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Gul F, Shah M, Waqar M, Bassi R, Shah S, Sethi N. Severe Central Nervous System and Respiratory Depression in a Neonate Following Accidental Oral Ingestion of Brimonidine Tartrate. Cureus 2024; 16:e63124. [PMID: 39055420 PMCID: PMC11271756 DOI: 10.7759/cureus.63124] [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: 06/25/2024] [Indexed: 07/27/2024] Open
Abstract
Brimonidine is a third-generation alpha-2 adrenergic agonist and is classified as an ocular hypotensive agent. It is used for chronic glaucoma treatment by lowering intraocular pressure, crucial for preventing blindness. Brimonidine works by reducing aqueous humor production and increasing uveoscleral outflow. The improper use of brimonidine in children can result in severe adverse effects. If brimonidine eye drops are ingested orally, it can cause significant depression of the cardiorespiratory and central nervous systems. This is a case report of a 27-day-old neonate, who presented with central nervous system and respiratory depression after accidental ingestion of one drop of brimonidine tartrate ophthalmic solution. On arrival, he was having shallow breathing, a low Glasgow Coma Scale score, pinpoint pupils, and absent deep tendon reflexes. Gastric lavage was performed and supportive treatment was started. The patient showed gradual improvement and completely recovered within 48 hours.
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Affiliation(s)
- Faiza Gul
- Paediatrics, Lady Reading Hospital, Peshawar, PAK
| | - Mudassir Shah
- Paediatrics, Hayatabad Medical Complex, Peshawar, PAK
| | | | - Radhika Bassi
- Internal Medicine, Ross University School of Medicine, Bridgetown, BRB
| | - Safdar Shah
- Paediatrics, Lady Reading Hospital, Peshawar, PAK
| | - Nida Sethi
- Paediatrics, Lady Reading Hospital, Peshawar, PAK
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Bhullar J, Patel A, Chitithoti J, Venter F, Win T, Joolhar F. Clonidine Overdose as an Unusual Cause of Heart Failure. J Investig Med High Impact Case Rep 2022; 10:23247096221106856. [PMID: 35748424 PMCID: PMC9235301 DOI: 10.1177/23247096221106856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Clonidine is used as an antihypertensive medication due to its effect on
decreasing peripheral vascular resistance and therefore lowering blood pressure.
Alpha antagonism in the medulla and the posterior hypothalamus causing a
reduction in sympathetic activation allows for clonidine to be used as an
effective off-label treatment for attention-deficit/hyperactivity disorder
(ADHD). This is a case of a 28-year-old female with hypertension, ADHD, and
depression who developed acute heart failure with significant troponemia after
ingesting 30 pills of clonidine. We illustrate the possible rare diagnosis of
systolic heart failure and coronary vasospasm secondary to clonidine
overdose.
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Affiliation(s)
| | - Arti Patel
- Kern Medical Center, Bakersfield, CA, USA
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Toce MS, Freiman E, O'Donnell KA, Burns MM. Clinical Effects of Pediatric Clonidine Exposure: A Retrospective Cohort Study at a Single Tertiary Care Center. J Emerg Med 2020; 60:58-66. [PMID: 33036823 DOI: 10.1016/j.jemermed.2020.09.018] [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: 04/28/2020] [Revised: 07/08/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pediatric clonidine ingestions frequently result in emergency department visits and admission for cardiac monitoring. Detailed information on the clinical course and specifically time of vital sign abnormalities of these patients is lacking. OBJECTIVE The objective of this study was to provide descriptive analysis of the rates and times to vital sign abnormalities, treatment, disposition, and outcomes in a single-center cohort of pediatric patients with report of clonidine poisoning. METHODS We performed a retrospective cohort study of patients younger than 21 years who presented to a large, urban, tertiary care center with a report of single substance clonidine exposure between January 2004 and November 2017. Patients were dichotomized into younger (≤9 years or younger) and older (10-21 years) groups based on the expected physiologic and psychologic differences between older and younger children. RESULTS Eighty-eight patients met our inclusion criteria. Younger patients (≤9 years or younger; n = 47) were more likely to be exposed to someone else's medication (53%) and older patients (10-21 years; n = 41) overwhelmingly (85%) were exposed to their own medication. Thirty-nine (45%) became bradycardic, 27 (32%) became bradypneic, and 38 (44%) became hypotensive. Eighty percent of patients had depressed mental status. Thirty-three (38%) patients received at least one dose of naloxone (median 0.07 mg/kg; interquartile range 0.03-0.11 mg/kg). Of those who received naloxone, 50% had a documented clinical response. CONCLUSIONS In this study of patients at a pediatric tertiary referral center, pediatric patients with report of clonidine exposures were likely to exhibit altered mental status and frequently develop vital sign abnormalities. Naloxone exhibited some effectiveness; given its wide safety margin, high-dose naloxone should be used in critically poisoned non-opioid-dependent patients. Because adolescents are much more likely to ingest their own clonidine medication, counseling with parents and other caregivers regarding safe medication storage is paramount.
