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De Las Cuevas C, de Leon VC, Blasco-Fontecilla H, Baca-García E, Sagud M, Sanz EJ, de Leon J. Clozapine may consistently protect from suicidal behaviors while other antipsychotics may lack a specific protective effect: a comprehensive VigiBase study interpreted in the context of the prior literature. Expert Opin Drug Saf 2024:1-11. [PMID: 39223773 DOI: 10.1080/14740338.2024.2399094] [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: 06/02/2024] [Revised: 08/05/2024] [Accepted: 08/10/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND In the United States, clozapine was first approved for treatment-resistant schizophrenia and then for suicidality in schizophrenia psychoses. Systematic reviews support clozapine's anti-suicidal effect, but the forensic literature stresses its lethality during overdoses. RESEARCH DESIGN AND METHODS Clozapine reports to the international pharmacovigilance database (VigiBase) were analyzed for suicidal ideation, suicide attempts, intentional overdose, and completed suicides from introduction to 1 January 2024. VigiBase uses the information component (IC) as a disproportionality analysis. RESULTS The clozapine ICs (range: other antipsychotics) were: 1) suicidal ideation IC = 0.570 with IC025 = 0.454 to IC975 = 0.680 (IC = 3.568 for aripiprazole and 1.729 for risperidone), 2) suicide attempt IC = 1.428 with IC025 = 1.323 to IC975 = 1.529 (IC = 4.150 for quetiapine and 2.968 for risperidone), 3) intentional overdose: IC = 0.995 with IC025 = 0.864 to IC975 = 1.120 (IC = 4.080 for quetiapine and 1.957 for aripiprazole), and 4) completed suicide IC = 1.133 with IC025 = 1.026 to IC975 = 1.235 (IC = 4.648 for quetiapine and 2.160 for risperidone). In summary, all clozapine ICs were significantly lower. We found 2391 clozapine-treated patients on the suicidality spectrum (627 cases with suicidal ideation, 752 with suicide attempt, 488 with intentional overdose, and 731 with completed suicide) but many were taking other antipsychotics. The most frequent reporting countries were the United States, the United Kingdom, and Croatia. CONCLUSION This pharmacovigilance study, with all its inherent limitations, provides independent proof, not overlapping with prior literature, that clozapine may have specific strong anti-suicidal effects that do not appear to be present in other antipsychotics. Further VigiBase studies are needed to compare the lethality of an intentional overdose of clozapine (14.3%) with other antipsychotics.
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Affiliation(s)
- Carlos De Las Cuevas
- Department of Internal Medicine, Dermatology, and Psychiatry and Instituto Universitario de Neurociencia (IUNE), Universidad de La Laguna, La Laguna, Spain
| | - Victoria C de Leon
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, MO, USA
| | - Hilario Blasco-Fontecilla
- Instituto de Investigación, Transferencia e Innovación, Ciencias de la Saludy Escuela de Doctorado, Universidad Internacional de La Rioja, Logroño, Spain
- Emooti, Madrid, Spain
- Center of Biomedical Network Research on Mental Health (CIBERSAM), Carlos III Institute of Health, Madrid, Spain
| | - Enrique Baca-García
- Center of Biomedical Network Research on Mental Health (CIBERSAM), Carlos III Institute of Health, Madrid, Spain
- Department of Psychiatry, Hospital Fundación Jiménez Díaz, Madrid, Spain
- Complutense University of Madrid, Madrid, Spain
- Universidad Católica del Maule, Talca, Chile
- Department of Psychiatry, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Marina Sagud
- School of Medicine, University of Zagreb, Zagreb, Croatia
- University Hospital Centre Zagreb, Zagreb, Croatia
| | - Emilio J Sanz
- Department of Physical Medicine and Pharmacology, School of Medicine, Universidad de La Laguna, Spain
- Hospital Universitario de Canarias, Tenerife, Spain
| | - Jose de Leon
- Mental Health Research Center, Eastern State Hospital, Lexington, KY, USA
- Biomedical Research Centre in Mental Health Net (CIBERSAM), Santiago Apóstol Hospital, University of the Basque Country, Vitoria, Spain
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Poliacoff Z. Three safety indices for the fourteen most prescribed antidepressants in the US, 2013-2020. Gen Hosp Psychiatry 2024; 90:1-5. [PMID: 38865833 DOI: 10.1016/j.genhosppsych.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE This study provides three prevalence-based metrics of potential harm, the fatal toxicity index (FTI), serious morbidity index (SMI) and healthcare utilization index (HUI) for fourteen of the most prescribed antidepressants in the US. METHOD For the years 2013-2020, adverse events for single drug exposures were obtained from the National Poison Data System. Prescription estimates were taken from the Agency for Healthcare Research and Quality's Medical Expenditure Survey. 95% confidence intervals were calculated using a Poisson distribution. Chi-square testing was used where significance was not clear. RESULTS SSRIs and SNRIs had the lowest overall indices (FTI 0.02-0.26). Bupropion's FTI (0.27-0.43) was not statistically significantly different from that of imipramine (FTI 0-1.3, p = .62) or nortriptyline (FTI 0.25-0.78, p = .22), though its SMI and HUI were significantly greater. There was a statistically significant difference in all indices between TCAs (p < .0047). The difference between the FTI of all SSRIs did not remain significant after correction (p = .045). CONCLUSION SSRIs and SNRIs are safer than alternative agents on all measures. Bupropion exposure was as likely to cause mortality, and more likely to cause morbidity or require treatment in a healthcare facility, than TCAs nortriptyline and imipramine.
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Affiliation(s)
- Zachary Poliacoff
- University of South Florida, Department of psychiatry, 3515 E Fletcher Ave, Tampa, FL 33613, United States.
