1
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Wang L, Wang Y, Zhang RY, Wang Y, Liang W, Li TG. Management of acute carbamazepine poisoning: A narrative review. World J Psychiatry 2023; 13:816-830. [DOI: 10.5498/wjp.v13.i11.816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/23/2023] [Accepted: 10/11/2023] [Indexed: 11/17/2023] Open
Abstract
Standard management protocols are lacking and specific antidotes are unavailable for acute carbamazepine (CBZ) poisoning. The objective of this review is to provide currently available information on acute CBZ poisoning, including its management, by describing and summarizing various therapeutic methods for its treatment according to previously published studies. Several treatment methods for CBZ poisoning will be briefly introduced, their advantages and disadvantages will be analyzed and compared, and suggestions for the clinical treatment of CBZ poisoning will be provided. A literature search was performed in various English and Chinese databases. In addition, the reference lists of identified articles were screened for additional relevant studies, including non-indexed reports. Non-peer-reviewed sources were also included. In the present review, 154 articles met the inclusion criteria including case reports, case series, descriptive cohorts, pharmacokinetic studies, and in vitro studies. Data on 67 patients, including 4 fatalities, were reviewed. Based on the summary of cases reported in the included articles, the cure rate of CBZ poisoning after symptomatic treatment was 82% and the efficiency of hemoperfusion was 58.2%. Based on the literature review, CBZ is moderately dialyzable and the recommendation for CBZ poisoning is supportive management and gastric lavage. In severe cases, extracorporeal treatment is recommended, with hemodialysis as the first choice.
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Affiliation(s)
- Luan Wang
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yang Wang
- Department of General Surgery, The 4th Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Ruo-Ying Zhang
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yao Wang
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Wei Liang
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Tie-Gang Li
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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2
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Nasif MA, Falana HH, Hamed HKH, Yousef QGH, Jaradat MA. Severe Carbamazepine Toxicity Treated with Continuous Venovenous Hemofiltration at Palestine Medical Complex: Two Case Reports. Int Med Case Rep J 2022; 15:205-208. [PMID: 35465260 PMCID: PMC9022740 DOI: 10.2147/imcrj.s358084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/12/2022] [Indexed: 12/23/2022] Open
Abstract
Carbamazepine intoxication is not uncommon and accounts for many cases of poisoning among anticonvulsive medications users. Since there is no specific antidote for carbamazepine overdose, management is limited to gastric decontamination and supportive therapy. With its high protein binding, the role of extracorporeal elimination in carbamazepine intoxication is still questionable. Here two cases of severe carbamazepine intoxication are presented; the cases were brought to the emergency department after the ingestion of 12,000 mg of controlled release carbamazepine for the first case, and unknown amounts of the same drug for the second case. Both cases were presented with altered mental status, convulsion, and high serum carbamazepine levels of more than 20 mcg/mL. They were intubated and treated with continuous venovenous hemofiltration, after which carbamazepine levels declined significantly along with subsequent clinical improvement and complete neurological recovery. Both cases were discharged home for further psychiatric care.