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Affiliation(s)
- Michael S Toce
- Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, Massachusetts; Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Eli Freiman
- Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine A O'Donnell
- Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, Massachusetts; Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, Boston, Massachusetts; Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts
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Nadeau N, Samuels-Kalow M, Wittels K, Wilcox SR. A Common Antidote for an Uncommon Indication. J Emerg Med 2019; 57:723-725. [PMID: 31629578 DOI: 10.1016/j.jemermed.2019.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 08/26/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Nicole Nadeau
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Margaret Samuels-Kalow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Affiliation(s)
- Michael S Toce
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical Toxicology Program, Boston, Children's Hospital, Boston, MA
| | - Todd W Lyons
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA
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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.
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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
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Topical Brimonidine Tartrate 0.33% Gel on Postlaser Erythema: Our Experience and Review of the Literature. Dermatol Surg 2018; 44:144-147. [PMID: 29077635 DOI: 10.1097/dss.0000000000001389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Greene S, AufderHeide E, French-Rosas L. Toxicologic Emergencies in Patients with Mental Illness: When Medications Are No Longer Your Friends. Psychiatr Clin North Am 2017; 40:519-532. [PMID: 28800806 DOI: 10.1016/j.psc.2017.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with psychiatric disorders are at risk for toxicologic emergencies. Psychotropic medications have numerous effects on the neurologic, cardiac, and other organ systems and interact with other medications, potentially leading to further side effects. It is important to become familiar with accepted psychiatric practice guidelines, common toxidromes, medical sequelae associated with prescribed medications, and the specific workup and treatment of overdoses of frequently prescribed psychotropics.
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Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila) 2017; 55:187-192. [DOI: 10.1080/15563650.2016.1277234] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Geoffrey K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
| | - Simon P. Heppell
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
| | - Colin B. Page
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
| | - Nicole M. Ryan
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
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Unintentional pediatric ophthalmic tetrahydrozoline ingestion: case files of the medical toxicology fellowship at the University of California, San Francisco. J Med Toxicol 2015; 10:388-91. [PMID: 24760708 DOI: 10.1007/s13181-014-0400-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Pfeffer AN, Williams SR. Annals of Emergency Medicine Journal Club. Treatment of calcium channel blocker poisoning: should we reprioritize our potpourri of treatment options?: answers to the September 2013 Journal Club questions. Ann Emerg Med 2014; 63:259-65. [PMID: 24438650 DOI: 10.1016/j.annemergmed.2013.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wang GS, Le Lait MC, Heard K. Unintentional pediatric exposures to central alpha-2 agonists reported to the National Poison Data System. J Pediatr 2014; 164:149-52. [PMID: 24094880 DOI: 10.1016/j.jpeds.2013.08.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/18/2013] [Accepted: 08/20/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate national trends in unintentional pediatric exposures to 3 common alpha-2 agonists: clonidine, guanfacine, and tizanidine. Secondary objectives were to describe outcomes, symptoms, treatments, and death. STUDY DESIGN Retrospective chart review from the American Association of Poison Control Centers National Poison Data System from January 2000 to December 2011 for unintentional exposure to clonidine, guanfacine, and tizanidine in children ≤ 12 years of age. RESULTS From 2000-2011, there was a significant increase (5.9% per year, CI 3.6, 8.2) in unintentional pediatric exposures to National Poison Data System for central alpha-2 agonists. There were 27,825 clonidine exposures (67.3% male, median age: 4 years), 6143 guanfacine exposures (69.8% male, median age: 6 years), and 856 tizanidine exposures (51.9% male, median age: 2 years). Guanfacine had the greatest proportional increase among the medications. Clonidine was associated with the most respiratory (799, 2.9%) and central nervous system symptoms (12,612, 45.3%), as well as the most episodes of bradycardia (2847, 10.2%) and hypotension (2365, 8.5%). Seven-hundred twenty-eight (2.0%) patients were intubated, and 141 patients (0.5%) were administered vasopressors. There were 7 cardiac arrests and 3 deaths from clonidine. CONCLUSIONS The number of unintentional pediatric exposures to alpha-2 agonists increased from 2000-2011. Clonidine exposures were the most commonly reported, more symptomatic, and associated with 3 deaths. Despite central nervous system depression, bradycardia, and hypotension being common, the need for intubation and vasopressors was rare.
