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Pavelka MM, Kohr R. Potential Dextromethorphan-Induced Serotonin Syndrome Leading to Homicide and Suicide. Acad Forensic Pathol 2024; 14:21-25. [PMID: 38505641 PMCID: PMC10947710 DOI: 10.1177/19253621231224531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/17/2023] [Indexed: 03/21/2024]
Abstract
Limited case reports have been published regarding serotonin syndrome due to the combined effects of supratherapeutic levels of dextromethorphan and selective serotonin reuptake inhibitor. We report a case of an adolescent with postmortem findings suggestive of a diagnosis of serotonin syndrome-induced psychosis associated with a double homicide and suicide. Postmortem toxicology of the suicide victim was remarkable for elevated serotonergic metabolites of fluoxetine and dextromethorphan in a 14-year-old male.
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Affiliation(s)
- Matthew M. Pavelka
- Matthew M. Pavelka, Indiana University School of Medicine-Terre Haute, IN 46202,
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2
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Shin EJ, Nguyen BT, Jeong JH, Hoai Nguyen BC, Tran NKC, Sharma N, Kim DJ, Nah SY, Lichtstein D, Nabeshima T, Kim HC. Ouabain inhibitor rostafuroxin attenuates dextromethorphan-induced manic potential. Food Chem Toxicol 2021; 158:112657. [PMID: 34740715 DOI: 10.1016/j.fct.2021.112657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 02/08/2023]
Abstract
Dextromethorphan (DM) abuse produces mania-like symptoms in humans. ERK/Akt signaling activation involved in manic potential can be attenuated by the inhibition of ouabain-like cardiac steroids. In this study, increased phosphorylations of ERK/Akt and hyperlocomotion induced by DM (30 mg/kg, i.p./day × 7) were significantly protected by the ouabain inhibitor rostafuroxin (ROSTA), suggesting that DM induces the manic potential. ROSTA significantly attenuated DM-induced protein kinase C δ (PKCδ) phosphorylation, GluN2B (i.e., MDA receptor subunit) expression, and phospho-PKCδ/GluN2B interaction. DM instantly upregulated the nuclear factor erythroid-2-related factor 2 (Nrf2)-dependent system. However, DM reduced Nrf2 nuclear translocation, Nrf2 DNA binding activity, γ-glutamylcysteine mRNA expression, and subsequent GSH/GSSG level and enhanced oxidative parameters following 1-h of administration. ROSTA, PKCδ inhibitor rottlerin, and GluN2B inhibitor traxoprodil significantly attenuated DM-induced alterations in Nrf2-related redox parameters and locomotor activity induced by DM in wild-type mice. Importantly, in PKCδ knockout mice, DM failed to alter the above parameters. Further, ROSTA and traxoprodil also failed to enhance PKCδ depletion effect, suggesting that PKCδ is a critical target for the anti-manic potential of ROSTA or GluN2B antagonism. Our results suggest that ROSTA inhibits DM-induced manic potential by attenuating ERK/Akt activation, GluN2B/PKCδ signalings, and Nrf2-dependent system.
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Affiliation(s)
- Eun-Joo Shin
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon, 24341, Republic of Korea
| | - Bao-Trong Nguyen
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon, 24341, Republic of Korea
| | - Ji Hoon Jeong
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, College of Medicine, Chung-Ang University, Seoul, 06974, Republic of Korea.
| | - Bao-Chau Hoai Nguyen
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon, 24341, Republic of Korea
| | - Ngoc Kim Cuong Tran
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon, 24341, Republic of Korea
| | - Naveen Sharma
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon, 24341, Republic of Korea; Department of Global Innovative Drugs, Graduate School of Chung-Ang University, College of Medicine, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - Dae-Joong Kim
- Department of Anatomy and Cell Biology, Medical School, Kangwon National University, Chunchon, 24341, Republic of Korea
| | - Seung-Yeol Nah
- Ginsentology Research Laboratory and Department of Physiology, College of Veterinary Medicine and Bio/Molecular Informatics Center, Konkuk University, Seoul, 05029, Republic of Korea
| | - David Lichtstein
- Walter and Greta Stiel Chair in Heart Studies, Dean, Faculty of Medicine 2013-2017, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Toshitaka Nabeshima
- Advanced Diagnostic System Research Laboratory, Fujita Health University Graduate School of Health Science, Toyoake, 470-1192, Japan
| | - Hyoung-Chun Kim
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon, 24341, Republic of Korea.
