Unusual causes of rhabdomyolysis

Evaluation of Knowledge of Food-Drug and Alcohol-Drug Interactions Among Undergraduate Students at King Saud University - An Observational Study

BACKGROUND AND OBJECTIVE

The role of pharmacists in society is unique since they are providers of drug information and medication counseling to patients. Hence, the present study was designed to investigate the knowledge, of undergraduate pharmacy students regarding food drug (FDIs) and alcohol-drug interactions (ADIs) at King Saud University, Riyadh Saudi Arabia.

METHODOLOGY

An online cross-sectional study was conducted among undergraduate pharmacy students at King Saud University, Riyadh, Saudi Arabia from October 2021 to January 2022, using self-administered 24-items questionnaires focused on evaluating the knowledge of FDIs and ADIs.

RESULTS

Of the 200 questionnaires distributed, 142 students responded, of whom 40.8% (n = 58) of the students did not agree with the statement that patients can eat more green leafy vegetables with warfarin. Just over half 52.8% (n = 75) agreed that milk affects the efficacy of tetracycline. Regarding the students' knowledge about amiodarone interactions with grapefruit 43% (n = 61) of them were knowledgeable, while 43.7% (n = 62), knew that atorvastatin cannot be taken with grapefruit. A total of 44.4% (n = 63) of the students reported being knowledgeable about FDIs. In terms of the individual questions, Alcohol interactions with antihistamines and paracetamol received the highest percentages of 52.8% (n = 75) and 50.7% (n = 72), respectively, followed by warfarin and methotrexate (45.1%; 41.5%). In this study, 39.4% (n = 56) of the participants were found knowledgeable about ADIs. The overall knowledge of interactions among the students was 47.9% (n = 68). The total knowledgeable levels were significantly associated with educational levels and having previous information about interaction (p = 0.0001).

CONCLUSION

In conclusion, undergraduate pharmacy students exhibited poor knowledge of FDIs and ADIs. As a result, more focus and effort should be given to raising awareness of potential FDIs and ADIs. Our study highlights the need for improving pharmacy students' knowledge about FDIs and ADIs.

Food-drug interactions: Knowledge among pharmacists in Jordan

Background

Pharmacists have crucial role in providing drug information and medication counseling to patients. This survey aimed to benchmark the current knowledge of the pharmacists concerning food-drug interactions (FDIs) in Jordan.

Methods

A cross-sectional study was conducted in Amman, the capital and largest city of Jordan, using a validated questionnaire. It was distributed to pharmacists working in community and hospital pharmacies using a convenience sampling technique. Descriptive and inferential statistics were performed in this study.

Results

A total of 340 questionnaires distributed, 300 (88%) pharmacists responded. Over 50% of pharmacists claimed that they have sufficient knowledge regarding FDI. Virtually, the overall median (interquartile range) knowledge score was 18 (15–21), approximately 60%. The highest knowledge scores were for alcohol-drug interactions section (66.6%) followed by both common food-drug interactions and the timing of drug intake to food consumption sections with a score of (58.3%) for each, reflecting a suboptimal knowledge of FDIs among the pharmacists.

Conclusion

Pharmacists had unsatisfactory knowledge about common FDIs, with no significant difference between hospital and community pharmacists. Therefore, more attention and efforts should be played to improve awareness about potential food-drug interactions.

Transporter-Mediated Drug-Drug Interactions and Their Significance

Drug transporters are considered to be determinants of drug disposition and effects/toxicities by affecting the absorption, distribution, and excretion of drugs. Drug transporters are generally divided into solute carrier (SLC) family and ATP binding cassette (ABC) family. Widely studied ABC family transporters include P-glycoprotein (P-GP), breast cancer resistance protein (BCRP), and multidrug resistance proteins (MRPs). SLC family transporters related to drug transport mainly include organic anion-transporting polypeptides (OATPs), organic anion transporters (OATs), organic cation transporters (OCTs), organic cation/carnitine transporters (OCTNs), peptide transporters (PEPTs), and multidrug/toxin extrusions (MATEs). These transporters are often expressed in tissues related to drug disposition, such as the small intestine, liver, and kidney, implicating intestinal absorption of drugs, uptake of drugs into hepatocytes, and renal/bile excretion of drugs. Most of therapeutic drugs are their substrates or inhibitors. When they are comedicated, serious drug-drug interactions (DDIs) may occur due to alterations in intestinal absorption, hepatic uptake, or renal/bile secretion of drugs, leading to enhancement of their activities or toxicities or therapeutic failure. This chapter will illustrate transporter-mediated DDIs (including food drug interaction) in human and their clinical significances.

Poisonous birds: A timely review

Until very recently, toxicity was not considered a trait observed in birds, but works published in the last two decades started to shed light on this subject. Poisonous birds are rare (or little studied), and comprise Pitohui and Ifrita birds from Papua New Guinea, the European quail, the Spoor-winged goose, the Hoopees, the North American Ruffed grouse, the Bronzewings, and the Red warbler. A hundred more species are considered unpalatable or malodorous to humans and other animals. The present review intends to present the current understanding of bird toxicity, possibly pointing to an ignored research field. Whenever possible, biochemical characteristics of these poisons and their effects on humans and other animals are discussed, along with historical aspects of poison discovery and evolutionary hypothesis regarding their function.

