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Lemoine C, Bréhin C, Micheau P, Lavit M, Claudet I. An unusual route of non-intentional intoxication by ecstasy in a toddler. Arch Pediatr 2023; 30:254-256. [PMID: 37061359 DOI: 10.1016/j.arcped.2023.03.001] [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: 06/10/2022] [Revised: 11/03/2022] [Accepted: 03/04/2023] [Indexed: 04/17/2023]
Abstract
We report a pediatric case of ecstasy intoxication via an unusual route. A mother called the emergency services after her daughter had inserted an ecstasy pill into her nose. During transportation, the child developed hypertension, tachycardia, and tachypnea. She was admitted to the nearest regional hospital, where a physical examination revealed psychomotor agitation, mydriasis, hypertension, tachycardia, and no hyperthermia. Blood tests showed no abnormalities. She was subsequently transferred to a tertiary-level pediatric hospital. During transportation, she was described as being intensely agitated with persistent mydriasis, tachycardia, and high blood pressure. Urinary toxicological screening confirmed the presence of MDMA. She was discharged after 24 h.
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Affiliation(s)
- C Lemoine
- Pediatric emergency department, Children Hospital, CHU Toulouse, France
| | - C Bréhin
- Pediatric emergency department, Children Hospital, CHU Toulouse, France; UMR 1416, Inserm, IRSD, Toulouse, France
| | - P Micheau
- Pediatric emergency department, Children Hospital, CHU Toulouse, France
| | - M Lavit
- Laboratory of Toxicology, CHU Toulouse, France
| | - I Claudet
- Pediatric emergency department, Children Hospital, CHU Toulouse, France; UMR 1295, Inserm, CERPOP, Paul Sabatier University, UPS, Toulouse, France.
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Pinkhasov A, Xiong G, Bourgeois JA, Heinrich TW, Huang H, Coriolan S, Annamalai A, Mangal JP, Frankel S, Lang M, Raj YP, Dandois M, Barth K, Stewart AL, Rado J, Pesek J, Sanders A, Spearman-McCarthy EV, Gagliardi J, Fiedorowicz JG. Management of SIADH-related hyponatremia due to psychotropic medications - An expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res 2021; 151:110654. [PMID: 34739943 PMCID: PMC10911096 DOI: 10.1016/j.jpsychores.2021.110654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/03/2021] [Accepted: 10/22/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Hyponatremia is the most common electrolyte imbalance encountered in clinical practice and is associated with negative healthcare outcomes and cost. SIADH is thought to account for one third of all hyponatremia cases and is typically an insidious process. Psychotropic medications are commonly implicated in the etiology of drug induced SIADH. There is limited guidance for clinicians on management of psychotropic-induced SIADH. METHODS After an extensive review of the existing literature, clinical-educators from the Association of Medicine and Psychiatry developed expert consensus recommendations for management of psychotropic-induced SIADH. A risk score was proposed based on risk factors for SIADH to guide clinical decision-making. RESULTS SSRIs, SNRIs, antipsychotics, carbamazepine, and oxcarbazepine have moderate to high level of evidence demonstrating their association with SIADH. Evaluation for an avoidance of medications that cause hyponatremia is particularly important. Substitution with medication that is less likely to cause SIADH should be considered when appropriate. We propose an algorithmic approach to monitoring hyponatremia with SIADH and corresponding treatment depending on symptom severity. CONCLUSIONS The proposed algorithm can help clinicians in determining whether psychotropic medication should be stopped, reduced or substituted where SIADH is suspected with recommendations for sodium (Na+) monitoring. These recommendations preserve a role for clinical judgment in the management of hyponatremia with consideration of the risks and benefits, which may be particularly relevant for complex patients that present with medical and psychiatric comorbidities. Further studies are needed to determine whether baseline and serial Na+ monitoring reduces morbidity and mortality.