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Shin EJ, Jeong JH, Nguyen BT, Sharma N, Nah SY, Chung YH, Lee Y, Byun JK, Nabeshima T, Ko SK, Kim HC. Ginsenoside Re Protects against Serotonergic Behaviors Evoked by 2,5-Dimethoxy-4-iodo-amphetamine in Mice via Inhibition of PKCδ-Mediated Mitochondrial Dysfunction. Int J Mol Sci 2021; 22:ijms22137219. [PMID: 34281274 PMCID: PMC8268959 DOI: 10.3390/ijms22137219] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023] Open
Abstract
It has been recognized that serotonin 2A receptor (5-HT2A) agonist 2,5-dimethoxy-4-iodo-amphetamine (DOI) impairs serotonergic homeostasis. However, the mechanism of DOI-induced serotonergic behaviors remains to be explored. Moreover, little is known about therapeutic interventions against serotonin syndrome, although evidence suggests that ginseng might possess modulating effects on the serotonin system. As ginsenoside Re (GRe) is well-known as a novel antioxidant in the nervous system, we investigated whether GRe modulates 5-HT2A receptor agonist DOI-induced serotonin impairments. We proposed that protein kinase Cδ (PKCδ) mediates serotonergic impairments. Treatment with GRe or 5-HT2A receptor antagonist MDL11939 significantly attenuated DOI-induced serotonergic behaviors (i.e., overall serotonergic syndrome behaviors, head twitch response, hyperthermia) by inhibiting mitochondrial translocation of PKCδ, reducing mitochondrial glutathione peroxidase activity, mitochondrial dysfunction, and mitochondrial oxidative stress in wild-type mice. These attenuations were in line with those observed upon PKCδ inhibition (i.e., pharmacologic inhibitor rottlerin or PKCδ knockout mice). Furthermore, GRe was not further implicated in attenuation mediated by PKCδ knockout in mice. Our results suggest that PKCδ is a therapeutic target for GRe against serotonergic behaviors induced by DOI.
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Affiliation(s)
- Eun-Joo Shin
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon 24341, Korea; (E.-J.S.); (B.-T.N.); (N.S.)
| | - Ji Hoon Jeong
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, College of Medicine, Chung-Ang University, Seoul 06974, Korea;
| | - Bao-Trong Nguyen
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon 24341, Korea; (E.-J.S.); (B.-T.N.); (N.S.)
| | - Naveen Sharma
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon 24341, Korea; (E.-J.S.); (B.-T.N.); (N.S.)
- Department of Global Innovative Drugs, Graduate School of Chung-Ang University, College of Medicine, Chung-Ang University, Seoul 06974, Korea;
| | - Seung-Yeol Nah
- Ginsentology Research Laboratory, Department of Physiology, College of Veterinary Medicine and Bio/Molecular Informatics Center, Konkuk University, Seoul 05029, Korea;
| | - Yoon Hee Chung
- Department of Anatomy, College of Medicine, Chung-Ang University, Seoul 06974, Korea;
| | - Yi Lee
- Department of Industrial Plant Science & Technology, Chungbuk National University, Chungju 28644, Korea;
| | - Jae Kyung Byun
- Korea Society of Forest Environmental Research, Namyanju 12106, Korea;
| | - Toshitaka Nabeshima
- Advanced Diagnostic System Research Laboratory, Fujita Health University Graduate School of Health Science, Toyoake 470-1192, Japan;
| | - Sung Kwon Ko
- Department of Oriental Medical Food and Nutrition, Semyung University, Jecheon 27136, Korea
- Correspondence: (S.K.K.); (H.-C.K.); Tel.: +82-33-250-6917 (H.-C.K.); Fax: +82-33-259-5631 (H.-C.K.)
| | - Hyoung-Chun Kim
- Neuropsychopharmacology and Toxicology Program, College of Pharmacy, Kangwon National University, Chunchon 24341, Korea; (E.-J.S.); (B.-T.N.); (N.S.)
