1
|
Murata T, Uno K, Nagamine T. Guanfacine Used With Antipsychotics May Cause Bradycardia to Become Apparent After Discontinuation of Antipsychotics. Am J Ther 2024; 31:e440-e444. [PMID: 38241083 DOI: 10.1097/mjt.0000000000001654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
|
2
|
Chou AK, Chiu CC, Wang JJ, Chen YW, Hung CH. Synergistic interaction of guanfacine or dexmedetomidine coadministered with lidocaine for cutaneous analgesia in rats. Neurol Res 2024; 46:662-668. [PMID: 38591725 DOI: 10.1080/01616412.2024.2340881] [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: 10/10/2023] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND This study examined the cutaneous analgesic effects of lidocaine co-injected with guanfacine and its comparison with dexmedetomidine. METHODS Cutaneous analgesic effects are quantified through the blocking effects of the cutaneous trunci muscle reflex against skin pinpricks in rats. The dose-response curves of guanfacine, dexmedetomidine, and lidocaine were constructed and drug-drug interactions were analyzed by the ED50 isobologram. RESULTS Subcutaneous injections of guanfacine, dexmedetomidine, and lidocaine produced dose-dependently nociceptive/sensory blockade. On the ED50 (50% effective dose) basis, the potency rankings of the drug are dexmedetomidine (0.09 [0.08-0.11] μmol/kg) > guanfacine (3.98 [2.96-5.34] μmol/kg) > lidocaine (25.40 [23.51-27.44] μmol/kg) (p < 0.01). On their equipotent doses (ED25, ED50, and ED75), the duration of sensory blockade induced by guanfacine or dexmedetomidine was longer than lidocaine's (p < 0.01). Both guanfacine and dexmedetomidine showed synergistic effects with lidocaine. CONCLUSIONS We showed that guanfacine elicits dose-dependent cutaneous analgesia when administered subcutaneously. Lidocaine is less potent than guanfacine or dexmedetomidine. Both guanfacine and dexmedetomidine enhance the potency and duration of lidocaine. Better synergistic responses we are getting with guanfacine plus lidocaine.
Collapse
Affiliation(s)
- An-Kuo Chou
- Department of Anesthesiology, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chong-Chi Chiu
- Department of General Surgery & Department of Medical Education and Research, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Jhi-Joung Wang
- Department of Anesthesiology, Tri-Service General Hospital & National Defense Medical Center, Taipei, Taiwan
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chen
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Physical Therapy, College of Health Care, China Medical University, Taichung, Taiwan
| | - Ching-Hsia Hung
- Department of Physical Therapy, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
3
|
Hirayama I, Kamijo Y, Abe H, Nonaka M, Yano T, Ishii M, Tominaga Y. Guanfacine poisoning resulting in transient ST-segment elevation: a case report. Int J Emerg Med 2024; 17:60. [PMID: 38671356 PMCID: PMC11046827 DOI: 10.1186/s12245-024-00634-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/21/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Guanfacine is an alpha-2 adrenergic agonist that decreases norepinephrine release and sympathetic outflow. With the increased use of guanfacine for attention-deficit hyperactivity disorder (ADHD), reports of guanfacine poisoning have also risen. CASE PRESENTATION A 15-year-old male (height: 170 cm, weight: 48 kg), who was taking 2 mg/day of guanfacine for ADHD, was brought to our emergency department after ingesting 40 tablets of guanfacine due to poor exam results. He presented with impaired consciousness and sinus bradycardia on an electrocardiogram (ECG), leading to diagnosis of guanfacine poisoning. Gastric lavage (5 L) was performed, and activated charcoal was administered. Although his consciousness gradually recovered, he developed ST-segment elevation on the ECG. Despite the absence of chest pain and elevated myocardial enzymes, coronary artery stenosis was not observed on coronary artery computed tomography. As his blood guanfacine level decreased, his ECG returned to normal. CONCLUSIONS This case highlights the need for careful monitoring of guanfacine poisoning patients due to the potential for various cardiovascular events.
Collapse
Affiliation(s)
- Ichiro Hirayama
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan.
