1
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Gona SR, Rosenberg J, Fyffe-Freil RC, Kozakiewicz JM, Money ME. Review: Failure of current digoxin monitoring for toxicity: new monitoring recommendations to maintain therapeutic levels for efficacy. Front Cardiovasc Med 2023; 10:1179892. [PMID: 37465455 PMCID: PMC10350506 DOI: 10.3389/fcvm.2023.1179892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/14/2023] [Indexed: 07/20/2023] Open
Abstract
The current recommendations for monitoring digoxin, a narrow therapeutic index drug, are limited to confirming medication use or investigating suspicion of toxicity and fail our oath to do no harm. Numerous meta-analyses evaluating digoxin use consistently recommend frequent monitoring to maintain the level of 0.5 to ≤1.0 ng/ml because higher levels lead to increased morbidity and mortality without benefit. Data from the United States National Poison Control Center (2012-2020) show annual deaths due to digoxin of 18-36 compared to lithium's 1-7, and warfarin's 0-2 respectively. The latter drugs also have narrow therapeutic indexes like digoxin yet are more carefully monitored. Recognition of digoxin toxicity is impaired as levels are not being routinely checked after medications are added to a patient's regimen. In addition, providers may be using ranges to guide treatment that are no longer appropriate. It is imperative that monitoring guidelines and laboratory therapeutic levels are revised to reduce morbidity and mortality due to digoxin. In this review, we provide a comprehensive literature review of digoxin monitoring guidelines, digoxin toxicity, and evidence to support revising the ranges for serum digoxin monitoring.
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Affiliation(s)
- Sridhar Rao Gona
- Department of Pharmacy, Meritus Medical Center, Hagerstown, MD, United States
| | - Joel Rosenberg
- MedStar Cardiology Associates, Washington, DC, United States
| | - Ria C. Fyffe-Freil
- Division of Clinical Biochemistry & Immunology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | | | - Mary E. Money
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Medicine, Meritus Medical Center, Hagerstown, MD, United States
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2
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Redzuan AM, Hui LY, Saffian SM, Islahudin FH, Bakry MM, Aziz SAA. Features of Digoxin Toxicity in Atrial Fibrillation and Congestive Heart Failure Patients: A Systematic Review. ARCHIVES OF PHARMACY PRACTICE 2023. [DOI: 10.51847/qoqv0p1dbk] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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3
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Muramatsu K, Nagasawa H, Takeuchi I, Jitsuiki K, Ohsaka H, Ishikawa K, Yanagawa Y. An analysis of patients with a chief complaint of difficulty moving. J Rural Med 2023; 18:36-41. [PMID: 36700130 PMCID: PMC9832309 DOI: 10.2185/jrm.2022-016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/20/2022] [Indexed: 01/06/2023] Open
Abstract
Objective: There have been few reports in English medical journals analyzing patients with difficulty moving. Herein, we conducted a retrospective survey of emergency patients admitted to our hospital with the chief complaint of difficulty moving, to clarify the clinical characteristics of the frequency, causative disease, and outcome in these patients. Patients and Methods: Between August 2017 and October 2021, we surveyed the patient database maintained by our department, covering cases in which the main complaint at the time of patient transport by ambulance to our hospital was difficulty moving. Results: In 111 cases, the patient's primary complaint was difficulty moving or adynamia. Patients included 59 males and 52 females, with a mean age of 76.3 years old. The most frequent diagnosis in these patients was rhabdomyolysis, followed by infection, body temperature abnormalities, electrolyte disorder, blood glucose abnormality, hypoxia, and renal failure. Trauma and various other diseases, such as stroke and malignancy, were also found to be causative diseases. After discharge from the hospital, the number of patients with a dependent status was greater than those with an independent status. Conclusion: Patients with difficulty moving were primarily elderly, and had a variety of causative diseases. Therefore, multiple approaches are required to manage these patients.