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Affiliation(s)
- Mowaffaq A Nasif
- Intensive Care Unit, Palestine Medical Complex, Ramallah, Palestine
| | - Hiba H Falana
- Department of Pharmacy, Birzeit University, Ramallah, Palestine
- Correspondence: Hiba H Falana, Department of Pharmacy, Birzeit University, PO Box 14, Birzeit, Ramallah, Palestine, Tel +970-595193486, Fax +970-2-2982017, Email
| | - Heba K H Hamed
- Intensive Care Unit, Palestine Medical Complex, Ramallah, Palestine
| | - Qusai G H Yousef
- Internal Medicine Department, Al-Quds University, Jerusalem, Palestine
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3
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Bouajram RH, Awdishu L. A Clinician's Guide to Dosing Analgesics, Anticonvulsants, and Psychotropic Medications in Continuous Renal Replacement Therapy. Kidney Int Rep 2021; 6:2033-2048. [PMID: 34386653 PMCID: PMC8343808 DOI: 10.1016/j.ekir.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022] Open
Abstract
Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) is a common complication in critical illness and has a significant impact on pharmacokinetic factors determining drug exposure, including absorption, distribution, transport, metabolism, and clearance. In this review, we provide a practical guide to drug dosing considerations in critically ill patients undergoing CRRT, focusing on the most commonly used analgesic, anticonvulsant, and psychotropic medications in the clinical care of critically ill patients. A literature search was conducted to identify articles in which drug dosing was evaluated in adult patients receiving CRRT between the years 1980 and 2020. We included articles with pharmacokinetic/pharmacodynamic analyses and those that described medication clearance via CRRT. A summary of the data focused on practical pharmacokinetic and pharmacodynamic principles is presented, with recommendations for drug dosing of analgesics, anticonvulsants, and psychotropic medications. Pharmacokinetic and pharmacodynamic studies to guide drug dosing of analgesics, anticonvulsants, and psychotropic medications in critically ill patients receiving CRRT are sparse. Considering the widespread use of these medications, narrow therapeutic index of these drug classes, and risks of over- and underdosing, additional studies in patients receiving CRRT are needed to inform drug dosing.
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Affiliation(s)
- Rima H. Bouajram
- Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Linda Awdishu
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, California, USA
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4
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Hughes TB, Dang NL, Kumar A, Flynn NR, Swamidass SJ. Metabolic Forest: Predicting the Diverse Structures of Drug Metabolites. J Chem Inf Model 2020; 60:4702-4716. [PMID: 32881497 PMCID: PMC8716321 DOI: 10.1021/acs.jcim.0c00360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Adverse drug metabolism often severely impacts patient morbidity and mortality. Unfortunately, drug metabolism experimental assays are costly, inefficient, and slow. Instead, computational modeling could rapidly flag potentially toxic molecules across thousands of candidates in the early stages of drug development. Most metabolism models focus on predicting sites of metabolism (SOMs): the specific substrate atoms targeted by metabolic enzymes. However, SOMs are merely a proxy for metabolic structures: knowledge of an SOM does not explicitly provide the actual metabolite structure. Without an explicit metabolite structure, computational systems cannot evaluate the new molecule's properties. For example, the metabolite's reactivity cannot be automatically predicted, a crucial limitation because reactive drug metabolites are a key driver of adverse drug reactions (ADRs). Additionally, further metabolic events cannot be forecast, even though the metabolic path of the majority of substrates includes two or more sequential steps. To overcome the myopia of the SOM paradigm, this study constructs a well-defined system-termed the metabolic forest-for generating exact metabolite structures. We validate the metabolic forest with the substrate and product structures from a large, chemically diverse, literature-derived dataset of 20 736 records. The metabolic forest finds a pathway linking each substrate and product for 79.42% of these records. By performing a breadth-first search of depth two or three, we improve performance to 88.43 and 88.77%, respectively. The metabolic forest includes a specialized algorithm for producing accurate quinone structures, the most common type of reactive metabolite. To our knowledge, this quinone structure algorithm is the first of its kind, as the diverse mechanisms of quinone formation are difficult to systematically reproduce. We validate the metabolic forest on a previously published dataset of 576 quinone reactions, predicting their structures with a depth three performance of 91.84%. The metabolic forest accurately enumerates metabolite structures, enabling promising new directions such as joint metabolism and reactivity modeling.