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Khalifa HK, Mostafa Mansour N, Elmansy A. Predictors for prolonged qt intervals in acute antipsychotic poisoned patients. Toxicol Res (Camb) 2024; 13:tfae038. [PMID: 38500514 PMCID: PMC10944555 DOI: 10.1093/toxres/tfae038] [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: 10/24/2023] [Revised: 02/16/2024] [Accepted: 02/26/2024] [Indexed: 03/20/2024] Open
Abstract
Background Acute antipsychotic poisoning is correlated to a high prevalence of qt interval prolongation. Aim This study aimed to evaluate early qt interval prolongation predictors in acute antipsychotic-poisoned patients. Methodology This prospective cohort study enrolled 70 symptomatic patients with acute antipsychotic poisoning. Sociodemographic data, toxicological, clinical, investigation, and outcomes were collected and analyzed. The estimation of the corrected qt interval (QTc) was performed using Bazett's method. Primary outcome was normal or abnormal length of QTc interval. Secondary outcomes included duration of hospital stay, complete recovery and mortality. The corrected qt interval was analyzed by univariate and multivariate logistic regression analysis. Results Patients were divided into groups A (normal QTc interval up to 440 msec; 58.6% of cases) and B (prolonged QTc interval ≥ 440 msec; 41.4% of cases). Patients in group B had significantly high incidences of quetiapine intake, bradycardia, hypotension, hypokalemia, and long duration of hospital stay. By multivariate analysis, quetiapine [Odd's ratio (OR): 39.674; Confidence Interval (C.I:3.426-459.476)], bradycardia [OR: 22.664; C.I (2.534-202.690)], and hypotension [OR: 16.263; (C.I: 2.168-122.009)] were significantly correlated with prolonged QTc interval. Conclusion In acute antipsychotic poisoning, quetiapine, bradycardia, and hypotension are early clinical predictors for prolonged QTc interval.
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Affiliation(s)
- Heba K Khalifa
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Medical collages campus, 6 Floor, Al-Geish Street, Tanta University, Tanta, Elgharbya, 31527, Egypt
| | - Nouran Mostafa Mansour
- Cardiology Department, Faculty of Medicine, Medical collages campus, Al-Geish Street, Tanta University, Tanta, Elgharbya, 31527, Egypt
| | - Alshaimma Elmansy
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Medical collages campus, 6 Floor, Al-Geish Street, Tanta University, Tanta, Elgharbya, 31527, Egypt
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Chandru P, Gunja N. Toxicity and Adverse Effects in Clozapine-Related Presentations to a Medical Toxicology Service in Western Sydney. J Med Toxicol 2023; 19:374-380. [PMID: 37624540 PMCID: PMC10522536 DOI: 10.1007/s13181-023-00963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/07/2023] [Accepted: 08/10/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Clozapine is an anti-psychotic agent, reserved for treatment-resistant schizophrenia, with demonstrated efficacy in an otherwise therapeutically challenging patient population. We aimed to review the full spectrum casemix of clozapine presentations to our tertiary toxicology service. METHODS In this retrospective study, we reviewed consecutive clozapine related toxicity presentations to a tertiary medical toxicology inpatient and consultation service-including deliberate self-poisoning (DSP), adverse drug reaction (ADR), recreational use, and therapeutic misadventure over a 10-year period from 2011 to 2021. Data were extracted for demographics, ingested dose, exposure characteristics, and patient outcome. RESULTS We identified 83 patients with clozapine-related presentations over the 10-year period. Twenty-two patients were excluded. Of the remaining 61 patients, 28 patients presented with DSP, 20 patients with accidental overdose, and 13 patients with an ADR; no patients presented with recreational use. It was noted that ADRs were largely idiosyncratic reactions and not always related to dose adjustments. In the context of therapeutic misadventure and DSP, we noted that a lower mean dose achieved a higher poison severity score (PSS) in clozapine-naive patients when compared to those patients on regular clozapine. CONCLUSIONS The presentation of clozapine-related toxicity differs depending on the modality of ingestion, whether DSP, accidental, or as a result of ADR. Patients naive to clozapine therapy tend to experience higher PSS with lower doses ingested either in a deliberate self-poisoning or accidental ingestion context. This is likely due to tolerance to the sedative properties of clozapine. No patients manifested clinical toxicity greater than 8 hours after ingestion, with an observation period of 6 hours accurately identifying toxicity in most patients.
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Affiliation(s)
- Pramod Chandru
- Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia.
| | - Naren Gunja
- Department of Clinical Pharmacology & Toxicology, Western Sydney Health, Sydney, Australia
- Discipline of Emergency Medicine, Sydney Medical School, University of Sydney, New South Wales, Australia
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Kriikku P, Ojanperä I. Fatal concentrations of antidepressant and antipsychotic drugs in postmortem femoral blood. J Anal Toxicol 2023; 47:615-622. [PMID: 37440364 PMCID: PMC10503646 DOI: 10.1093/jat/bkad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/16/2023] [Accepted: 07/12/2023] [Indexed: 07/15/2023] Open
Abstract
Antidepressants and antipsychotics are both an important class of prescription drugs within postmortem (PM) toxicology because most of the substances are toxic in overdose and the mental disorders being treated may be associated with suicidality. A wide range of antidepressants and antipsychotics are currently included in up-to-date PM toxicology analysis protocols. However, apart from case studies, few reports on fatal concentrations based on large number of cases have been published in the literature. Based on PM investigations in Finland between 2000 and 2020, this study provides fatal reference concentrations in poisonings due to an antidepressant or an antipsychotic drug assigned as the principal intoxicant. Summary statistics for drug concentrations in PM femoral blood (min, max, mean, 10th, 25th, 50th, 75th, 90th percentile) were calculated for 17 antidepressant (N = 2,007) and for 12 antipsychotic drugs (N = 1,161). The proportion of suicide, accident and undetermined manner of death is indicated for each drug. Further, the fatal concentrations obtained in this study were evaluated by comparison with fatal and "normal" PM concentrations reported by two previously published approaches, the grouped causes of death approach and the all causes of death approach, respectively. This study shows that, despite the well-known variation in PM drug concentrations, competently generated fatal concentration results for the drugs studied are consistent to such an extent that they can be used as a reference in the interpretation process.