- Correspondence: (S.K.K.); (H.-C.K.); Tel.: +82-33-250-6917 (H.-C.K.); Fax: +82-33-259-5631 (H.-C.K.)
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Declercq PL, Eraldi JP, Beuzelin M, Gélinotte S, Marchalot A, Bougerol F, Allorge D, Loriot MA, Paret N, Mégarbane B, Rigaud JP. Severe serotonin syndrome caused by an interaction between an antidepressant and a cough syrup. Therapie 2021; 76:249-252. [DOI: 10.1016/j.therap.2020.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/09/2019] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
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Schifano F, Chiappini S, Miuli A, Mosca A, Santovito MC, Corkery JM, Guirguis A, Pettorruso M, Di Giannantonio M, Martinotti G. Focus on Over-the-Counter Drugs' Misuse: A Systematic Review on Antihistamines, Cough Medicines, and Decongestants. Front Psychiatry 2021; 12:657397. [PMID: 34025478 PMCID: PMC8138162 DOI: 10.3389/fpsyt.2021.657397] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/15/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Over the past 20 years or so, the drug misuse scenario has seen the emergence of both prescription-only and over-the-counter (OTC) medications being reported as ingested for recreational purposes. OTC drugs such as antihistamines, cough/cold medications, and decongestants are reportedly the most popular in being diverted and misused. Objective: While the current related knowledge is limited, the aim here was to examine the published clinical data on OTC misuse, focusing on antihistamines (e.g., diphenhydramine, promethazine, chlorpheniramine, and dimenhydrinate), dextromethorphan (DXM)- and codeine-based cough medicines, and the nasal decongestant pseudoephedrine. Methods: A systematic literature review was carried out with the help of Scopus, Web of Science databases, and the related gray literature. For data gathering purposes, both the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and PROSPERO guidelines were followed (PROSPERO identification code CRD42020209261). Results: After completion of the selection, eligibility, and screening phases, some 92 articles were here taken into consideration; case reports, surveys, and retrospective case series analyses were included. Findings were organized according to the specific OTC recorded. Most articles focused here on DXM (n = 54) and diphenhydramine (n = 12). When specified, dosages, route(s) of administration, toxicity symptoms (including both physical and psychiatric ones), and outcomes were here reported. Conclusion: Results from the systematic review showed that the OTC misusing issues are both widespread worldwide and popular; vulnerable categories include adolescents and young adults, although real prevalence figures remain unknown, due to a lack of appropriate monitoring systems. Considering the potential, and at times serious, adverse effects associated with OTC misusing issues, healthcare professionals should be vigilant, and ad hoc preventative actions should be designed and implemented.
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Affiliation(s)
- Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom.,Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Andrea Miuli
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Alessio Mosca
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Maria Chiara Santovito
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - John M Corkery
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, United Kingdom
| | - Amira Guirguis
- Swansea University Medical School, Institute of Life Sciences 2, Swansea University, Swansea, United Kingdom
| | - Mauro Pettorruso
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
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Ott M, Mannchen JK, Jamshidi F, Werneke U. Management of severe arterial hypertension associated with serotonin syndrome: a case report analysis based on systematic review techniques. Ther Adv Psychopharmacol 2019; 9:2045125318818814. [PMID: 30886699 PMCID: PMC6413434 DOI: 10.1177/2045125318818814] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 08/01/2018] [Indexed: 12/14/2022] Open
Abstract
Serotonin syndrome is thought to arise from serotonin excess. In many cases, symptoms are mild and self-limiting. But serotonin syndrome can become life threatening, when neuromuscular hyperexcitability spins out of control. Uncontainable neuromuscular hyperexcitability may lead to cardiovascular complications, linked to extreme changes in blood pressure. Currently, there is little guidance on how to control blood pressure in hyperserotonergic states. We report a case with treatment-resistant arterial hypertension, followed by a clinical review (using systematic review principles and techniques) of the available evidence from case reports published between 2004 and 2016 to identify measures to control arterial hypertension associated with serotonin syndrome. We conclude that classic antihypertensives may not be effective for the treatment of severe hypertension associated with serotonin syndrome. Benzodiazepines may lower blood pressure. Patients with severe hypertension not responding to benzodiazepines may benefit from cyproheptadine, propofol or both. In severe cases, higher cyproheptadine doses than currently recommended may be necessary.