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Affiliation(s)
- Tyler B Hughes
- Department of Pathology and Immunology, Washington University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
| | - Na Le Dang
- Department of Pathology and Immunology, Washington University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
| | - Ayush Kumar
- Department of Pathology and Immunology, Washington University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
| | - Noah R Flynn
- Department of Pathology and Immunology, Washington University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
| | - S Joshua Swamidass
- Department of Pathology and Immunology, Washington University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
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5
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Thompson A, Li F, Gross AK. Considerations for Medication Management and Anticoagulation During Continuous Renal Replacement Therapy. AACN Adv Crit Care 2017; 28:51-63. [PMID: 28254856 DOI: 10.4037/aacnacc2017386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Providing safe and high-quality care to critically ill patients receiving continuous renal replacement therapy (CRRT) includes adequate drug dosing and evaluation of patients' response to medications during therapy. Pharmacokinetic drug studies in acute kidney injury and CRRT are limited, considering the number of medications used in critical care. Therefore, it is important to understand the basic principles of drug clearance during CRRT by evaluating drug properties, CRRT modalities, and how they affect medication clearance. Few published studies have addressed drug disposition and clinical response during CRRT. Additionally, clotting in the CRRT circuit is a concern, so a few options for anticoagulation strategies are presented. This article reviews (1) the CRRT system and drug property factors that affect medication management, (2) the evidence available to guide drug dosing, and (3) anticoagulation strategies for critically ill patients receiving CRRT.
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Affiliation(s)
- Ashley Thompson
- Ashley Thompson is Critical Care Pharmacist, Senior Pharmacist Supervisor, University of California, San Francisco (UCSF) Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Ave. Box 0622, San Francisco, CA 94143 . Fanny Li is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Fran-cisco, California. A. Kendall Gross is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California
| | - Fanny Li
- Ashley Thompson is Critical Care Pharmacist, Senior Pharmacist Supervisor, University of California, San Francisco (UCSF) Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Ave. Box 0622, San Francisco, CA 94143 . Fanny Li is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Fran-cisco, California. A. Kendall Gross is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California
| | - A Kendall Gross
- Ashley Thompson is Critical Care Pharmacist, Senior Pharmacist Supervisor, University of California, San Francisco (UCSF) Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, 533 Parnassus Ave. Box 0622, San Francisco, CA 94143 . Fanny Li is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Fran-cisco, California. A. Kendall Gross is Critical Care Pharmacist, UCSF Medical Center, and Health Sciences Assistant Clinical Professor, Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, California
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6
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Mahmoud SH. Antiepileptic Drug Removal by Continuous Renal Replacement Therapy: A Review of the Literature. Clin Drug Investig 2017; 37:7-23. [PMID: 27587068 DOI: 10.1007/s40261-016-0457-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Continuous renal replacement therapy (CRRT) is used for managing acute kidney injury in critically ill patients. Removal of antiepileptic drugs (AEDs) by CRRT could be significant and may complicate patients' intensive care unit stay. The objective of the current review was to summarize the available evidence for AED removal by CRRT. An electronic literature search of PubMed (1946 to May 2016), Medline (1946 to May 2016), and Embase (1974 to May 2016) databases for studies discussing AED removal by CRRT was conducted. A total of 31 case reports discussing 32 patients were found. AEDs reported were levetiracetam (n = 3), valproic acid (n = 9), carbamazepine (n = 10), phenytoin (n = 3), phenobarbital (n = 4), lacosamide (n = 1), gabapentin (n = 1), and topiramate (n = 1). Two-thirds of the reports were about using CRRT in drug overdose and one-third was about AED removal by CRRT during therapy. Based on the current limited evidence and pharmacokinetic characteristics of AEDs, renally eliminated AEDs and/or AEDs with limited protein binding such as levetiracetam are more likely to be removed by CRRT than AEDs that are mainly metabolized and extensively protein bound such as carbamazepine. In conclusion, there is not enough evidence to provide robust dosing recommendations for AEDs in patients undergoing CRRT. Further studies are needed.
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Affiliation(s)
- Sherif Hanafy Mahmoud
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-228 Edmonton Clinic Health Academy, Edmonton, AB, T6G 1C9, Canada.