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Affiliation(s)
- Pirkko Kriikku
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare (THL), P.O. Box 30, Mannerheimintie 166, Helsinki FI-00271, Finland
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21, Haartmaninkatu 3, Helsinki FI-00014, Finland
| | - Ilkka Ojanperä
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare (THL), P.O. Box 30, Mannerheimintie 166, Helsinki FI-00271, Finland
- Department of Forensic Medicine, University of Helsinki, P.O. Box 21, Haartmaninkatu 3, Helsinki FI-00014, Finland
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Anestopoulos I, Kyriakou S, Tragkola V, Paraskevaidis I, Tzika E, Mitsiogianni M, Deligiorgi MV, Petrakis G, Trafalis DT, Botaitis S, Giatromanolaki A, Koukourakis MI, Franco R, Pappa A, Panayiotidis MI. Targeting the epigenome in malignant melanoma: Facts, challenges and therapeutic promises. Pharmacol Ther 2022; 240:108301. [PMID: 36283453 DOI: 10.1016/j.pharmthera.2022.108301] [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: 06/06/2022] [Revised: 10/03/2022] [Accepted: 10/19/2022] [Indexed: 11/16/2022]
Abstract
Malignant melanoma is the most lethal type of skin cancer with high rates of mortality. Although current treatment options provide a short-clinical benefit, acquired-drug resistance highlights the low 5-year survival rate among patients with advanced stage of the disease. In parallel, the involvement of an aberrant epigenetic landscape, (e.g., alterations in DNA methylation patterns, histone modifications marks and expression of non-coding RNAs), in addition to the genetic background, has been also associated with the onset and progression of melanoma. In this review article, we report on current therapeutic options in melanoma treatment with a focus on distinct epigenetic alterations and how their reversal, by specific drug compounds, can restore a normal phenotype. In particular, we concentrate on how single and/or combinatorial therapeutic approaches have utilized epigenetic drug compounds in being effective against malignant melanoma. Finally, the role of deregulated epigenetic mechanisms in promoting drug resistance to targeted therapies and immune checkpoint inhibitors is presented leading to the development of newly synthesized and/or improved drug compounds capable of targeting the epigenome of malignant melanoma.
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Affiliation(s)
- I Anestopoulos
- Department of Cancer Genetics, Therapeutics & Ultrastructural Pathology, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | - S Kyriakou
- Department of Cancer Genetics, Therapeutics & Ultrastructural Pathology, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | - V Tragkola
- Department of Cancer Genetics, Therapeutics & Ultrastructural Pathology, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | - I Paraskevaidis
- Department of Cancer Genetics, Therapeutics & Ultrastructural Pathology, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | - E Tzika
- Department of Cancer Genetics, Therapeutics & Ultrastructural Pathology, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus
| | | | - M V Deligiorgi
- Laboratory of Pharmacology, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - G Petrakis
- Saint George Hospital, Chania, Crete, Greece
| | - D T Trafalis
- Laboratory of Pharmacology, Medical School, National & Kapodistrian University of Athens, Athens, Greece
| | - S Botaitis
- Department of Surgery, Alexandroupolis University Hospital, Democritus University of Thrace School of Medicine, Alexandroupolis, Greece
| | - A Giatromanolaki
- Department of Pathology, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - M I Koukourakis
- Radiotherapy / Oncology, Radiobiology & Radiopathology Unit, Department of Medicine, School of Health Sciences, Democritus University of Thrace, Alexandroupolis, Greece
| | - R Franco
- Redox Biology Centre, University of Nebraska-Lincoln, Lincoln, NE, USA; School of Veterinary Medicine & Biomedical Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - A Pappa
- Department of Molecular Biology & Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | - M I Panayiotidis
- Department of Cancer Genetics, Therapeutics & Ultrastructural Pathology, The Cyprus Institute of Neurology & Genetics, Nicosia, Cyprus.
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7
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Comparing characteristics of suicide to non-suicide drug poisoning deaths, by sex, in Ireland. J Affect Disord 2022; 306:80-89. [PMID: 35306124 DOI: 10.1016/j.jad.2022.03.030] [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] [Received: 09/24/2021] [Revised: 01/17/2022] [Accepted: 03/10/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Suicide by drug poisoning is potentially preventable; however, evidence on associated risk factors by sex is limited. AIM To assist in understanding how individual and social contextual factors, and specific drugs, influence risk of suicide compared to non-suicide drug poisoning deaths, and how this differs by sex. METHODS Data were extracted from the National Drug-Related Deaths Index. Analysis included univariable and multivariable logistic regression to estimate unadjusted and adjusted odds ratios (OR) and 95% confidence intervals (CI) for factors associated with suicide drug poisoning deaths (SDPD) (primary outcome) compared with non-suicide drug poisoning deaths (NSDPD) and stratified by sex. RESULTS SDPD accounted for 240 (22%) of 1114 poisoning deaths, the majority among men (n = 147, 61%). Increasing age, mental ill health (AOR 7.85, 95% CI: 5.46-11.28), chronic pain (AOR 5.57, 95% CI: 3.28-9.46), and history of previous overdose (AOR 5.06, 95% CI: 3.39-7.56) were associated with increased odds of SDPD, with similar results for both sexes. The main drugs associated with SDPD were non-opioid analgesics (OR 4.06 [95% CI 2.66-6.18]), antipsychotics (OR 2.42 [95% CI 1.63-3.60]) and antidepressants (OR 2.18 [95% CI 1.59-2.97]). Pregabalin was associated with SDPD among women only. LIMITATIONS Secondary analysis of coronial data on drug poisoning deaths therefore findings may not be relevant to suicide deaths in general. CONCLUSIONS Ongoing monitoring for signs of suicidal intent in individuals with mental illness, chronic pain, overdose, and/or prescribed mental health medications may identify individuals in need of additional intervention.