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Affiliation(s)
- Aaron Pinkhasov
- Department of Psychiatry, NYU Langone Hospital-Long Island, NY, United States of America; Psychiatry and Medicine, NYULI - SOM, NY, United States of America.
| | - Glen Xiong
- University of California at Davis, CA, United States of America
| | - James A Bourgeois
- Psychiatry, Baylor Scott & White Health, TX, United States of America
| | - Thomas W Heinrich
- Psychiatry and Behavioral Medicine and Family and Community Medicine, Medical College of Wisconsin, WI, United States of America
| | - Heather Huang
- Psychiatry and Internal Medicine, University of WI, WI, United States of America
| | - Shanice Coriolan
- NYU Langone Hospital - Long Island, NY, United States of America
| | - Aniyizhai Annamalai
- Psychiatry and Internal Medicine, Yale School of Medicine, CT, United States of America
| | - Jed P Mangal
- Psychiatry, Uniformed Services University of the Health Sciences, MD, United States of America
| | - Steven Frankel
- Psychiatry, University of Minnesota Medical School, MN, United States of America; Psychiatry, UCSF, Medical School, University of Minnesota, MN, United States of America
| | - Michael Lang
- Internal Medicine and Psychiatry, Brody School of Medicine at East Carolina University, NC, United States of America
| | - Y Pritham Raj
- Depts of Internal Medicine & Psychiatry, Oregon Health & Science University, United States of America
| | | | - Kelly Barth
- Psychiatry and Internal Medicine, Medical University of South Carolina, SC, United States of America
| | - Anne Louise Stewart
- Consultation-Liaison Psychiatry, University of Texas Southwestern, TX, United States of America
| | - Jeffrey Rado
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, IL, United States of America
| | - Justin Pesek
- Baylor Scott & White Health, TX, United States of America
| | - Aaron Sanders
- Baylor Scott & White Health, TX, United States of America
| | - E Vanessa Spearman-McCarthy
- Internal Medicine and Psychiatry, Medical College of Georgia, Augusta University, GA, United States of America
| | - Jane Gagliardi
- Psychiatry and Behavioral Sciences, Duke University School of Medicine, NC, United States of America
| | - Jess G Fiedorowicz
- Mental Health, The Ottawa Hospital, ON, Canada; Ottawa Hospital Research Institute, Department of Psychiatry, School of Epidemiology and Public Health, ON, Canada; University of Ottawa, and uOttawa Brain and Mind Research Institute, ON, Canada
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Rudin D, Liechti ME, Luethi D. Molecular and clinical aspects of potential neurotoxicity induced by new psychoactive stimulants and psychedelics. Exp Neurol 2021; 343:113778. [PMID: 34090893 DOI: 10.1016/j.expneurol.2021.113778] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/25/2021] [Accepted: 05/29/2021] [Indexed: 12/20/2022]
Abstract
New psychoactive stimulants and psychedelics continue to play an important role on the illicit new psychoactive substance (NPS) market. Designer stimulants and psychedelics both affect monoaminergic systems, although by different mechanisms. Stimulant NPS primarily interact with monoamine transporters, either as inhibitors or as substrates. Psychedelic NPS most potently interact with serotonergic receptors and mediate their mind-altering effects mainly through agonism at serotonin 5-hydroxytryptamine-2A (5-HT2A) receptors. Rarely, designer stimulants and psychedelics are associated with potentially severe adverse effects. However, due to the high number of emerging NPS, it is not possible to investigate the toxicity of each individual substance in detail. The brain is an organ particularly sensitive to substance-induced toxicity due to its high metabolic activity. In fact, stimulant and psychedelic NPS have been linked to neurological and cognitive impairments. Furthermore, studies using in vitro cell models or rodents indicate a variety of mechanisms that could potentially lead to neurotoxic damage in NPS users. Cytotoxicity, mitochondrial dysfunction, and oxidative stress may potentially contribute to neurotoxicity of stimulant NPS in addition to altered neurochemistry. Serotonin 5-HT2A receptor-mediated toxicity, oxidative stress, and activation of mitochondrial apoptosis pathways could contribute to neurotoxicity of some psychedelic NPS. However, it remains unclear how well the current preclinical data of NPS-induced neurotoxicity translate to humans.
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Affiliation(s)
- Deborah Rudin
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland; Institute of Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Dino Luethi
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Basel, Switzerland; Institute of Pharmacology, Medical University of Vienna, Vienna, Austria; Institute of Applied Physics, TU Wien, Vienna, Austria.