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Acikgoz M, Paksu MS, Guzel A, Alacam A, Alacam F. Severe Carbamazepine Intoxication in Children: Analysis of a 40-Case Series. Med Sci Monit 2016; 22:4729-4735. [PMID: 27911891 PMCID: PMC5142583 DOI: 10.12659/msm.898899] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We compared the factors that might impact the severity and the prognosis of carbamazepine (CBZ) intoxication in children, as well as the efficacy levels of the treatment options. MATERIAL AND METHODS Demographic information and clinical and laboratory findings for 40 patients were evaluated retrospectively. Predictive parameters for the development of serious complications were studied. RESULTS Median age of patients was 14 years; 65% of the patients were female. The most common pathological clinical finding and laboratory abnormality were inability to awaken the patient and hyperglycemia (45% and 60%, respectively). The incidences of convulsion, coma, and respiratory failure were 14 (35%), 10 (25%), and 3 (7.5%), respectively. The Glasgow Coma Scale (GCS) scores and pH levels at emergency service admission were significantly lower in the severe intoxication group and the ICU admission group, and body temperature and serum glucose and lactate levels were significantly higher in these groups. A significantly negative correlation was found between the serum CBZ level and the GCS score, but the serum CBZ level was found to be significantly positively correlated with the lactate level. CONCLUSIONS According to our study, the GCS score at admission to hospital, the serum CBZ, glucose, pH, and lactate levels, and body temperature might be useful in predicting serious CBZ intoxication and prognosis in pediatric cases. We conclude that invasive treatment methods, such as hemodialysis or albumin-enhanced continuous venovenous hemodialysis, should be used in patients who do not respond to supportive treatment.
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Affiliation(s)
- Mehmet Acikgoz
- Department of Pediatrics, Ondokuz Mayıs University, Medical Faculty, Samsun, Turkey
| | - M Sukru Paksu
- Department of Pediatrics, Ondokuz Mayıs University, Medical Faculty, Samsun, Turkey
| | - Ahmet Guzel
- Department of Pediatrics, Ondokuz Mayıs University, Medical Faculty, Samsun, Turkey
| | - Abdurrahman Alacam
- Department of Pediatrics, Ondokuz Mayıs University, Medical Faculty, Samsun, Turkey
| | - Fatma Alacam
- Department of Pediatrics, Ondokuz Mayıs University, Medical Faculty, Samsun, Turkey
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8
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The Role of Renal Replacement Therapy in the Management of Pharmacologic Poisonings. Int J Nephrol 2016; 2016:3047329. [PMID: 28042482 PMCID: PMC5155094 DOI: 10.1155/2016/3047329] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/20/2023] Open
Abstract
Pharmacologic toxicities are common and range from mild to life-threatening. The aim of this study is to review and update the data on the role of renal replacement therapy (RRT) in the management of various pharmacologic poisonings. We aim to provide a focused review on the role of RRT in the management of pharmacological toxicities. Relevant publications were searched in MEDLINE with the following search terms alone or in combination: pharmacologic toxicity, hemodialysis, hemofiltration, renal replacement therapy, toxicology, poisonings, critical illness, and intensive care. The studies showed that a pharmacologic substance should meet several prerequisites to be deemed dialyzable. These variables include having a low molecular weight (<500 Da) and low degree of protein binding (<80%), being water-soluble, and having a low volume of distribution (<1 L/kg). RRT should be strongly considered in critically ill patients presenting with toxic alcohol ingestion, salicylate overdose, severe valproic acid toxicity, metformin overdose, and lithium poisoning. The role of RRT in other pharmacologic toxicities is less certain and should be considered on a case-by-case basis.