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Fitzgerald C, Christensen RHB, Simons J, Andersen PK, Benros ME, Nordentoft M, Erlangsen A, Hawton K. Effectiveness of medical treatment for bipolar disorder regarding suicide, self-harm and psychiatric hospital admission: between- and within-individual study on Danish national data. Br J Psychiatry 2022; 221:1-9. [PMID: 35450547 DOI: 10.1192/bjp.2022.54] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Mood stabilisers are the main treatment for bipolar disorder. However, it is uncertain which drugs have the best outcomes. AIMS To investigate whether rates of suicide, self-harm and psychiatric hospital admission in individuals with bipolar disorder differ between mood stabilisers. METHOD A cohort design was applied to people aged ≥15 years who were diagnosed with bipolar disorder and living in Denmark during 1995-2016. Treatment with lithium, valproate, other mood stabilisers and antipsychotics were compared in between- and within-individual analyses, and adjusted for sociodemographic characteristics and previous self-harm. RESULTS A total of 33 337 individuals with bipolar disorder were included (266 900 person-years). When compared with individuals not receiving treatment, those receiving lithium had a lower rate of suicide (hazard ratio 0.40, 95% CI 0.31-0.51). When comparing treatment and non-treatment periods in the same individuals, lower rates of self-harm were found for lithium (hazard ratio 0.74, 95% CI 0.61-0.91). Lower rates of psychiatric hospital admission were found for all drug categories compared with non-treatment periods in within-individual analyses (P<0.001). The low rates of self-harm and hospital admission for lithium in within-individual analyses were supported by results of between-individual analyses. CONCLUSIONS Lithium was associated with lower rates of suicide, self-harm and psychiatric hospital readmission in all analyses. With respect to suicide, lithium was superior to no treatment. Although confounding by indication cannot be excluded, lithium seems to have better outcomes in the treatment of bipolar disorder than other mood stabilisers.
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Affiliation(s)
- Cecilie Fitzgerald
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Denmark; and Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Denmark
| | | | | | | | | | - Merete Nordentoft
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Denmark; Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Denmark; and Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Annette Erlangsen
- Danish Research Institute for Suicide Prevention, Mental Health Centre Copenhagen, Denmark; Copenhagen Research Center for Mental Health, Mental Health Centre Copenhagen, Denmark; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, USA; and Center of Mental Health Research, Australian National University, Australia
| | - Keith Hawton
- Centre for Suicide Research, University of Oxford, UK; and, Oxford Health NHS Foundation Trust, UK
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Nagashima K, Hosono H, Watanabe M. Relationship between tracheal intubation and the drugs used by patients with drug overdose due to self-harm. J Pharm Health Care Sci 2022; 8:2. [PMID: 34980270 PMCID: PMC8722335 DOI: 10.1186/s40780-021-00234-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/29/2021] [Indexed: 12/04/2022] Open
Abstract
Background Tracheal intubation may be performed in patients with drug overdose due to self-harm; however, the details of the causative drug are unknown. The purpose of this study was to clarify the relationship between drugs or its blood levels of patients with drug overdose and the need for tracheal intubation based on the actual measurement results. Methods From October 2018 to March 2020, 132 patients with drug overdose due to self-harm who were transported to the emergency department (ED) were studied. Patient drugs were measured using gas chromatography–mass spectrometry (GC-MS) and were analyzed on the basis of the GC/MS Forensic Toxicological Database. Logistic analysis was performed by combining patient information and GC-MS information. Results The Glasgow Coma Scale (GCS) and Japan Coma Scale (JCS) efficiently predicted tracheal intubation in patients with drug overdose during transport triage; GCS (cut-off value: 12, area under the curve (AUC): 0.81, 95% confidence interval (CI): 0.71–0.88, sensitivity: 0.85, specificity: 0.71, P < 0.05) and JCS (cut-off value: 3, AUC: 0.74, 95% CI: 0.60–0.84, sensitivity: 0.60, specificity: 0.84, P < 0.05). The drugs detected in all patients with drug overdose in order were benzodiazepine receptor agonists (BZs; 43.9%), anticonvulsants (38.6%), antipsychotics (25.0%), and antidepressants (9.8%). In univariate logistic analysis, antipsychotics (odds ratio (OR) 2.46, 95% CI 1.19–5.20, P < 0.05), anticonvulsants (OR 2.71, 95% CI 1.26–5.98, P < 0.05), and anticonvulsants above alert blood levels (OR 27.8, 95% CI 2.92–264.1, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose, but not BZs and antidepressants. Also, in multivariate logistic analysis, antipsychotics (OR 2.27, 95% CI 1.07–4.83, P < 0.05), anticonvulsants (OR 2.50, 95% CI 1.14–5.64, P < 0.05) and in multivariate logistic analysis of blood levels, anticonvulsants above the alert blood levels (OR 24.9, 95% CI 2.56–241.6, P < 0.05) were significantly associated with tracheal intubation in patients with drug overdose respectively. Conclusions Logistic analysis revealed that the use of anticonvulsants and antipsychotics were significantly associated with an increased OR in the tracheal intubation of patients with drug overdose due to self-harm.