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan.
| | - Yoshito Kamijo
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Hiroko Abe
- Department of Clinical Toxicology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
- Biodesign Inc, Tokyo, Japan
| | - Minaho Nonaka
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Tetsuhiro Yano
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Mitsuru Ishii
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| | - Yoshiteru Tominaga
- Department of Emergency Medicine, National Hospital Organization Saitama Hospital, 2-1 Suwa, Wako, Saitama, 351-0102, Japan
| |
Collapse
|
4
|
Inoue F, Okazaki Y, Kashiwa K, Ichiba T, Namera A. QT-Interval Prolongation Associated with Supratherapeutic Guanfacine Concentration: A Case Report. J Med Toxicol 2024; 20:218-221. [PMID: 38231419 PMCID: PMC10959869 DOI: 10.1007/s13181-023-00986-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/09/2023] [Accepted: 12/17/2023] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Guanfacine, an alpha-2 adrenergic agonist, is used to treat attention deficit hyperactivity disorder (ADHD). Although cardiovascular effects including hypotension and bradycardia are common adverse effects of guanfacine, the effect of guanfacine on QT intervals remains unclear. The association between the serum concentration of guanfacine and its toxicity has also not been fully investigated. CASE REPORT This is a case of a 21-year-old woman with ADHD who developed repeated presyncope 1 day before admission. She was taking 3 mg of extended-release guanfacine and 50 mg of sertraline. On admission, she had bradycardia and hypotension. An electrocardiogram (ECG) showed a QT interval of 0.68 s and a QTcF interval of 0.648 s. The QT intervals were manually measured and corrected by the Fridericia formula (QTcF = QT/RR1/3). Although she denied taking an overdose of guanfacine and other drugs, we suspected guanfacine toxicity. The serum guanfacine concentration was 13.0 ng/mL on admission and decreased to 3.2 ng/mL on day 1 and 0.4 ng/mL on day 2. Changes in QTcF intervals and her vital signs correlated with serum guanfacine concentrations. CONCLUSION Supratherapeutic serum guanfacine concentrations may induce QT prolongation.
Collapse
Affiliation(s)
- Fumiya Inoue
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan.
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-Ku, Hiroshima City, 730-8518, Japan
| | - Akira Namera
- Department of Forensic Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-Ku, Hiroshima City, 734-8553, Japan
| |
Collapse
|
5
|
DeCoster MM, Spiller HA, Badeti J, Casavant MJ, Rine NI, Michaels NL, Zhu M, Smith GA. Pediatric ADHD Medication Errors Reported to United States Poison Centers, 2000 to 2021. Pediatrics 2023; 152:e2023061942. [PMID: 37718991 DOI: 10.1542/peds.2023-061942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 09/19/2023] Open
Abstract
OBJECTIVES To investigate the characteristics and trends of out-of-hospital attention-deficit/hyperactivity disorder (ADHD) medication-related therapeutic errors among youth <20 years old reported to US poison centers. METHODS National Poison Data System data from 2000 through 2021 were analyzed. Population-based rates were calculated using US census data. RESULTS There were 124 383 ADHD medication-related therapeutic errors reported to US poison centers from 2000 through 2021, with the annual frequency increasing by 299.0% during that period. Two-thirds (66.6%) of the 87 691 first-ranked exposures involved children 6 to 12 years old, three-fourths (76.4%) were among males, and half (50.5%) involved amphetamines and related compounds. Most (79.7%) therapeutic errors were single-substance exposures. Although most (82.7%) individuals did not receive treatment in a health care facility (HCF), 2.3% were admitted to a HCF and 4.2% had a serious medical outcome. Children <6 years old were more likely to experience a serious medical outcome (odds ratio = 2.1; 95% confidence interval: 1.9-2.3) or be admitted to a HCF (odds ratio = 3.4; 95% confidence interval: 3.0-3.7) than 6 to 19-year-olds. The most common scenarios were "inadvertently taken or given medication twice" (53.9%), followed by "inadvertently taken or given someone else's medication" (13.4%), and "wrong medication taken or given" (12.9%). CONCLUSIONS The frequency of cases reported to poison centers of pediatric out-of-hospital therapeutic errors related to ADHD medications increased by almost 300% during the 22-year study period and is likely attributable to increased prescribing of these medications. Because therapeutic errors are preventable, more attention should be given to patient and caregiver education and development of improved child-resistant medication dispensing and tracking systems.