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Affiliation(s)
- Michael Ott
- Department of Public Health and Clinical
Medicine – Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Julie K. Mannchen
- Department of Public Health and Clinical
Medicine – Family Medicine, Umeå University, Umeå, Sweden
| | | | - Ursula Werneke
- Sunderby Research Unit, Department of Clinical
Sciences – Psychiatry, Umeå University, Umeå, Sweden
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Abstract
Serotonin syndrome is an iatrogenic drug-induced synaptic serotonin concentration related toxidrome. A 29-year-old man developed agitation, tachycardia and myoclonus of limbs after an intramuscular injection of 100 mg tramadol. He had recently been given multiple medications, including dextromethorphan (DXM) by a private doctor for flu-like symptoms. The patient was stabilised with diazepam, midazolam and supportive treatment. Both tramadol and DXM could cause the serotonin syndrome, but usually in combination with monoamine oxidase inhibitors or serotonin reuptake inhibitors. This was the first reported case in the English literature of serotonin syndrome with tramadol and DXM. Therefore, a detailed drug history and knowledge of potential serotonergic drugs are important.
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Robo-Tripping: A Case of Robitussin Abuse in a Methadone Maintenance Patient. PSYCHOSOMATICS 2017; 58:544-550. [PMID: 28576306 DOI: 10.1016/j.psym.2017.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 11/23/2022]
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Bao S, Zhang J, Lin Z, Su K, Mo J, Hong L, Qian S, Chen L, Sun F, Wen C, Wu Q, Hu L, Lin G, Wang X. Serum metabolic changes in rats after intragastric administration of dextromethorphan. Biomed Chromatogr 2016; 31. [PMID: 27528536 DOI: 10.1002/bmc.3814] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 08/01/2016] [Accepted: 08/11/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Shihui Bao
- The Second Affiliated Hospital & Yuying Children's Hospital; Wenzhou Medical University; Wenzhou China
| | - Jing Zhang
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Zixia Lin
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Ke Su
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Jingjing Mo
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Lin Hong
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Shuyi Qian
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Lianguo Chen
- Department of Pharmacy; Wenzhou People's Hospital; Wenzhou China
| | - Fa Sun
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Congcong Wen
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
| | - Qing Wu
- The First Affiliated Hospital of Wenzhou Medical University; Wenzhou China
| | - Lufeng Hu
- The First Affiliated Hospital of Wenzhou Medical University; Wenzhou China
| | - Guanyang Lin
- The First Affiliated Hospital of Wenzhou Medical University; Wenzhou China
| | - Xianqin Wang
- Anlytical and Testing Center of Wenzhou Medical University; Wenzhou China
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Deaths due to abuse of dextromethorphan sold over-the-counter in Pakistan. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2016. [DOI: 10.1016/j.ejfs.2015.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Piątek A, Koziarska-Rościszewska M, Zawilska JB. Rekreacyjne używanie leków dostępnych w odręcznej sprzedaży: odurzanie i doping mózgu. ALCOHOLISM AND DRUG ADDICTION 2015. [DOI: 10.1016/j.alkona.2015.