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Affiliation(s)
- Kazuki Nagashima
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Hiroyuki Hosono
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Machiko Watanabe
- Laboratory of Clinical Pharmaceutics, Faculty of Pharma-Science, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
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10
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Dawson JL, Sluggett JK, Schumann JL, Procter NG, Bell JS. Fatal poisonings involving clozapine: A 16-year review of Australian coronial investigations. Aust N Z J Psychiatry 2022; 56:50-58. [PMID: 33736477 DOI: 10.1177/0004867421998788] [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
OBJECTIVE Concerns about intentional and unintentional poisoning present a barrier to wider use of clozapine in treatment-resistant schizophrenia. The objective of this study was to investigate decedent demographics and trends in fatal poisonings in Australia involving clozapine. METHODS This was a retrospective case series of all fatal drug toxicity reported to an Australian coroner between 1 May 2000 and 31 December 2016 where toxicological analysis detected clozapine. Cases were identified using the National Coronial Information System. Demographics extracted included age and gender of the decedent, year and location of death, cause and manner of death and drugs detected in post-mortem samples. RESULTS There were 278 poisoning deaths where clozapine was detected in toxicological analyses. Three-quarters of all cases (n = 207) involved men and the median age at death was 38.5 years (interquartile range: 16 years). Three-quarters of the deaths occurred in the home. Overall, 15.8% of deaths were deemed intentional, 57.5% unintentional and 24.5% of unknown intent. While the annual number of intentional self-poisonings remained constant with <5 per year, the overall number of fatalities increased due to an increase in unintentional poisonings. Multiple drug toxicity was reported in 55.0% of cases and clozapine alone in 45.0% of cases. The most common co-reported medications were antidepressants, benzodiazepines and opioids detected in 47.1%, 44.4% and 41.2% of multiple drug toxicities, respectively. CONCLUSION This was the first Australia-wide review of all fatal drug poisonings reported to a coroner involving clozapine. Fatalities were most common in men and occurred at home. Multiple drug toxicity generally involved psychotropic, sedative or opioid analgesic medications. Despite increasing clozapine use, rates of intentional poisoning have remained constant and low. Developing a better knowledge of unintentional fatalities presents an opportunity to minimise harm.
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Affiliation(s)
- Jessica L Dawson
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.,SA Pharmacy, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.,UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Jennifer L Schumann
- Department of Forensic Medicine, Monash University, Southbank, VIC, Australia.,Victorian Institute of Forensic Medicine, Southbank, VIC, Australia
| | - Nicholas G Procter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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11
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Mainoli B, Gonçalves N, Ferreira JJ, Mégarbane B. Potential drug-drug interactions in acute poisonings managed in the intensive care unit: Occurrence, risk factors and relationship to patient severity on admission. Basic Clin Pharmacol Toxicol 2021; 130:337-345. [PMID: 34873835 DOI: 10.1111/bcpt.13698] [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: 09/30/2021] [Revised: 11/27/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022]
Abstract
Beyond the direct toxicity resulting from each drug in the poisoned patient, additional toxicities may result from drug-drug interactions (DDIs). We aimed to determine the frequency of potential DDIs in the poisoned patient and investigate whether DDIs are associated with severity. We conducted a 1-year cohort study in a toxicological ICU. DDIs were identified using an electronic interaction-checker tool. Among our 354 ICU poisoned patients, 134 (38%) presented at least one potential DDI between acute poisoning drugs and 180 (51%) at least one potential DDI between acute poisoning and long-term treatment drugs. Using multivariate analyses, previous suicide attempt was associated with the presence of potential DDIs between acute poisoning drugs in suicide attempt patients (P = 0.014). Chronic alcoholism (P = 0.005) and tobacco smoking (P = 0.022) were associated with the presence of potential DDIs between acute poisoning and long-term treatment drugs in recreational drug users. Presence of potential DDIs between acute poisoning and long-term treatment drugs was associated with catecholamine infusion (P = 0.022) in suicidal self-exposure patients. Presence of potential pharmacodynamic DDIs between acute poisoning and long-term treatment drugs was associated with aspiration pneumonia onset in recreational drug users (P = 0.03). ICU poisoned patients present a high rate of potential DDIs that may influence the outcome.
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Affiliation(s)
- Beatrice Mainoli
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, APHP, Paris University, INSERM UMRS-1144, Paris, France.,Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina Universidade de Lisboa, Lisbon, Portugal.,IMM, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nilza Gonçalves
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina Universidade de Lisboa, Lisbon, Portugal.,IMM, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Joaquim J Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina Universidade de Lisboa, Lisbon, Portugal.,IMM, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, APHP, Paris University, INSERM UMRS-1144, Paris, France
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Antipsychotic-Related Fatal Poisoning, England and Wales, 1993-2019: The Impact of Second-Generation Antipsychotics. J Clin Psychopharmacol 2021; 41:650-657. [PMID: 34668874 DOI: 10.1097/jcp.0000000000001479] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Deaths from antipsychotic (AP) poisoning have increased in England and Wales despite restriction of the use of thioridazine in 2000. METHODS We analyzed data from the Office for National Statistics drug-related death database, England and Wales, 1993-2019, to investigate fatal AP poisoning. RESULTS There were 2286 deaths (62% male patients). Annual numbers of intentional AP-related fatal poisonings (suicides) were relatively stable (1993, 35; 2019, 44; median, 44; range, 30-60). Intentional overdose deaths involving clozapine (96 male, 25 female) increased from 1 in 1994 to 5 in 2003 and have since remained relatively constant (median, 6; range, 3-10 per annum). Unintentional second-generation AP-related fatal poisonings have increased steadily since 1998, featuring in 828 (74%) of all unintentional, AP-related fatal poisonings in the period studied (2019, 89%). There were 181 unintentional clozapine-related deaths, (107 [59%] alone without other drugs ± alcohol) as compared with 291 quetiapine-related deaths (86 [30%] alone without other drugs ± alcohol) and 314 unintentional olanzapine-related deaths (77 [25%] alone without other drugs ± alcohol). Some 75% of all unintentional clozapine- and olanzapine-related deaths were of male patients (78% and 73%, respectively) as compared with 58% of unintentional quetiapine-related fatal poisonings. Clozapine now features prominently in intentional and in unintentional AP-related fatal poisoning in England and Wales. Deaths of male patients predominate in both categories. There were also 77 and 86 deaths attributed to unintentional poisoning with olanzapine and with quetiapine, respectively, in the absence of other drugs. CONCLUSIONS More effort is needed to prevent unintentional deaths not only from clozapine but also from olanzapine and quetiapine.