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Drinking to death: Hyponatraemia induced by synthetic phenethylamines. Drug Alcohol Depend 2020; 212:108045. [PMID: 32460203 DOI: 10.1016/j.drugalcdep.2020.108045] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 11/21/2022]
Abstract
Synthetic phenethylamines are widely abused drugs, comprising new psychoactive substances such as synthetic cathinones, but also well-known amphetamines such as methamphetamine and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy). Cathinones and amphetamines share many toxicodynamic mechanisms. One of their potentially life-threatening consequences, particularly of MDMA, is serotonin-mediated hyponatraemia. Herein, we review the state of the art on phenethylamine-induced hyponatremia; discuss the mechanisms involved; and present the preventive and therapeutic measures. Hyponatraemia mediated by phenethylamines results from increased secretion of antidiuretic hormone (ADH) and consequent kidney water reabsorption, additionally involving diaphoresis and polydipsia. Data for MDMA suggest that acute hyponatraemia elicited by cathinones may also be a consequence of metabolic activation. The literature often reveals hyponatraemia-associated complications such as cerebral oedema, cerebellar tonsillar herniation and coma that may evolve to a fatal outcome, particularly in women. Ready availability of fluids and the recommendation to drink copiously at the rave scene to counteract hyperthermia, often precipitate water intoxication. Users should be advised about the importance of controlling fluid intake while using phenethylamines. At early signs of adverse effects, medical assistance should be promptly sought. Severe hyponatraemia (<130 mmol sodium/L plasma) may be corrected with hypertonic saline or suppression of fluid intake. Also, clinicians should be made aware of the hyponatraemic potential of these drugs and encouraged to report future cases of toxicity to increase knowledge on this potentially lethal outcome.
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Luethi D, Liechti ME. Designer drugs: mechanism of action and adverse effects. Arch Toxicol 2020; 94:1085-1133. [PMID: 32249347 PMCID: PMC7225206 DOI: 10.1007/s00204-020-02693-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/25/2020] [Indexed: 12/18/2022]
Abstract
Psychoactive substances with chemical structures or pharmacological profiles that are similar to traditional drugs of abuse continue to emerge on the recreational drug market. Internet vendors may at least temporarily sell these so-called designer drugs without adhering to legal statutes or facing legal consequences. Overall, the mechanism of action and adverse effects of designer drugs are similar to traditional drugs of abuse. Stimulants, such as amphetamines and cathinones, primarily interact with monoamine transporters and mostly induce sympathomimetic adverse effects. Agonism at μ-opioid receptors and γ-aminobutyric acid-A (GABAA) or GABAB receptors mediates the pharmacological effects of sedatives, which may induce cardiorespiratory depression. Dissociative designer drugs primarily act as N-methyl-D-aspartate receptor antagonists and pose similar health risks as the medically approved dissociative anesthetic ketamine. The cannabinoid type 1 (CB1) receptor is thought to drive the psychoactive effects of synthetic cannabinoids, which are associated with a less desirable effect profile and more severe adverse effects compared with cannabis. Serotonergic 5-hydroxytryptamine-2A (5-HT2A) receptors mediate alterations of perception and cognition that are induced by serotonergic psychedelics. Because of their novelty, designer drugs may remain undetected by routine drug screening, thus hampering evaluations of adverse effects. Intoxication reports suggest that several designer drugs are used concurrently, posing a high risk for severe adverse effects and even death.
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Affiliation(s)
- Dino Luethi
- Center for Physiology and Pharmacology, Institute of Pharmacology, Medical University of Vienna, Währinger Strasse 13a, 1090, Vienna, Austria.
- Institute of Applied Physics, Vienna University of Technology, Getreidemarkt 9, 1060, Vienna, Austria.
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
| | - Matthias E Liechti
- Division of Clinical Pharmacology and Toxicology, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
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Abstract
3,4-methylenedioxy-methamphetamine is taken recreationally by thousands of people, especially the young, across the globe. It is highly associated with electronic music and its use in the UK remains high at around 4.5% of 16-24 year olds. This review discusses both the short- and long-term effects of 3,4-methylenedioxy-methamphetamine including methods by which some of these adverse effects can be prevented or even reversed to increase the safety of the commonly used drug.