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Affiliation(s)
- Kenichi Muramatsu
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
| | - Hiroki Nagasawa
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
| | - Ikuto Takeuchi
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
| | - Kei Jitsuiki
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
| | - Hiromichi Ohsaka
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
| | - Kouhei Ishikawa
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
| | - Youichi Yanagawa
- Department of Acute Critical Care Medicine, Shizuoka
Hospital, Juntendo University, Japan
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4
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Use of Visual Electrophysiology to Monitor Retinal and Optic Nerve Toxicity of Medications. Biomolecules 2022; 12:biom12101390. [PMID: 36291599 PMCID: PMC9599231 DOI: 10.3390/biom12101390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 12/03/2022] Open
Abstract
It is important for clinicians to consider exposure to toxic substances and nutritional deficiencies when diagnosing and managing cases of vision loss. In these cases, physiologic damage can alter the function of key components of the visual pathway before morphologic changes can be detected by traditional imaging methods. Electrophysiologic tests can aid in the early detection of such functional changes to visual pathway components, including the retina or optic nerve. This review provides an overview of various electrophysiologic techniques, including multifocal electroretinogram (mfERG), full-field ERG (ffERG), electrooculogram (EOG), pattern electroretinogram (PERG), and visual evoked potential (VEP) in monitoring the retinal and optic nerve toxicities of alcohol, amiodarone, cefuroxime, cisplatin, deferoxamine, digoxin, ethambutol, hydroxychloroquine, isotretinoin, ocular siderosis, pentosane, PDE5 inhibitors, phenothiazines (chlorpromazine and thioridazine), quinine, tamoxifen, topiramate, vigabatrin, and vitamin A deficiency.
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5
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Mendoza-Moreira AL, Rodrigo-Rey S, Figuerola-García MB, González-Alonso Á, Marcos-Parra MT, Pérez-Santonja JJ. Corneal Endothelial Dysfunction as a Manifestation of Digoxin Toxicity. Cornea 2022; 41:1174-1176. [PMID: 35120352 DOI: 10.1097/ico.0000000000002981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to report a case of corneal endothelial dysfunction and subsequent corneal edema in a patient with digoxin toxicity. METHOD This was a case report. RESULTS A 77-year-old woman diagnosed with open-angle glaucoma and treated with a topical prostaglandin analog for 5 years developed blurred vision and photopsia in both eyes. Systemic medications included digoxin, furosemide, apixaban, amlodipine, enalapril, and simvastatin. Ocular examination revealed folds in Descemet membrane and corneal stromal edema in both eyes, with normal fundoscopy. Ancillary tests revealed elevated serum digoxin levels. No intervention other than discontinuation of digoxin was initiated. The corneal edema improved after that and resolved in the next 2 weeks. CONCLUSIONS We encountered 1 case of corneal edema secondary to corneal endothelial dysfunction in a patient with digoxin toxicity. Special care should be taken to elicit a complete history because ocular signs can be manifestations of systemic alterations with vital importance for patients.
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6
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Dorgau B, Georgiou M, Chaudhary A, Moya-Molina M, Collin J, Queen R, Hilgen G, Davey T, Hewitt P, Schmitt M, Kustermann S, Pognan F, Steel DH, Sernagor E, Armstrong L, Lako M. Human Retinal Organoids Provide a Suitable Tool for Toxicological Investigations: A Comprehensive Validation Using Drugs and Compounds Affecting the Retina. Stem Cells Transl Med 2022; 11:159-177. [PMID: 35298655 PMCID: PMC8929478 DOI: 10.1093/stcltm/szab010] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/13/2021] [Indexed: 12/04/2022] Open
Abstract
Retinal drug toxicity screening is essential for the development of safe treatment strategies for a large number of diseases. To this end, retinal organoids derived from human pluripotent stem cells (hPSCs) provide a suitable screening platform due to their similarity to the human retina and the ease of generation in large-scale formats. In this study, two hPSC cell lines were differentiated to retinal organoids, which comprised all key retinal cell types in multiple nuclear and synaptic layers. Single-cell RNA-Seq of retinal organoids indicated the maintenance of retinal ganglion cells and development of bipolar cells: both cell types segregated into several subtypes. Ketorolac, digoxin, thioridazine, sildenafil, ethanol, and methanol were selected as key compounds to screen on retinal organoids because of their well-known retinal toxicity profile described in the literature. Exposure of the hPSC-derived retinal organoids to digoxin, thioridazine, and sildenafil resulted in photoreceptor cell death, while digoxin and thioridazine additionally affected all other cell types, including Müller glia cells. All drug treatments caused activation of astrocytes, indicated by dendrites sprouting into neuroepithelium. The ability to respond to light was preserved in organoids although the number of responsive retinal ganglion cells decreased after drug exposure. These data indicate similar drug effects in organoids to those reported in in vivo models and/or in humans, thus providing the first robust experimental evidence of their suitability for toxicological studies.