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Bai R, Xie B, Cong B, Ma CL, Wen D. Epidemiological Characteristics of Sedative-Hypnotics and Opioid Painkillers at High-Frequency Exposure. FA YI XUE ZA ZHI 2021; 37:694-698. [PMID: 35187923 DOI: 10.12116/j.issn.1004-5619.2020.300702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Drug poisoning has a high incidence and serious consequences in medical institutions; its epidemiological characteristics also directly affect the changes in national laws and policies and the implementation of local management policies. Chinese statistics on drug-related abnormal death cases generally come from judicial appraisal centers and medical units. However, due to differences in work content and professional restrictions, there are differences in information management forms, which makes it difficult for appraisers to conduct a professional and systematic analysis of drug-related cases. This article focuses on the analysis of epidemiological characteristics of sedative-hypnotics and opioid painkillers and their exposure patterns in cases of poisoning death by analyzing the annual report of the American Association of Poison Control Center, combined with the characteristics of drug exposure in China.
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Affiliation(s)
- Rui Bai
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Bing Xie
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Bin Cong
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Chun-Ling Ma
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
| | - Di Wen
- Hebei Key Laboratory of Forensic Medicine, Collaborative Innovation Center of Forensic Medical Molecular Identification, College of Forensic Medicine, Hebei Medical University, Shijiazhuang 050017, China
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14
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Babkina AS, Khadzhiyeva MB, Ostrova IV, Ryzhkov IA, Golubev AM. Global DNA Methylation Of Brain Neurons In Acute Poisoning With Clozapine And Its Combination With Alcohol: An Experimental Study. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background — Acute poisoning with atypical neuroleptic clozapine is characterized by rapid progression, high risk of death and severe neurological manifestations. Neurotoxic effects of this pharmaceutical drug have also been reported at therapeutic doses. The pathogenesis of brain damage in acute clozapine poisoning is not fully understood. Changes in DNA methylation level may play an important role in the mechanisms of drug neurotoxicity. The available data on the effect of clozapine on brain cell DNA provide a rationale for studying the epigenetic aspects of the pathogenesis of acute poisoning with this neuroleptic agent. The objective of our study was to evaluate the global DNA methylation level in rat brain neurons in acute poisoning with clozapine and its combination with ethanol. Material and methods — Clozapine – 150 mg/kg in 2.0 ml of normal saline solution, or clozapine – 150 mg/kg in 2.0 ml of 40% ethanol were administered via a gastric tube to adult male Wistar rats (n=21) under anesthesia with sevoflurane. In the control group, saline was administered via a gastric tube. Animals were euthanized four hours after drug administration. Autopsy was performed with the collection of brain samples for histochemical examination and determination of the DNA methylation level using the fluorometric method. To detect DNA in sections of paraffin-embedded tissue, we used the Feulgen staining. The TUNEL method was employed to detect DNA fragmentation. Results — An increase in the level of global DNA methylation in brain neurons was found in the clozapine and clozapine+ethanol groups. The average level of methylated DNA in the clozapine+ethanol group was higher than in the control group or clozapine group (2.56±0.31 vs. 1.35±0.1, p=0.007 and 1.70±0.33, p=0.044, respectively). An increase in the mean optical density of the cortical neuron nuclei was observed in the clozapine+ethanol group compared with the control group and clozapine group. DNA fragmentation was not detected in any experimental group. Conclusion — Acute poisoning with clozapine in combination with alcohol caused an increase in the global DNA methylation level in brain neurons, which may have played a significant role in the pathogenesis of acute clozapine poisoning and could be an important factor in the neurotoxicity of this medication.
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Affiliation(s)
- Anastasiya S. Babkina
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Maryam B. Khadzhiyeva
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Irina V. Ostrova
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Ivan A. Ryzhkov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Arkady M. Golubev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
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15
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Fukushima HCS, Bailone RL, Corrêa T, Janke H, De Aguiar LK, Setti PG, Borra RC. Zebrafish toxicological screening could aid Leishmaniosis drug discovery. Lab Anim Res 2021; 37:27. [PMID: 34530926 PMCID: PMC8444568 DOI: 10.1186/s42826-021-00104-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/05/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Recently a screen from a library of 1.8 million compounds identified in vitro a potent activity of the 2-aminobenzimidazoles series against Leishmania infantum, the etiological agent responsible by over 20.000 deaths each year. Several analogs were synthesized and in vitro tested through an optimization program, leading to a promising 2-aminobenzimidazoles derived compound (2amnbzl-d) that was progressed to in vivo mice studies. However, the not expected toxic effects prevented its progression to more advanced preclinical and clinical phases of drug development. Due to limitations of cell models in detecting whole organism complex interactions, 90% of the compounds submitted to pre-clinical tests are reproved. The use of Zebrafish embryo models could improve this rate, saving mammals, time and costs in the development of new drugs. To test this hypothesis, we compared 2amnbzl-d with two compounds with already established safety profile: carbamazepine and benznidazole, using an embryo Zebrafish platform based on acute toxicity, hepatotoxicity, neurotoxicity and cardiotoxicity assays (Pltf-AcHpNrCd). RESULTS Tests were performed blindly, and the results demonstrated the presence of lethal and teratogenic effects (CL50%: 14.8 µM; EC50%: 8.6 µM), hepatotoxic in concentrations above 7.5 µM and neurotoxic in embryos exposed to 15 µM of 2amnbzl-d. Nevertheless, benznidazole exposition showed no toxicity and only the 100 µM of carbamazepine induced a bradycardia. CONCLUSIONS Results using Pltf-AcHpNrCd with zebrafish reproduced that found in the toxicological tests with mammals to a portion of the costs and time of experimentation.