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Affiliation(s)
- George Sam Wang
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO.
| | | | - Kennon Heard
- Rocky Mountain Poison and Drug Center, Denver Health, Denver, CO
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Abstract
We describe a 4-year-old boy who presents to the emergency department with lethargy, bradycardia, and initial hypertension followed by hypotension due to guanfacine toxicity after ingestion of standard doses of the extended release formulation. This is the first case report to describe the use of naloxone to treat these symptoms and document improvements in level of consciousness, blood pressure, and heart rate associated with this therapy.
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Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a practical review. Am J Health Syst Pharm 2012; 69:199-212. [PMID: 22261941 DOI: 10.2146/ajhp110014] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use. SUMMARY Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability. CONCLUSION Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.
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Affiliation(s)
- Jeanna M Marraffa
- Upstate New York Poison Center, 750 East Adams Street, Syracuse, NY 13210, USA.
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Toxic bradycardias in the critically ill poisoned patient. Emerg Med Int 2012; 2012:852051. [PMID: 22545217 PMCID: PMC3321542 DOI: 10.1155/2012/852051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/15/2011] [Accepted: 01/18/2012] [Indexed: 11/17/2022] Open
Abstract
Cardiovascular drugs are a common cause of poisoning, and toxic bradycardias can be refractory to standard ACLS protocols. It is important to consider appropriate antidotes and adjunctive therapies in the care of the poisoned patient in order to maximize outcomes. While rigorous studies are lacking in regards to treatment of toxic bradycardias, there are small studies and case reports to help guide clinicians' choices in caring for the poisoned patient. Antidotes, pressor support, and extracorporeal therapy are some of the treatment options for the care of these patients. It is important to make informed therapeutic decisions with an understanding of the available evidence, and consultation with a toxicologist and/or regional Poison Control Center should be considered early in the course of treatment.
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Patil PM, Patil SP. Is Clonidine an Adequate Alternative to Epinephrine as a Vasoconstrictor in Patients With Hypertension? J Oral Maxillofac Surg 2012; 70:257-62. [DOI: 10.1016/j.joms.2011.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Revised: 07/09/2011] [Accepted: 07/11/2011] [Indexed: 11/15/2022]
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Affiliation(s)
- Selahattin Katar
- Department of Pediatrics, Dicle University Faculty of Medicine, Diyarbakir, Turkey.
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Xie HG, Cao YJ, Gauda EB, Agthe AG, Hendrix CW, Lee H. Clonidine clearance matures rapidly during the early postnatal period: a population pharmacokinetic analysis in newborns with neonatal abstinence syndrome. J Clin Pharmacol 2010; 51:502-11. [PMID: 20484620 DOI: 10.1177/0091270010370587] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The population pharmacokinetic (PK) profile of oral clonidine was characterized in newborns with neonatal abstinence syndrome, and significant covariates affecting its PK parameters were identified. Plasma clonidine concentration data were obtained from a clinical trial in which 36 newborns, aged 1 to 25 days (postnatal age, PNA) and weighing 2.1 to 3.9 kg, were enrolled to take multiple oral doses of clonidine. The population PK model of clonidine was developed by NONMEM, and significant covariates were identified, followed by nonparametric bootstraps (2000 replicates) and simulation experiments. A 1-compartment open linear PK model was chosen to describe plasma concentrations of clonidine, and body weight and PNA were significant covariates for apparent clearance (CL/F) as follows: CL/F (L/h) = 15.2 × [body weight (kg)/70](0.75) × [PNA (day)(0.441)/(4.06(0.441) + PNA (day)(0.441))]. Furthermore, CL/F of clonidine increased rapidly with PNA during the first month of life after body weight was adjusted. Any optimal dosage regimen for clonidine in term neonates should be based on infant's age and body weight, and 1.5 µg/kg every 4 hours is proposed starting the second week of life based on the simulation results.
