diseases.
Collapse
Affiliation(s)
- Susan Hua
- School of Biomedical Sciences and Pharmacy, University of NewcastleCallaghan, NSW, Australia.,Hunter Medical Research InstituteNew Lambton Heights, NSW, Australia
| | - Thilani H Dias
- School of Biomedical Sciences and Pharmacy, University of NewcastleCallaghan, NSW, Australia
| | - Debbie-Gai Pepperall
- School of Biomedical Sciences and Pharmacy, University of NewcastleCallaghan, NSW, Australia
| | - Yuan Yang
- Centre for Inflammatory Diseases, Monash UniversityMelbourne, VIC, Australia
| |
Collapse
|