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Affiliation(s)
- Hirla Costa Silva Fukushima
- Center of Biological and Health Sciences, Federal University of Sao Carlos, Washington Luis Road km 235, Sao Carlos, 13565-905, Brazil.
| | - Ricardo Lacava Bailone
- Department of Federal Inspection Service, Ministry of Agriculture, Livestock and Supply of Brazil, Federal Inspection Service,, Treze de Maio, Street n°1558, Bela Vista, São Paulo, 01327-00, Brazil.,Department of Genetic and Evolution, Federal University of São Carlos, Washington Luis Road km 235, São Carlos, 13565-905, Brazil
| | - Tatiana Corrêa
- Department of Genetic and Evolution, Federal University of São Carlos, Washington Luis Road km 235, São Carlos, 13565-905, Brazil
| | - Helena Janke
- Department of Genetic and Evolution, Federal University of São Carlos, Washington Luis Road km 235, São Carlos, 13565-905, Brazil
| | - Luís Kluwe De Aguiar
- Department of Food Technology and Innovation, Harper Adams University, Edgmond, Newport, TF10 8NB, UK
| | - Princia Grejo Setti
- Department of Genetic and Evolution, Federal University of São Carlos, Washington Luis Road km 235, São Carlos, 13565-905, Brazil
| | - Ricardo Carneiro Borra
- Department of Genetic and Evolution, Federal University of São Carlos, Washington Luis Road km 235, São Carlos, 13565-905, Brazil
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16
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Mainio A, Kuusisto L, Hakko H, Riipinen P. Antipsychotics as a method of suicide: population based follow-up study of suicide in Northern Finland. Nord J Psychiatry 2021; 75:281-285. [PMID: 33215967 DOI: 10.1080/08039488.2020.1847323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
AIM This study examined the trend and role of antipsychotics as a method of self-poisoning suicide. MATERIALS AND METHODS The basic data covered 483 poisoning suicides, occurring between the years 1988 and 2011, in Northern Finland, of which 178 (115 men, 63 women) were completed using antipsychotics. RESULTS During the 23-year follow-up period, second-generation antipsychotics (SGAs) overtook first-generation antipsychotics (FGAs) as a suicide method. Female victims, compared to males, had more commonly used quetiapine (17.5% vs. 6.1%, p = .016), while suicides using promazine were more common in males compared to females (36.5% vs. 22.2%, p = .049). People with unipolar depression had more frequently used SGAs (40.0%) or a combination of SGAs and FGAs (12.5%) than FGAs (19.2%) (p = .019) in their suicides. CONCLUSION The use of SGAs in suicides is becoming increasingly common, which calls for further studies.
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Affiliation(s)
- Arja Mainio
- Research Unit of Clinical Neuroscience, Psychiatry, University of Oulu, Oulu, Finland
| | - Liisa Kuusisto
- Research Unit of Clinical Neuroscience, Psychiatry, University of Oulu, Oulu, Finland
| | - Helinä Hakko
- Department of Psychiatry, Oulu University Hospital, Oulu, Finland
| | - Pirkko Riipinen
- Department of Psychiatry, Oulu University Hospital, Oulu, Finland
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Witt KG, Hetrick SE, Rajaram G, Hazell P, Taylor Salisbury TL, Townsend E, Hawton K. Pharmacological interventions for self-harm in adults. Cochrane Database Syst Rev 2021; 1:CD013669. [PMID: 35608866 PMCID: PMC8094615 DOI: 10.1002/14651858.cd013669.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most countries, often repeated, and associated with suicide. Evidence assessing the effectiveness of pharmacological agents and/or natural products in the treatment of SH is lacking, especially when compared with the evidence for psychosocial interventions. This review therefore updates a previous Cochrane Review (last published in 2015) on the role of pharmacological interventions for SH in adults. OBJECTIVES To assess the effects of pharmacological agents or natural products for SH compared to comparison types of treatment (e.g. placebo or alternative pharmacological treatment) for adults (aged 18 years or older) who engage in SH. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic Reviews [CDSR]), together with MEDLINE. Ovid Embase and PsycINFO (to 4 July 2020). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing pharmacological agents or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment acceptability, treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence internals (CIs). For continuous outcomes we calculated the mean difference (MD) or standardised mean difference (SMD) and 95% CI. The overall certainty of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS We included data from seven trials with a total of 574 participants. Participants in these trials were predominately female (63.5%) with a mean age of 35.3 years (standard deviation (SD) 3.1 years). It is uncertain if newer generation antidepressants reduce repetition of SH compared to placebo (OR 0.59, 95% CI 0.29 to 1.19; N = 129; k = 2; very low-certainty evidence). There may be a lower rate of SH repetition for antipsychotics (21%) as compared to placebo (75%) (OR 0.09, 95% CI 0.02 to 0.50; N = 30; k = 1; low-certainty evidence). However, there was no evidence of a difference between antipsychotics compared to another comparator drug/dose for repetition of SH (OR 1.51, 95% CI 0.50 to 4.58; N = 53; k = 1; low-certainty evidence). There was also no evidence of a difference for mood stabilisers compared to placebo for repetition of SH (OR 0.99, 95% CI 0.33 to 2.95; N = 167; k = 1; very low-certainty evidence), or for natural products compared to placebo for repetition of SH (OR 1.33, 95% CI 0.38 to 4.62; N = 49; k = 1; lo- certainty) evidence. AUTHORS' CONCLUSIONS Given the low or very low quality of the available evidence, and the small number of trials identified, there is only uncertain evidence regarding pharmacological interventions in patients who engage in SH. More and larger trials of pharmacotherapy are required, preferably using newer agents. These might include evaluation of newer atypical antipsychotics. Further work should also include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.