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Objective: To review dextromethorphan abuse patterns from 2002–2012 and emphasize the pharmacist's role in prevention, education, and sales surveillance. Data Sources: A literature search was conducted through PubMed (2002-November 2012), EMBASE (2002-November 2012), and International Pharmaceutical Abstracts (2002-November 2012), using the search term dextromethorphan abuse. The Drug Enforcement Administration and National Association of Boards of Pharmacy websites were searched for dextromethorphan abuse and legislative updates. The search was limited to a 10-year period to identify the most current case reports and studies. Study Selection and Data Extraction: The limits used were studies/case reports evaluating humans and published in the English language. Only studies and case reports that assessed dextromethorphan abuse were included in the review. Eight studies and 9 case reports met the inclusion criteria. Data Synthesis: Case reports and studies demonstrate that there are patterns associated with dextromethor phan abuse. A study using data reported to the National Poison Data System identified Coricidin as the most (65.5%) commonly abused dextromethorphan product until 2006; its abuse has decreased since that time (p < 0.0001). The most common abuse effects and toxicities cited in studies and case reports include agitation, confusion, central nervous system depression, tachycardia, hypertension, lethargy, psychosis, hallucinations, mydriasis, dizziness, and cardiotoxicity. One study identified that 96% of samples tested positive for other substances in addition to dextromethorphan. Coingestion of other substances is also common among dextromethorphan abusers. Conclusions: Case reports and studies demonstrate that there are patterns associated with dextromethorphan abuse. It is difficult to identify dextromethorphan as the causative agent of abuse effects because of coingestion of other substances. Studies should examine the pharmacist's role and the association between dextromethorphan sales restrictions and abuse patterns.
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Affiliation(s)
- Jennifer A Gershman
- JENNIFER A GERSHMAN PharmD CPh, Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, Nova Southeastern University, Ft. Lauderdale, FL
| | - Andrea D Fass
- ANDREA D FASS PharmD, Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, Nova Southeastern University
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Yust E, Slattery A. Cold and Cough Medications for Children: Dangerous and Over the Counter! CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Monte AA, Chuang R, Bodmer M. Dextromethorphan, chlorphenamine and serotonin toxicity: case report and systematic literature review. Br J Clin Pharmacol 2011; 70:794-8. [PMID: 21175434 DOI: 10.1111/j.1365-2125.2010.03747.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The aim of this review was to describe a patient with serotonin toxicity after an overdose of dextromethorphan and chlorphenamine and to perform a systematic literature review exploring whether dextromethorphan and chlorphenamine may be equally contributory in the development of serotonin toxicity in overdose. A Medline literature review was undertaken to identify cases of serotonin toxicity due to dextromethorphan and/or chlorphenamine. Case reports were included if they included information on the ingested dose or plasma concentrations of dextromethorphan and/or chlorphenamine, information about co-ingestions and detailed clinical information to evaluate for serotonin toxicity. Cases were reviewed by two toxicologists and serotonin toxicity, defined by the Hunter criteria, was diagnosed when appropriate. The literature was then reviewed to evaluate whether chlorphenamine may be a serotonergic agent. One hundred and fifty-five articles of dextromethorphan or chlorphenamine poisoning were identified. There were 23 case reports of dextromethorphan, of which 18 were excluded for lack of serotonin toxicity. No cases were identified in which serotonin toxicity could be solely attributed to chlorphenamine. This left six cases of dextrometorphane and/or chlorphenamine overdose, including our own, in which serotonin toxicity could be diagnosed based on the presented clinical information. In three of the six eligible cases dextromethorphan and chlorphenamine were the only overdosed drugs. There is substantial evidence from the literature that chlorphenamine is a similarly potent serotonin re-uptake inhibitor when compared with dextrometorphan. Chlorphenamine is a serotonergic medication and combinations of chlorphenamine and dextromethorphan may be dangerous in overdose due to an increased risk of serotonin toxicity.