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9
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Smetana KS, Cook AM, Bastin MLT, Oyler DR. Antiepileptic dosing for critically ill adult patients receiving renal replacement therapy. J Crit Care 2016; 36:116-124. [PMID: 27546759 DOI: 10.1016/j.jcrc.2016.06.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/06/2016] [Accepted: 06/28/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this review was to evaluate current literature for dosing recommendations for the use of antiepileptic medications in patients receiving renal replacement therapy (RRT). DATA SOURCES With the assistance of an experienced medical librarian specialized in pharmacy and toxicology, we searched MEDLINE, EMBASE, CINAHL, Web of Science, WorldCat, and Scopus through May 2016. STUDY SELECTION AND DATA EXTRACTION Four hundred three articles were screened for inclusion, of which 130 were identified as potentially relevant. Micromedex® DRUGDEX as well as package inserts were used to obtain known pharmacokinetic properties and dosage adjustment recommendations in RRT if known. DATA SYNTHESIS Data regarding antiepileptic drug use in RRT are limited and mostly consist of case reports limiting our proposed dosing recommendations. Known pharmacokinetic parameters should guide dosing, and recommendations are provided where possible. CONCLUSION Additional studies are necessary before specific dosing recommendations can be made for most antiepileptic drugs in critically ill patients receiving RRT, specifically with newer agents.
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Affiliation(s)
- Keaton S Smetana
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY.
| | - Aaron M Cook
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Melissa L Thompson Bastin
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
| | - Douglas R Oyler
- University of Kentucky HealthCare, Department of Pharmacy, Lexington, KY; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science (UK College of Pharmacy), University of Kentucky, Lexington, KY.
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Smollin CG, Petrie MS, Kearney T. Carbamazepine and carbamazepine-10,11-epoxide clearance measurements during continuous venovenous hemofiltration in a massive overdose. Clin Toxicol (Phila) 2016; 54:424-7. [DOI: 10.3109/15563650.2016.1148721] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Craig Geoffrey Smollin
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Thomas Kearney
- School of Pharmacy, University of California San Francisco, San Francisco, CA, USA
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11
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Markedly Elevated Carbamazepine-10,11-epoxide/Carbamazepine Ratio in a Fatal Carbamazepine Ingestion. Case Rep Med 2015; 2015:369707. [PMID: 26550016 PMCID: PMC4621337 DOI: 10.1155/2015/369707] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/14/2015] [Accepted: 09/16/2015] [Indexed: 11/25/2022] Open
Abstract
Carbamazepine is a widely used anticonvulsant. Its metabolite, carbamazepine-10,11-epoxide, has been found to display similar anticonvulsant and neurotoxic properties. While the ratio of parent to metabolite concentration varies significantly, at therapeutic doses the epoxide concentration is generally about 20% of the parent. We report a case of fatal carbamazepine overdose in which the epoxide metabolite concentration was found to be 450% higher than the parent compound, suggesting a potential role for metabolite quantification in severe toxicity.
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12
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Mut L, Grobosch T, Binscheck-Domaß T, Frenzel W. Toxicological screening of human plasma by on-line SPE-HPLC-DAD: identification and quantification of acidic and neutral drugs. Biomed Chromatogr 2015; 30:343-62. [DOI: 10.1002/bmc.3554] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 06/02/2015] [Accepted: 07/02/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Ludmila Mut
- Berlin Institute of Technology; Department of Environmental Technology; Straße des 17. Juni 135 D-10623 Berlin Germany
| | - Thomas Grobosch
- Labor Berlin - Charité Vivantes GmbH; Department for Laboratory Medicine and Toxicology; Sylter Str. 2 D-13353 Berlin Germany
| | - Torsten Binscheck-Domaß
- Labor Berlin - Charité Vivantes GmbH; Department for Laboratory Medicine and Toxicology; Sylter Str. 2 D-13353 Berlin Germany
| | - Wolfgang Frenzel
- Berlin Institute of Technology; Department of Environmental Technology; Straße des 17. Juni 135 D-10623 Berlin Germany
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13
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Hughes TB, Miller GP, Swamidass SJ. Modeling Epoxidation of Drug-like Molecules with a Deep Machine Learning Network. ACS CENTRAL SCIENCE 2015; 1:168-80. [PMID: 27162970 PMCID: PMC4827534 DOI: 10.1021/acscentsci.5b00131] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Indexed: 05/02/2023]
Abstract