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Affiliation(s)
- Hong-Guang Xie
- Center for Drug Development Science, Department of Bio-pharmaceutical Sciences, School of Pharmacy, University of California San Francisco, San Francisco, California, USA
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Respiratory Depression in Young Prader Willi Syndrome Patients following Clonidine Provocation for Growth Hormone Secretion Testing. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2010; 2010:103742. [PMID: 20368793 PMCID: PMC2846681 DOI: 10.1155/2010/103742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 12/29/2009] [Accepted: 01/16/2010] [Indexed: 11/29/2022]
Abstract
Objectives. To determine the sedative and respiratory effects of clonidine when used to evaluate growth hormone (GH) secretion in children with
Prader Willi Syndrome (PWS). Methods. The study prospectively
evaluated children with PWS who received clonidine (0.15 mg/m2) to assess GH responsiveness. Patients were studied up to four
times over three years. Vital signs, oxygen saturation, and
sedation level were recorded at baseline and every five minutes
following clonidine. Changes between baseline and post-clonidine
were evaluated using a repeated measurement analysis.
Results. Sixty studies were performed on 17 patients, mean age 30.4 ± 15.0 months. The mean ± SD dose of clonidine was 0.074 ± 0.027 mg (5.3 ± 1.72 mcg/kg). All patients achieved a sedation score of 4 to 5 (drowsy to asleep). Mean declines in respiratory rate (7.5 ± 6.1 breaths/min; P < .001), and oxygen saturation (2.2 ± 2.0%; P < .001) occurred following clonidine. Five patients (29%) experienced oxygen saturations
≤94% on nine occasions. Three oxygen desaturations were accompanied by partial airway obstruction. Conclusions. Clonidine doses to assess GH secretion often exceed doses used for sedation and result in significant respiratory depression in some children with PWS. There was no association between oxygen desaturation and BMI.
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Unexplained high fever in an elderly patient treated with clonidine, duloxetine, and atorvastatin. Clin Ther 2010; 31:2894-9. [PMID: 20110028 DOI: 10.1016/j.clinthera.2009.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND Drug-induced fever is a clinical diagnosis and should always be considered when the fever is constant and high without a clear source of infection. Although drug-induced fever has been reported with other centrally acting antihypertensive drugs such as methyldopa, published reports of this adverse effect with clonidine in humans were not identified in a search of the literature. CASE SUMMARY A 66-year-old institutionalized white female with a history of morbid obesity (body mass index, 40 kg/m2), Alzheimer's dementia, hypertension, and depression presented to a hospital in Boston, Massachusetts (Caritas Saint Elizabeth's Medical Center) with generalized weakness and shortness of breath and was found to have a non-ST segment elevation myocardial infarction. Before hospitalization, the patient was taking memantine 10 mg PO BID, donepezil 10 mg PO once daily, duloxetine 60 mg PO once daily, clonidine 0.1 mg PO TID, metoprolol 50 mg PO BID, and amlodipine 10 mg PO once daily. On admission, the patient was initiated on aspirin 325 mg, atorvastatin 80 mg, and clopidogrel 75 mg PO daily. Her dose of clonidine was increased to 0.2 mg PO TID to optimize blood pressure control, and metoprolol and amlodipine were continued at the same doses. The patient developed fever on the third day after the cardiac catheterization. The fever ranged from 99.0 degrees F to 102.7 degrees F. The physical examination, laboratory data analysis, multiple blood cultures, urinalysis, chest radiograph, and a computed tomography of the head, chest, abdomen, and pelvis did not reveal any source of infection. On the sixth day after admission, clonidine was reduced to the baseline dose of 0.1 mg PO TID and on the ninth day it was stopped. The patient was afebrile on the twelfth day and remained so for the duration of her hospitalization. Naranjo scores for her newly initiated concomitant medications were as follows: aspirin, 1; atorvastatin, 3; clonidine, 6; and clopidogrel, 1. The rating of 6 for clonidine suggests that it was probably associated with the fever in this patient. CONCLUSION We describe a case of drug-induced fever probably associated with clonidine administration. The higher dose of clonidine alone or in interaction with duloxetine and atorvastatin may have contributed to the development of drug-induced fever.