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Affiliation(s)
- Katrina G Witt
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Gowri Rajaram
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
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18
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Farooqui WA, Uddin M, Qadeer R, Shafique K. Trajectories of vital status parameters and risk of mortality among acute organophosphorus poisoning patients - a latent class growth analysis. BMC Public Health 2020; 20:1538. [PMID: 33046064 PMCID: PMC7552362 DOI: 10.1186/s12889-020-09637-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 09/30/2020] [Indexed: 01/24/2023] Open
Abstract
Background Acute organophosphorus (OP) poisoning is one of the major causes of mortality among patients presenting to emergency departments in developing countries. Although various predictors of mortality among OP poisoning patients have been identified, the role of repeated measurements of vital signs in determining the risk of mortality is not yet clear. Therefore, the present study examined the relationship between trajectories of vital signs and mortality among OP poisoning patients using latent class growth analysis (LCGA). Methods This was a retrospective cohort study using data for 449 OP poisoning patients admitted to Civil-Hospital Karachi from Aug’10 to Sep’16. Demographic data and vital signs, including body temperature, blood pressure, heart rate, respiratory rate, and partial-oxygen pressure, were retrieved from medical records. The trajectories of vital signs were formed using LCGA, and these trajectories were applied as independent variables to determine the risk of mortality using Cox-proportional hazards models. P-values of < 0.05 were considered statistically significant. Results Data for 449 patients, with a mean age of 25.4 years (range 13–85 years), were included. Overall mortality was 13.4%(n = 60). In trajectory analysis, a low-declining systolic blood pressure, high-declining heart rate trajectory, high-remitting respiratory rate trajectory and normal-remitting partial-oxygen pressure trajectory resulted in the greatest mortality, i.e. 38.9,40.0,50.0, and 60.0%, respectively, compared with other trajectories of the same parameters. Based on multivariable analysis, patients with low-declining systolic blood pressure were three times [HR:3.0,95%CI:1.2–7.1] more likely to die compared with those who had a normal-stable systolic blood pressure. Moreover, patients with a high-declining heart rate were three times [HR:3.0,95%CI:1.5–6.2] more likely to die compared with those who had a high-stable heart rate. Patients with a high-remitting respiratory rate were six times [HR:5.7,95%CI:1.3–23.8] more likely to die than those with a high-stable respiratory rate. Patients with normal-remitting partial oxygen pressure were five times [HR:4.7,95%CI:1.4–15.1] more likely to die compared with those who had a normal-stable partial-oxygen pressure. Conclusion The trajectories of systolic blood pressure, heart rate, respiratory rate and partial-oxygen pressure were significantly associated with an increased risk of mortality among OP poisoning patients.
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Affiliation(s)
- Waqas Ahmed Farooqui
- Department of Statistics, University of Karachi, Karachi, Pakistan. .,School of Public Health, Dow University of Health Sciences, Karachi, Pakistan.
| | - Mudassir Uddin
- Department of Statistics, University of Karachi, Karachi, Pakistan
| | - Rashid Qadeer
- Department of Medicine, Dr. Ruth K.M. Pfau/Civil Hospital Karachi, Dow University of Health Sciences, Karachi, Pakistan
| | - Kashif Shafique
- School of Public Health, Dow University of Health Sciences, Karachi, Pakistan.,Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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A comprehensive analysis of attempted and fatal suicide cases involving frequently used psychotropic medications. Gen Hosp Psychiatry 2020; 63:16-20. [PMID: 31327529 DOI: 10.1016/j.genhosppsych.2019.07.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/08/2019] [Accepted: 07/15/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Self-poisoning is the most common suicide method in non-lethal suicide attempts and the third most frequent in fatal suicides. Psychoactive drugs are often used for intentional self-poisoning. While poisons centre data typically focus on survived suicide attempts and underrepresent fatal self-poisoning, medical examiner reports give insight into suicide deaths. To close this gap, we combined and compared data sets from both sources, assessing the mortality of psychotropic drugs used for self-poisoning. METHODS Anonymized cases of self-poisoning with suicidal intention from 2000 to 2010 were extracted from the national poisons centre case database and compared with cases of suicide documented in the project "Suicides, a national survey". All cases with single substance exposure to a psychoactive drug (antidepressants, mood stabilizers, antipsychotics, sedatives) were included in the analyses. Opioids, over-the-counter- and illicit- drugs were excluded from the analysis. A mortality index was calculated by the ratio of the number of suicides and the sum of all (lethal and non-lethal) suicide attempts. RESULTS Tricyclics had a higher mortality rate than other antidepressants. Among the sedatives, zolpidem was found to have a higher mortality index compared to benzodiazepines. Clozapine and levomepromazine were found to be the most lethal antipsychotics. Non-lethal suicide cases with single substance exposure (n = 4697) diminished as age increased, while the rate of suicide cases (n = 165) was higher in elderly subjects (>65 years of age, p < 0.001). CONCLUSION In summary, our findings confirm previous study results on the relative toxicity of distinct classes of psychotropic drugs. In this comprehensive analysis of a national cohort lorazepam had a lower mortality rate compared to other sedatives.
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