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Affiliation(s)
- Andrew A Monte
- Rocky Mountain Poison and Drug Center, Denver University of Colorado Denver School of Medicine, Aurora, USA
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Monte AA, Chuang R, Bodmer M. Dextromethorphan, chlorphenamine and serotonin toxicity: case report and systematic literature review. Br J Clin Pharmacol 2011; 70:799-806. [PMID: 21175434 DOI: 10.1111/j.1365-2125.2010.03745.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The aim of this review was to describe a patient with serotonin toxicity after an overdose of dextromethorphan and chlorphenamine and to perform a systematic literature review exploring whether dextromethorphan and chlorphenamine may be equally contributory in the development of serotonin toxicity in overdose. A Medline literature review was undertaken to identify cases of serotonin toxicity due to dextromethorphan and/or chlorphenamine. Case reports were included if they included information on the ingested dose or plasma concentrations of dextromethorphan and/or chlorphenamine, information about co-ingestions and detailed clinical information to evaluate for serotonin toxicity. Cases were reviewed by two toxicologists and serotonin toxicity, defined by the Hunter criteria, was diagnosed when appropriate. The literature was then reviewed to evaluate whether chlorphenamine may be a serotonergic agent. One hundred and fifty-five articles of dextromethorphan or chlorphenamine poisoning were identified. There were 23 case reports of dextromethorphan, of which 18 were excluded for lack of serotonin toxicity. No cases were identified in which serotonin toxicity could be solely attributed to chlorphenamine. This left six cases of dextrometorphane and/or chlorphenamine overdose, including our own, in which serotonin toxicity could be diagnosed based on the presented clinical information. In three of the six eligible cases dextromethorphan and chlorphenamine were the only overdosed drugs. There is substantial evidence from the literature that chlorphenamine is a similarly potent serotonin re-uptake inhibitor when compared with dextrometorphan. Chlorphenamine is a serotonergic medication and combinations of chlorphenamine and dextromethorphan may be dangerous in overdose due to an increased risk of serotonin toxicity.
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Affiliation(s)
- Andrew A Monte
- Rocky Mountain Poison and Drug Center, Denver University of Colorado Denver School of Medicine, Aurora, USA
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16
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Abstract
Dextromethorphan is a nonprescription antitussive which has been gaining in popularity as an abused drug, because of the hallucinogenic, dissociative, and intoxicating effects it produces at high doses. This report describes a series of eight drivers arrested for driving under the influence of the combined effects of dextromethorphan and chlorpheniramine, and a further four drivers under the influence of dextromethorphan alone. In the combined dextromethorphan/chlorpheniramine cases, blood dextromethorphan concentrations ranged from 150 to 1220 ng/mL (n = 8; mean 676 ng/mL, median 670 ng/mL), and chlorpheniramine concentrations ranged from 70 to 270 ng/mL (n = 8; mean 200 ng/mL, median 180 ng/mL). The four cases without chlorpheniramine present had blood dextromethorphan concentrations between 190 and 1000 ng/mL (mean 570 ng/mL, median 545 ng/mL). Some drivers had therapeutic concentrations of other drugs present. Drivers generally displayed symptoms of central nervous system (CNS) depressant intoxication, and there was gross evidence of impairment in their driving, including weaving, leaving the lane of travel, failing to obey traffic signals, and involvement in collisions. Drug Recognition Expert opinions confirmed that the subjects were under the influence of a drug in the CNS-depressant category.
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Romanelli F, Smith KM. Dextromethorphan abuse: clinical effects and management. J Am Pharm Assoc (2003) 2009; 49:e20-5; quiz e26-7. [PMID: 19289333 DOI: 10.1331/japha.2009.08091] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the epidemiology, patient presentation, and clinical management associated with dextromethorphan (DM) abuse. DATA SOURCES PubMed/Medline search using terms dextromethorphan and abuse through July 2008, bibliographies of selected publications, epidemiology tracking databases. STUDY SELECTION By the authors. DATA EXTRACTION English language-published review articles, clinical trials, and case reports that described the epidemiologic and toxicologic profile of DM were included. DATA SYNTHESIS DM is a relatively inexpensive and easily accessible over-the-counter (OTC) medication intended for use as an antitussive. Increasingly, illicit use of the drug has been reported. At clinical doses, the drug produces few adverse effects. However, when abused in large quantities (>2 mg/kg), the drug has been associated with a dissociative effect similar to those described by ketamine and phencyclidine abusers. Massive ingestions of the drug may be associated with untoward effects, including tachycardia, hypertension, and respiratory depression. Overdose symptoms may also be associated with coformulated products such as antihistamines and sympathomimetic amines. Management is primarily supportive. Naloxone has been used to manage DM toxicity but with conflicting reports of effectiveness. CONCLUSION Recent reports indicate that DM is often abused by individuals seeking its dissociative effects. Clinicians should be aware of the abuse potential of DM. Pharmacists might be particularly cognizant of the risks involved with DM abuse as they control OTC access to the drug.