Consumption of clarified grapefruit juice ameliorates high-fat diet induced insulin resistance and weight gain in mice

To determine the metabolic effects of grapefruit juice consumption we established a model in which C57Bl/6 mice drank 25–50% sweetened GFJ, clarified of larger insoluble particles by centrifugation (cGFJ), ad libitum as their sole source of liquid or isocaloric and sweetened water. cGFJ and control groups consumed similar amounts of liquids and calories. Mice fed a high-fat diet and cGFJ experienced a 18.4% decrease in weight, a 13–17% decrease in fasting blood glucose, a three-fold decrease in fasting serum insulin, and a 38% decrease in liver triacylglycerol values, compared to controls. Mice fed a low-fat diet that drank cGFJ experienced a two-fold decrease in fasting insulin, but not the other outcomes observed with the high-fat diet. cGFJ consumption decreased blood glucose to a similar extent as the commonly used anti-diabetic drug metformin. Introduction of cGFJ after onset of diet-induced obesity also reduced weight and blood glucose. A bioactive compound in cGFJ, naringin, reduced blood glucose and improved insulin tolerance, but did not ameliorate weight gain. These data from a well-controlled animal study indicate that GFJ contains more than one health-promoting neutraceutical, and warrant further studies of GFJ effects in the context of obesity and/or the western diet.

Phenotype standardization for statin-induced myotoxicity

Statins are widely used lipid-lowering drugs that are effective in reducing cardiovascular disease risk. Although they are generally well tolerated, they can cause muscle toxicity, which can lead to severe rhabdomyolysis. Research in this area has been hampered to some extent by the lack of standardized nomenclature and phenotypic definitions. We have used numerical and descriptive classifications and developed an algorithm to define statin-related myotoxicity phenotypes, including myalgia, myopathy, rhabdomyolysis, and necrotizing autoimmune myopathy.

Adolescent with Rhabdomyolysis due to Undiagnosed Hypothyroidism

Exercise-induced rhabdomyolysis has been described in military recruits, trained athletes and daily runners. Statin use, quail ingestion, infection by Epstein-Barr virus (EBV), and hypothyroidism, though rare, are risk factors for the development of rhabdomyolysis. We describe the case of a 15-year-old female who presented with myalgias, weakness, and pigmenturia following marching band practice. Laboratory tests confirmed an elevated creatine kinase (CK) level as well as a profound hypothyroid state. Muscle biopsy revealed severe muscle necrosis and myositis. Treatment with levothyroxine resulted in obtaining an euthyroid state and regain of muscle strength as well as decrease in CK levels. Although rare, hypothyroidism should be considered as a potential cause of rhabdomyolysis in pediatric patients undergoing a myopathy workup.

Fruit juice inhibition of uptake transport: a new type of food-drug interaction

A new type of interaction in which fruit juices diminish oral drug bioavailability through inhibition of uptake transport is the focus of this review. The discovery was based on an opposite to anticipated finding when assessing the possibility of grapefruit juice increasing oral fexofenadine bioavailability in humans through inhibition of intestinal MDR1-mediated efflux transport. In follow-up investigations, grapefruit or orange juice at low concentrations potentially and selectively inhibited in vitro OATP1A2-mediated uptake compared with MDR1-caused efflux substrate transport. These juices at high volume dramatically depressed oral fexofenadine bioavailability. Grapefruit was the representative juice to characterize the interaction subsequently. A volume-effect relationship study using a normal juice amount halved average fexofenadine absorption. Individual variability and reproducibility data indicated the clinical interaction involved direct inhibition of intestinal OATP1A2. Naringin was a major causal component suggesting that other flavonoids in fruits and vegetables might also produce the effect. Duration of juice clinical inhibition of fexofenadine absorption lasted more than 2 h but less than 4 h indicating the interaction was avoidable with appropriate interval of time between juice and drug consumption. Grapefruit juice lowered the oral bioavailability of several medications transported by OATP1A2 (acebutolol, celiprolol, fexofenadine, talinolol, L-thyroxine) while orange juice did the same for others (atenolol, celiprolol, ciprofloxacin, fexofenadine). Juice clinical inhibition of OATP2B1 was unresolved while that of OATP1B1 seemed unlikely. The interaction between grapefruit juice and etoposide also seemed relevant. Knowledge of both affected uptake transporter and drug hydrophilicity assisted prediction of the clinical interaction with grapefruit or orange juice.

Fenofibrate-induced rhabdomyolysis in a patient with chronic kidney disease: an unusual presenting feature of hypothyroidism

Clinical and most often moderate skeletal muscle involvement is a frequent problem in adults with hypothyroidism, and includes a number of different manifestations. Severe involvement with rhabdomyolysis, however, is very rare, and only a few cases have been reported to date, most of them with an additional factor of muscle injury. We described a patient with stage 3 chronic kidney disease who presented with rhabdomyolysis while taking fenofibrate, and was found to have hypothyroidism. We also highlighted the importance of excluding the diagnosis of thyroid dysfunction before treatment with lipid-lowering agents.

Negative evidence for stachydrine or Galeopsis ladanum L. seeds as the causal agents of coturnism after quail meat ingestion

Quail poisoning is known to produce an acute myoglobinuric syndrome called coturnism. The cause of this syndrome is still unknown, although it has been postulated that Galeopsis ladanum L. seeds, in particular lipidic compounds or stachydrine, are responsible for this toxicity. Thus, we aimed to study the implication of this plant in coturnism in order to explore the physiopathology of the disease, especially with regard to stachydrine and lipidic compounds extracted from seeds. For this purpose, Wistar rats were fed with G. ladanum seed extracts or with quail meat. However, the rhabdomyolysis outbreak could not be reproduced in any case. Therefore, in view of our results and experimental conditions, seeds of G. ladanum and stachydrine do not appear to be the responsible agents of the myopathic outbreak. This conclusion is supported by the following facts: direct administration of extracts of seeds of G. ladanum or stachydrine produces no myotoxicity in rats; G. ladanum seeds are not toxic to quails and meat from quails fed G. ladanum seeds is not toxic to rats.