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Opioids and Derivatives. Clin Toxicol (Phila) 2010. [DOI: 10.3109/9781420092264-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The treatment of patients poisoned with drugs and pharmaceuticals can be quite challenging. Diverse exposure circumstances, varied clinical presentations, unique patient-specific factors, and inconsistent diagnostic and therapeutic infrastructure support, coupled with relatively few definitive antidotes, may complicate evaluation and management. The historical approach to poisoned patients (patient arousal, toxin elimination, and toxin identification) has given way to rigorous attention to the fundamental aspects of basic life support--airway management, oxygenation and ventilation, circulatory competence, thermoregulation, and substrate availability. Selected patients may benefit from methods to alter toxin pharmacokinetics to minimize systemic, target organ, or tissue compartment exposure (either by decreasing absorption or increasing elimination). These may include syrup of ipecac, orogastric lavage, activated single- or multi-dose charcoal, whole bowel irrigation, endoscopy and surgery, urinary alkalinization, saline diuresis, or extracorporeal methods (hemodialysis, charcoal hemoperfusion, continuous venovenous hemofiltration, and exchange transfusion). Pharmaceutical adjuncts and antidotes may be useful in toxicant-induced hyperthermias. In the context of analgesic, anti-inflammatory, anticholinergic, anticonvulsant, antihyperglycemic, antimicrobial, antineoplastic, cardiovascular, opioid, or sedative-hypnotic agents overdose, N-acetylcysteine, physostigmine, L-carnitine, dextrose, octreotide, pyridoxine, dexrazoxane, leucovorin, glucarpidase, atropine, calcium, digoxin-specific antibody fragments, glucagon, high-dose insulin euglycemia therapy, lipid emulsion, magnesium, sodium bicarbonate, naloxone, and flumazenil are specifically reviewed. In summary, patients generally benefit from aggressive support of vital functions, careful history and physical examination, specific laboratory analyses, a thoughtful consideration of the risks and benefits of decontamination and enhanced elimination, and the use of specific antidotes where warranted. Data supporting antidotes effectiveness vary considerably. Clinicians are encouraged to utilize consultation with regional poison centers or those with toxicology training to assist with diagnosis, management, and administration of antidotes, particularly in unfamiliar cases.
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Affiliation(s)
- Silas W Smith
- New York City Poison Control Center, New York University School of Medicine, New York, USA.
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Perera PMS, Jayamanna SF, Hettiarachchi R, Abeysinghe C, Karunatilake H, Dawson AH, Buckley NA. A phase II clinical trial to assess the safety of clonidine in acute organophosphorus pesticide poisoning. Trials 2009; 10:73. [PMID: 19691854 PMCID: PMC2743678 DOI: 10.1186/1745-6215-10-73] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Accepted: 08/20/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated 2-3 million people are acutely poisoned by organophosphorus pesticides each year, mostly in the developing world. There is a pressing need for new affordable antidotes and clonidine has been shown to be effective in animal studies. Our aim was to determine the safety of clonidine given as an antidote in adult patients presenting with signs or symptoms of acute organophosphate ingestion. METHODS This study was a dose finding, open-label, multicentre, phase II trial. Forty eight patients with acute organophosphate poisoning were randomized to receive either clonidine or placebo: Four to receive placebo and twelve to receive clonidine at each dose level. The first dose level was an initial loading dose of 0.15 mg followed by an infusion of 0.5 mg of clonidine over 24 hours. The initial loading dose was increased to 0.3 mg, 0.45 and 0.6 mg. at all dosing levels however the subsequent infusion remained at 0.5 mg of clonidine over 24 hours. RESULTS The baseline characteristics of both groups were similar. The trial was stopped after completion of the 3rd dosing level. At the 1st and 2nd dosing level there were no reported adverse drug reactions. At the 3rd dosing level 5 patients (42%) developed significant hypotension during clonidine treatment that responded to intravenous fluids. There were no statistical differences in ventilation rate, pre and post GCS, and mortality rates over all levels. CONCLUSION Our findings suggest use of moderate doses of clonidine in acute organophosphate poisoning can be used without causing frequent clinical problems but that higher doses are associated with a high incidence of hypotension requiring intervention. Further studies are needed to study the efficacy of clonidine as an antidote in organophosphate poisoning.
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Affiliation(s)
- Polwattage M S Perera
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka.