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Affiliation(s)
- Frank Romanelli
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY 40536, USA.
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Abstract
INTRODUCTION The ability of dextromethorphan to potentiate serotonin levels and lead to serotonin syndrome is well known but few case reports are published. The lack of published cases suggests therapeutic doses of these drugs are not enough to cause serotonin syndrome. We present two cases of serotonin syndrome associated with supra-therapeutic doses of dextromethorphan and therapeutic levels of a selective serotonin reuptake inhibitors (SSRI). CASE SERIES In case one, serum drug levels from admission revealed a dextromethorphan level of 950 ng/mL (normal < 5), escitalopram of 23 ng/mL (normal < 200), chlorpheniramine of 430 ng/mL (normal < 20) and undetectable levels of aripiprazole and benztropine. In case two, serum drug levels from admission revealed a dextromethorphan level of 2820 ng/mL, sertraline of 12.5 ng/mL (normal < 200), and caffeine of 1.4 microg/mL (normal < or = 9 microg/mL). DISCUSSION To our knowledge, these are the first cases to use serum levels of dextromethorphan and a SSRI to confirm dextromethorphan-induced serotonin syndrome. CONCLUSION Our cases suggest supra-therapeutic dextromethorphan doses with a therapeutic amount of a SSRI are required for serotonin syndrome. More work is needed to answer this question more completely.
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Affiliation(s)
- Anna R Schwartz
- University of Pittsburgh, Division of Medical Toxicology, UPMC Presbyterian, Pittsburgh, Pennsylvania 15213, USA
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Chyka PA, Erdman AR, Manoguerra AS, Christianson G, Booze LL, Nelson LS, Woolf AD, Cobaugh DJ, Caravati EM, Scharman EJ, Troutman WG. Dextromethorphan poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2008; 45:662-77. [PMID: 17849242 DOI: 10.1080/15563650701606443] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
The objective of this guideline is to assist poison center personnel in the appropriate out-of-hospital triage and initial out-of-hospital management of patients with a suspected ingestion of dextromethorphan by 1) describing the process by which an ingestion of dextromethorphan might be managed, 2) identifying the key decision elements in managing cases of dextromethorphan ingestion, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline applies to the ingestion of dextromethorphan alone. Co-ingestion of additional substances could require different referral and management recommendations depending on the combined toxicities of the substances. This guideline is based on an assessment of current scientific and clinical information. The expert consensus panel recognizes that specific patient care decisions might be at variance with this guideline and are the prerogative of the patient and the health professionals providing care, considering all of the circumstances involved. This guideline does not substitute for clinical judgment. The grade of recommendation is in parentheses. 1) All patients with suicidal intent, intentional abuse, or in cases in which a malicious intent is suspected (e.g., child abuse or neglect) should be referred to an emergency department (Grade D). 2) Patients who exhibit more than mild effects (e.g., infrequent vomiting or somnolence [lightly sedated and arousable with speaking voice or light touch]) after an acute dextromethorphan ingestion should be referred to an emergency department (Grade C). 3) Patients who have ingested 5-7.5 mg/kg should receive poison center-initiated follow-up approximately every 2 hours for up to 4 hours after ingestion. Refer to an emergency department if more than mild symptoms develop (Grade D). 4) Patients who have ingested more than 7.5 mg/kg should be referred to an emergency department for evaluation (Grade C). 5) If the patient is taking other medications likely to interact with dextromethorphan and cause serotonin syndrome, such as monoamine oxidase inhibitors or selective serotonin reuptake inhibitors, poison center-initiated follow-up every 2 hours for 8 hours is recommended (Grade D). 6) Patients who are asymptomatic and more than 4 hours have elapsed since the time of ingestion can be observed at home (Grade C). 7) Do not induce emesis (Grade D). 