Drug toxicity is frequently caused by electrophilic reactive metabolites that covalently bind to proteins. Epoxides comprise a large class of three-membered cyclic ethers. These molecules are electrophilic and typically highly reactive due to ring tension and polarized carbon-oxygen bonds. Epoxides are metabolites often formed by cytochromes P450 acting on aromatic or double bonds. The specific location on a molecule that undergoes epoxidation is its site of epoxidation (SOE). Identifying a molecule's SOE can aid in interpreting adverse events related to reactive metabolites and direct modification to prevent epoxidation for safer drugs. This study utilized a database of 702 epoxidation reactions to build a model that accurately predicted sites of epoxidation. The foundation for this model was an algorithm originally designed to model sites of cytochromes P450 metabolism (called XenoSite) that was recently applied to model the intrinsic reactivity of diverse molecules with glutathione. This modeling algorithm systematically and quantitatively summarizes the knowledge from hundreds of epoxidation reactions with a deep convolution network. This network makes predictions at both an atom and molecule level. The final epoxidation model constructed with this approach identified SOEs with 94.9% area under the curve (AUC) performance and separated epoxidized and non-epoxidized molecules with 79.3% AUC. Moreover, within epoxidized molecules, the model separated aromatic or double bond SOEs from all other aromatic or double bonds with AUCs of 92.5% and 95.1%, respectively. Finally, the model separated SOEs from sites of sp(2) hydroxylation with 83.2% AUC. Our model is the first of its kind and may be useful for the development of safer drugs. The epoxidation model is available at http://swami.wustl.edu/xenosite.
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Affiliation(s)
- Tyler B. Hughes
- Department
of Pathology and Immunology, Washington
University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
| | - Grover P. Miller
- Department
of Biochemistry and Molecular Biology, University
of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, United States
| | - S. Joshua Swamidass
- Department
of Pathology and Immunology, Washington
University School of Medicine, Campus Box 8118, 660 South Euclid Avenue, St. Louis, Missouri 63110, United States
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14
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Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo THV, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila) 2014; 52:993-1004. [PMID: 25355482 PMCID: PMC4782683 DOI: 10.3109/15563650.2014.973572] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Context. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup was created to provide evidence and consensus-based recommendations on the use of extracorporeal treatments (ECTRs) in poisoning. Objectives. To perform a systematic review and provide clinical recommendations for ECTR in carbamazepine poisoning. Methods. After a systematic literature search, the subgroup extracted the data and summarized the findings following a pre-determined format. The entire workgroup voted via a two-round modified Delphi method to reach a consensus on voting statements, using a RAND/UCLA Appropriateness Method to quantify disagreement. Anonymous votes were compiled, returned, and discussed in person. A second vote determined the final recommendations. Results. Seventy-four articles met inclusion criteria. Articles included case reports, case series, descriptive cohorts, pharmacokinetic studies, and in-vitro studies; two poor-quality observational studies were identified, yielding a very low quality of evidence for all recommendations. Data on 173 patients, including 6 fatalities, were reviewed. The workgroup concluded that carbamazepine is moderately dialyzable and made the following recommendations: ECTR is suggested in severe carbamazepine poisoning (2D). ECTR is recommended if multiple seizures occur and are refractory to treatment (1D), or if life-threatening dysrhythmias occur (1D). ECTR is suggested if prolonged coma or respiratory depression requiring mechanical ventilation are present (2D) or if significant toxicity persists, particularly when carbamazepine concentrations rise or remain elevated, despite using multiple-dose activated charcoal (MDAC) and supportive measures (2D). ECTR should be continued until clinical improvement is apparent (1D) or the serum carbamazepine concentration is below 10 mg/L (42 the μ in μmol/L looks weird.) (2D). Intermittent hemodialysis is the preferred ECTR (1D), but both intermittent hemoperfusion (1D) or continuous renal replacement therapies (3D) are alternatives if hemodialysis is not available. MDAC therapy should be continued during ECTR (1D). Conclusion. Despite the low quality of the available clinical evidence and the high protein binding capacity of carbamazepine, the workgroup suggested extracorporeal removal in cases of severe carbamazepine poisoning.