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Benson BE, Spyker DA, Troutman WG, Watson WA. TESS-based dose–response using pediatric clonidine exposures. Toxicol Appl Pharmacol 2006; 213:145-51. [PMID: 16343577 DOI: 10.1016/j.taap.2005.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2005] [Revised: 10/03/2005] [Accepted: 10/17/2005] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The toxic and lethal doses of clonidine in children are unclear. This study was designed to determine whether data from the American Association of Poison Control Centers Toxic Exposure Surveillance System (TESS) could be utilized to determine a dose-response relationship for pediatric clonidine exposure. METHODS 3,458 single-substance clonidine exposures in children <6 years of age reported to TESS from January 2000 through December 2003 were examined. Dose ingested, age, and medical outcome were available for 1550 cases. Respiratory arrest cases (n = 8) were classified as the most severe of the medical outcome categories (Arrest, Major, Moderate, Mild, and No effect). Exposures reported as a "taste or lick" (n = 51) were included as a dose of 1/10 of the dosage form involved. Dose ranged from 0.4 to 1980 (median 13) microg/kg. Weight was imputed based on a quadratic estimate of weight for age. Dose certainty was coded as exact (26% of cases) or not exact (74%). Medical outcome (response) was examined via logistic regression using SAS JMP (release 5.1). RESULTS The logistic model describing medical outcome (P < 0.0001) included Log dose/kg (P = 0.0000) and Certainty (P = 0.045). CONCLUSION TESS data can provide the basis for a statistically sound description of dose-response for pediatric clonidine poisoning exposures.
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Affiliation(s)
- Blaine E Benson
- New Mexico Poison and Drug Information Center and University of New Mexico College of Pharmacy, Albuquerque, 87131, USA.
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Michael JB, Sztajnkrycer MD. Deadly pediatric poisons: nine common agents that kill at low doses. Emerg Med Clin North Am 2004; 22:1019-50. [PMID: 15474780 DOI: 10.1016/j.emc.2004.05.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
More than 97% of pediatric exposures reported to the AAPCC in 2001 had either no effect or mild clinical effects. Despite the large number of exposures, only 26 of the 1074 reported fatalities occurred in children younger than age 6. These findings reflect the fact that, in contrast to adolescent or adult ingestions, pediatric ingestions are unintentional events secondary to development of exploration behaviors and the tendency to place objects in the mouth. Ingested substances typically are nontoxic or ingested in such small quantities that toxicity would not be expected. As a result, it commonly is believed that ingestion of one or two tablets by a toddler is a benign act and not expected to produce any consequential toxicity. Select agents have the potential to produce profound toxicity and death, however, despite the ingestion of only one or two tablets or sips. Although proven antidotes are a valuable resource, their value is diminished if risk after ingestion is not adequately appreciated and assessed. Future research into low-dose, high-risk exposures should be directed toward further clarification of risk, improvements in overall management strategies,and, perhaps most importantly, prevention of toxic exposure through parental education and appropriate safety legislation.
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Affiliation(s)
- Joshua B Michael
- Department of Emergency Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Affiliation(s)
- Kevin C Osterhoudt
- Section of Medical Toxicology, Division of Emergency Medicine, The Poison Control Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Exner HJ, Peters J, Eikermann M. Epidural Analgesia at End of Life: Facing Empirical Contraindications. Anesth Analg 2003; 97:1740-1742. [PMID: 14633552 DOI: 10.1213/01.ane.0000086725.01761.8b] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED In a patient with unbearable cancer pain at the end of life, long-lasting analgesia without impairment of consciousness could only be achieved with an epidural infusion of local anesthetics combined with opioids and clonidine. Despite leptomeningeal infection during prolonged treatment, epidural analgesia at the lumbar level provided analgesia using very large doses of local anesthetics combined with clonidine and morphine. Thus, terminal sedation was avoided, allowing the patient's end-of-life planning of an "aware" death surrounded by her family. It may be useful to reconsider institutional pain management standards when unbearable pain occurs in patients with limited life expectancy. IMPLICATIONS We report a patient with severe visceral and neurogenic pain from metastatic carcinoma of the colon resistant to multimodal oral analgesic therapy. Although there were empirical contraindications, epidural analgesia was successful, allowing the patient's end-of-life planning of an "aware" death surrounded by the family.
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Affiliation(s)
- Hans Juha Exner
- *Keski-Suomen Saivaanhoitopiiri, Anestesiologia ja tehohoito, Jyväskylä, Finland; and †Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany
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