Collapse
Affiliation(s)
- Mikaela M DeCoster
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Jaahnavi Badeti
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Marcel J Casavant
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Natalie I Rine
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Nichole L Michaels
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Motao Zhu
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Gary A Smith
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
- Child Injury Prevention Alliance, Columbus, Ohio
| |
Collapse
|
6
|
Schwartz KR, Donovan AL, Hayes BD, Uchida M, Rosen JB. Case 16-2023: A 13-Year-Old Boy with Depression and Hypotension. N Engl J Med 2023; 388:1992-1999. [PMID: 37224201 PMCID: PMC10965308 DOI: 10.1056/nejmcpc2201237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Kevin R Schwartz
- From the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), Pharmacy (B.D.H.), and Behavioral Health (J.B.R.), Massachusetts General Hospital, and the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), and Behavioral Health (J.B.R.), Harvard Medical School - both in Boston
| | - Abigail L Donovan
- From the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), Pharmacy (B.D.H.), and Behavioral Health (J.B.R.), Massachusetts General Hospital, and the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), and Behavioral Health (J.B.R.), Harvard Medical School - both in Boston
| | - Bryan D Hayes
- From the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), Pharmacy (B.D.H.), and Behavioral Health (J.B.R.), Massachusetts General Hospital, and the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), and Behavioral Health (J.B.R.), Harvard Medical School - both in Boston
| | - Mai Uchida
- From the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), Pharmacy (B.D.H.), and Behavioral Health (J.B.R.), Massachusetts General Hospital, and the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), and Behavioral Health (J.B.R.), Harvard Medical School - both in Boston
| | - Joy B Rosen
- From the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), Pharmacy (B.D.H.), and Behavioral Health (J.B.R.), Massachusetts General Hospital, and the Departments of Pediatrics (K.R.S.), Emergency Medicine (K.R.S., B.D.H.), Psychiatry (A.L.D., M.U.), and Behavioral Health (J.B.R.), Harvard Medical School - both in Boston
| |
Collapse
|
7
|
Delayed Signs and Symptoms of Extended Release Guanfacine Overdose in Two Adolescent Patients: Implications of Monitoring on the Psychiatry Unit. Case Rep Psychiatry 2022; 2022:2149301. [PMID: 35371580 PMCID: PMC8975677 DOI: 10.1155/2022/2149301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/14/2022] [Indexed: 11/17/2022] Open
Abstract
Guanfacine is a selective alpha-2a adrenoreceptor agonist that with overdose can cause symptoms ranging from mild sedation to coma, respiratory depression, hyporeflexia, hypotonia, bradycardia, and hypotension. Despite a well-defined and predictable toxidrome, variations can be seen based on multiple factors including age, quantity ingested, organ functions, coingestions, time since ingestion, and specific dosage form. Here, we describe two cases of delayed presentation of extended release guanfacine toxicity and highlight the variations encountered in the toxidrome presentation. These cases bring to attention the importance of maintaining a high suspicion for such atypical presentations, keeping in mind the limitations of managing these complications on an inpatient psychiatric unit.
Collapse
|
8
|
Snyder MH, Ross JA, Rege SV, Holstege CP. Comment on "Pediatric guanfacine exposures reported to the National Poison Data System, 2000-2016". Clin Toxicol (Phila) 2020; 59:767. [PMID: 33135517 DOI: 10.1080/15563650.2020.1837387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- M Harrison Snyder
- Medical Toxicology Department, University of Virginia, Charlottesville, VA, USA
| | - Jennifer A Ross
- Medical Toxicology Department, University of Virginia, Charlottesville, VA, USA
| | - Saumitra V Rege
- Medical Toxicology Department, University of Virginia, Charlottesville, VA, USA
| | | |
Collapse
|
9
|
Downs JW, Wills BK, Cumpston KL, Wolf CE, Rose SR. Pediatric Guanfacine Toxicity with Severely Elevated Plasma Concentration. J Child Adolesc Psychopharmacol 2020; 30:473-474. [PMID: 32667829 DOI: 10.1089/cap.2020.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- John W Downs
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - Brandon K Wills
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - Kirk L Cumpston
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - Carl E Wolf
- Toxicology Laboratory, Department of Pathology, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| | - S Rutherfoord Rose
- Division of Clinical Toxicology, Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond, Virginia, USA.,Funding: The authors received no funding towards the creation of this article
| |
Collapse
|