8) Do not use activated charcoal at home. Activated charcoal can be administered to asymptomatic patients who have ingested overdoses of dextromethorphan within the preceding hour. Its administration, if available, should only be carried out by health professionals and only if no contraindications are present. Do not delay transportation in order to administer activated charcoal (Grade D). 9) For patients who have ingested dextromethorphan and are sedated or comatose, naloxone, in the usual doses for treatment of opioid overdose, can be considered for prehospital administration, particularly if the patient has respiratory depression (Grade C). 10) Use intravenous benzodiazepines for seizures and benzodiazepines and external cooling measures for hyperthermia (>104 degrees F, >40 degrees C) for serotonin syndrome. This should be done in consultation with and authorized by EMS medical direction, by a written treatment protocol or policy, or with direct medical oversight (Grade C). 11) Carefully ascertain by history whether other drugs, such as acetaminophen, were involved in the incident and assess the risk for toxicity or for a drug interaction.
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Affiliation(s)
- Peter A Chyka
- American Association of Poison Control Centers, Washington, District of Columbia, USA
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Abstract
An 18-year-old male developed a severe serotonin syndrome after recreational ingestion of Coricidin HBP (chlorpheniramine 4 mg and dextromethorphan hydrobromide 30 mg). Propofol infusion rapidly normalized his agitation, neuromuscular hyperactivity, and autonomic instability. Confirmatory analysis demonstrated a dextromethorphan serum concentration of 930 ng/mL. Dextromethorphan can produce serotonin syndrome in the absence of another serotonergic drug.
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Mayhew M. Dextromethorphan Abuse. J Nurse Pract 2007. [DOI: 10.1016/j.nurpra.2007.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Bechtel LK, Holstege CP. Criminal poisoning: drug-facilitated sexual assault. Emerg Med Clin North Am 2007; 25:499-525; abstract x. [PMID: 17482030 DOI: 10.1016/j.emc.2007.02.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Drug-facilitated sexual assault (DFSA) is a complex and ever-prevalent problem presenting to emergency departments. Emergency personnel should consider DFSA in patients who are amnestic to the specific details of the event following a reported sexual assault. The presence of ethanol or a positive routine drug screen in a sexual assault victim does not exclude the potential of a surreptitious drug being present. In addition, a negative routine drug screen does not exclude all potential agents that are used in DFSA. This article discusses agents reported in DFSA. It is imperative for emergency personnel to clearly document the history and the presenting signs and symptoms to assist laboratory personnel to hone in and detect the correct agent used in a DFSA.
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Affiliation(s)
- Laura K Bechtel
- Blue Ridge Poison Center, University of Virginia Health System, Charlottesville, VA 22908-0774, USA
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Looper KJ. Potential Medical and Surgical Complications of Serotonergic Antidepressant Medications. PSYCHOSOMATICS 2007; 48:1-9. [PMID: 17209143 DOI: 10.1176/appi.psy.48.1.1] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Serotonergic antidepressants are the most widely used group of antidepressant medications. Although generally considered to have a favorable adverse-effect profile, serotonergic antidepressants are associated with potentially dangerous medical complications, some of which have only recently become apparent to patients and clinicians. This article reviews the association of serotonergic antidepressants and the following medical complications: syndrome of inappropriate antidiuretic hormone secretion, bleeding, serotonin syndrome, serotonin-discontinuation syndrome, and adverse pregnancy and neonatal effects. Physicians need to remain aware of these potential medical complications and integrate this information into their clinical decision-making, informed-consent process, baseline assessment, and follow-up monitoring.
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Affiliation(s)
- Karl J Looper
- Department of Psychiatry, McGill University, Montreal, Canada.
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