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Affiliation(s)
- Marc Ghannoum
- Division of Nephrology, Verdun Hospital, University of Montreal , Montreal, QC , Canada
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15
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Ghannoum M, Roberts DM, Hoffman RS, Ouellet G, Roy L, Decker BS, Bouchard J. A stepwise approach for the management of poisoning with extracorporeal treatments. Semin Dial 2014; 27:362-70. [PMID: 24697864 DOI: 10.1111/sdi.12228] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of an extracorporeal treatment (ECTR) in a poisoned patient may be life-saving in a limited number of scenarios. The decision-processes surrounding the use of ECTR in poisoning is complex: most nephrologists are not trained to assess a poisoned patient while clinical toxicologists rarely prescribe ECTRs. Deciding on which ECTR is most appropriate for a poison requires a good understanding of the poison's physicochemical and pharmacokinetic properties. Further, a detailed understanding of the capabilities and limitations of the different ECTRs can be useful to select the most appropriate ECTR for a given clinical situation. This manuscript provides a stepwise approach to assess the usefulness of ECTRs in poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Montreal, Canada
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Ouellet G, Bouchard J, Ghannoum M, Decker BS. Available extracorporeal treatments for poisoning: overview and limitations. Semin Dial 2014; 27:342-9. [PMID: 24697909 DOI: 10.1111/sdi.12238] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Poisoning is a significant public health problem. In severe cases, extracorporeal treatments (ECTRs) may be required to prevent or reverse major toxicity. Available ECTRs include intermittent hemodialysis, sustained low-efficiency dialysis, intermittent hemofiltration and hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, peritoneal dialysis, albumin dialysis, cerebrospinal fluid exchange, and extracorporeal life support. The aim of this article was to provide an overview of the technical aspects, as well as the potential indications and limitations of the different ECTRs used for poisoned patients.
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Affiliation(s)
- Georges Ouellet
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, University of Montreal, Montreal, Quebec, Canada
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Chung YK, Chang KY, Park HS, Kim MH, Lee KM, Lim TS, Kim HW. Severe carbamazepine intoxication unresponsive to albumin-enhanced continuous venovenous hemodiafiltration with low dialysate flow. Hemodial Int 2014; 18:551-5. [PMID: 24422855 DOI: 10.1111/hdi.12132] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Carbamazepine (CBZ) intoxication can be associated with severe toxicity, including neurological and cardio-respiratory abnormalities. Highly protein-bound, CBZ is not removed efficiently through conventional hemodialysis. Charcoal hemoperfusion is the most effective extracorporeal elimination therapy for CBZ intoxication. Recent reports have indicated that continuous venovenous hemodiafiltration (CVVHDF), albumin-enhanced continuous venovenous hemodialysis, high-flux hemodialysis and plasma exchange can be as effective as charcoal hemoperfusion. In contrast to recent reports, which demonstrated the effectiveness of CVVHDF with high dialysate flow in CBZ intoxication, we observed that serum CBZ level was decreased minimally by albumin-enhanced CVVHDF with low dialysate flow. Therefore, albumin-enhanced CVVHDF with high dialysate flow should be considered in severe CBZ intoxication, if hemoperfusion is unavailable because of the lack of facilities or if it cannot be performed.
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Affiliation(s)
- Young K Chung
- Division of Nephrology, Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea; St. Vincent's Hospital, Suwon, Korea
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Sanaei-Zadeh H. Is early hemodialysis indicated in the treatment of carbamazepine intoxication? Blood Purif 2012; 33:309; author reply 310. [PMID: 22678242 DOI: 10.1159/000337861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wong YC, Qian S, Zuo Z. Regioselective biotransformation of CNS drugs and its clinical impact on adverse drug reactions. Expert Opin Drug Metab Toxicol 2012; 8:833-54. [DOI: 10.1517/17425255.2012.688027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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