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Affiliation(s)
- Birthe Dorgau
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcells Biotech, Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Maria Georgiou
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Alexander Chaudhary
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Marina Moya-Molina
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcells Biotech, Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Joseph Collin
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Rachel Queen
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Gerrit Hilgen
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Northumbria University, Applied Sciences, Faculty of Health and Life Science, Newcastle upon Tyne, UK
| | - Tracey Davey
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Electron Microscopy Research Services, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Stefan Kustermann
- Pharmaceutical Sciences, F. Hoffmann-La Roche, Pharma Research and Early Development, Roche Innovation Center Basel, Switzerland
| | | | - David H Steel
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Evelyne Sernagor
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Lyle Armstrong
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
- Newcells Biotech, Biosphere, Newcastle Helix, Newcastle upon Tyne, UK
| | - Majlinda Lako
- Newcastle University, Biosciences Institute, Faculty of Medical Sciences, Newcastle upon Tyne, UK
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7
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Ahmad R, Mehta H. The ocular adverse effects of oral drugs. Aust Prescr 2021; 44:129-136. [PMID: 34421178 PMCID: PMC8377292 DOI: 10.18773/austprescr.2021.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Some commonly prescribed drugs have ocular adverse effects. Many parts of the eye can be affected by oral drugs. Some ocular adverse effects may be reversed with medical or surgical intervention whereas other drugs may cause irreversible loss of vision The risk of visual loss can be reduced by a number of approaches, including monitoring for ocular toxicity, reducing the drug dose, or stopping the drug and looking for an alternative. This can be supported by good communication between the prescribing clinician and ophthalmologist Infrequent or delayed ocular adverse effects may not be identified in clinical trials of new drugs. Reporting adverse events is therefore important
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Affiliation(s)
| | - Hemal Mehta
- Strathfield Retina Clinic, Sydney.,Save Sight Registries, University of Sydney
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8
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OCT Findings in Presumed Digoxin Retinal Toxicity. Ophthalmol Retina 2021; 5:1173-1175. [PMID: 33965642 DOI: 10.1016/j.oret.2021.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 04/28/2021] [Accepted: 04/30/2021] [Indexed: 11/23/2022]
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9
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Syed MF, Rehmani A, Yang M. Ocular Side Effects of Common Systemic Medications and Systemic Side Effects of Ocular Medications. Med Clin North Am 2021; 105:425-444. [PMID: 33926639 DOI: 10.1016/j.mcna.2021.02.003] [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] [Indexed: 11/28/2022]
Abstract
When prescribing medications, it is important to consider the ocular side effects of common systemic therapy as well as potential systemic side effects of ocular medications. Although not an exhaustive list of medications/classes of medications, this article does include many commonly used drugs and also provides information on some topical therapies commonly used by ophthalmologists. These ocular medications may result in systemic effects and/or alter patients' management of systemic conditions.
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Affiliation(s)
- Misha F Syed
- University of Texas Medical Branch, 700 University Boulevard, Galveston, TX 77555, USA.