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A Case of MDMA-Associated Cerebral and Pulmonary Edema Requiring ECMO. Case Rep Crit Care 2017; 2017:6417012. [PMID: 29270322 PMCID: PMC5705885 DOI: 10.1155/2017/6417012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/05/2017] [Indexed: 11/18/2022] Open
Abstract
A 20-year-old female presented with confusion, generalized tonic-clonic seizures, and severe hyponatremia after ingesting 3,4-methylenedioxymethamphetamine (MDMA). Brain computed tomography (CT) demonstrated cerebral edema. Her hospital course was rapidly complicated by respiratory failure and shock requiring intubation and vasopressors. Refractory acute respiratory distress syndrome (ARDS) was diagnosed which was unresponsive to conventional and salvage therapies, requiring initiation of extracorporeal membrane oxygenation (ECMO), leading to normalization of oxygenation parameters. Hyponatremia was corrected and the encephalopathy resolved. The patient was decannulated and extubated after three days. MDMA-induced hyponatremia is hypothesized to result from enhanced serotonergic activity and arginine vasopressin (AVP) release in the brain leading to hyperthermia-induced polydipsia and syndrome of inappropriate antidiuretic hormone (SIADH) secretion. A common but often unrecognized complication of severe hyponatremia is the Ayus-Arieff syndrome where cerebral edema causes neurogenic pulmonary edema via centrally mediated increases in catecholamine release and capillary injury. For our patient, ECMO was required for three days while the hyponatremia was corrected which led to rapid clearing of the cerebral edema and neurogenic pulmonary edema. This case illustrates that, in selecting patients with refractory ARDS from MDMA-associated cerebral and pulmonary edema, ECMO may be a temporizing and life-saving modality of treatment.
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Abstract
Dysnatremias occur simultaneously with disorders in water balance. The first priority is to correct dehydration; once the patient is euvolemic, the sodium level can be reassessed. In unstable patients with hyponatremia, the clinician should rapidly administer hypertonic saline. In unstable patients with hypernatremia, the clinician should administer isotonic intravenous fluid. In stable patients with either hyponatremia or hypernatremia, the clinician should aim for correction over 24 to 48 hours, with the maximal change in serum sodium between 8 to 12 mEq/L over the first 24 hours. This rate of correction decreases the chances of cerebral edema or osmotic demyelination syndrome.
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Affiliation(s)
- Theresa R Harring
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA.
| | - Nathan S Deal
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA
| | - Dick C Kuo
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA.
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van Dijken GD, Blom RE, Hené RJ, Boer WH, NIGRAM Consortium. High incidence of mild hyponatraemia in females using ecstasy at a rave party. Nephrol Dial Transplant 2013; 28:2277-83. [PMID: 23476039 DOI: 10.1093/ndt/gft023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Globally, millions of subjects regularly use ecstasy, a drug popular due to its empathogenic and entactogenic effects. Dilutional hyponatraemia, mainly caused by direct stimulation of antidiuretic hormone (ADH) secretion by ecstasy, is among the many side effects of the drug (active substance 3, 4-methylenedioxymethamphetamine, MDMA). Severe, symptomatic hyponatraemia related to the use of MDMA has been reported in more than 30 cases. The mortality of this complication is high and mainly females are involved. Dramatic cases that reach the literature probably represent the tip of the iceberg. We decided to study the incidence of hyponatraemia in subjects using MDMA at an indoor rave party. METHODS The study was performed at the indoor event 'Awakenings', held in Amsterdam in the fall of 2010. The plasma sodium concentration was measured at the party using a point of care method in 63 subjects using MDMA and 44 controls. The use of MDMA was confirmed by a urine test. RESULTS The plasma sodium concentration in subjects using MDMA was significantly lower than in those not using the drug (138 ± 2 mmol/L versus 140 ± 2 mmol/L, respectively, P < 0.001). The overall incidence of hyponatraemia, defined as a plasma sodium concentration <136 mmol/L, was 14.3% in MDMA users (9/63 subjects). Most cases of hyponatraemia occurred in females, in whom the incidence was 26.7% (8 of 30 females), with lowest values of 133 mmol/L. The number of ecstasy pills ingested by the females developing hyponatraemia was not different from that ingested by those who did not develop this complication. Fluid intake in ecstasy users exceeded that of non-users, suggesting a dipsogenic effect of the drug. CONCLUSIONS Only 3% of males, but no less than ∼25% of females attending a rave party and using MDMA developed mild hyponatraemia during the event. Especially females are therefore probably also at risk of developing severe symptomatic hyponatraemia. Not using MDMA is obviously the best option to prevent MDMA-induced hyponatraemia. However, accepting the fact that millions use the drug every weekend, strategies should also be developed to prevent hyponatraemia in subjects choosing to take MDMA. This would include matching the electrolyte content of the fluids and food ingested to that of the fluids that are lost during the use of MDMA, mainly by perspiration. Users of MDMA and emergency health care workers should become more aware of the relatively high incidence of MDMA-induced hyponatraemia and of potential strategies to prevent this complication.
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Affiliation(s)
- Geetruida D van Dijken
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands
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