| | - Ahmad Rehmani
- University of Texas Medical Branch, 700 University Boulevard, Galveston, TX 77555, USA
| | - Matthew Yang
- University of Texas Medical Branch, 700 University Boulevard, Galveston, TX 77555, USA
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10
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Kelly MA. Neurological complications of cardiovascular drugs. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:319-344. [PMID: 33632450 DOI: 10.1016/b978-0-12-819814-8.00020-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiovascular drugs are used to treat arterial hypertension, hyperlipidemia, arrhythmias, heart failure, and coronary artery disease. They also include antiplatelet and anticoagulant drugs that are essential for prevention of cardiogenic embolism. Most neurologic complications of the cardiovascular drugs are minor or transient and are far outweighed by the anticipated benefits of treatment. Other neurologic complications are more serious and require early recognition and management. Overtreatment of arterial hypertension may cause lightheadedness or fatigue but often responds readily to dose adjustment or an alternative drug. Other drug complications may be more troublesome as in myalgia associated with statins or headache associated with vasodilators. The recognized bleeding risk of the antithrombotics requires careful calculation of risk/benefit ratios for individual patients. Many neurologic complications of cardiovascular drugs are well documented in clinical trials with known frequency and severity, but others are rare and recognized only in isolated case reports or small case series. This chapter draws on both sources to report the adverse effects on muscle, nerve, and brain associated with commonly used cardiovascular drugs.
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Affiliation(s)
- Michael A Kelly
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States.
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11
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Ferrari F, Santander IRMF, Stein R. Digoxin in Atrial Fibrillation: An Old Topic Revisited. Curr Cardiol Rev 2020; 16:141-146. [PMID: 31237216 PMCID: PMC7460705 DOI: 10.2174/1573403x15666190618110941] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 12/19/2022] Open
Abstract
Digoxin has been used for more than 50 years in patients with Atrial Fibrillation (AF), with the goal of Controlling Heart Rate (HR) and restoring sinus rhythm. In the last two decades, several studies have correlated therapeutic use of digoxin with increased mortality. However, such studies have potential biases that cannot be disregarded, mainly because they are cross-sectional experiments or post-hoc analyses of Randomized Controlled Trials (RCTs). Despite uncertainties regarding the safety of digoxin in this setting, it remains one of the most prescribed drugs for AF worldwide. On the other hand, the absence of any RCTs designed to evaluate mortality makes a definitive conclusion more difficult to reach; therefore, this medication must be used with care. In this review, we explored the therapeutic use of digoxin in the context of AF, discussed mortality data by means of critical analysis in the light of the best available evidence, and position ourselves in relation to more rigorous control of serum levels of this drug in daily practice.
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Affiliation(s)
- Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Exercise Cardiology Research Group (CardioEx) HCPA/UFRGS, Porto Alegre, Brazil
| | | | - Ricardo Stein
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Exercise Cardiology Research Group (CardioEx) HCPA/UFRGS, Porto Alegre, Brazil.,School of Medicine, HCPA/UFRGS, Porto Alegre, Brazil
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12
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Slenter IJM, Djajadiningrat-Laanen SC, de Vries I, Dijkman MA. Intoxication with Ornithogalum arabicum is a potential cause of visual impairment and irreversible blindness in dogs. Toxicon X 2020; 4:100014. [PMID: 32550571 PMCID: PMC7286106 DOI: 10.1016/j.toxcx.2019.100014] [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: 04/25/2019] [Revised: 08/21/2019] [Accepted: 09/01/2019] [Indexed: 01/04/2023] Open
Abstract
We describe two dogs with persistent visual impairment after initially mild intoxication signs following ingestion of Ornithogalum arabicum plant material. Additionally, a 12-year analysis of the Dutch Poisons Information Centre database additionally reveals that ingestion of Ornithogalum plant material can be potentially life-threatening to companion animals. Further studies are necessary to confirm the involvement of cardiac glycoside-like toxins present in Ornithogalum arabicum and the toxicity of these substances to the retina. Intoxication with Ornithogalum arabicum leads to visual impairment and irreversible blindness in dogs. Intoxication with Ornithogalum arabicum may be life-threatening in companion animals. Ornithogalum arabicum and other species are suspected to contain heart glycosides.
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Affiliation(s)
- Inge J M Slenter
- Ophthalmology Section, Department of Clinical Sciences of Companion Animals, Utrecht University, the Netherlands
| | | | - Irma de Vries
- Dutch Poisons Information Centre (DPIC), University Medical Centre Utrecht, Utrecht University, the Netherlands
| | - Marieke A Dijkman
- Dutch Poisons Information Centre (DPIC), University Medical Centre Utrecht, Utrecht University, the Netherlands
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13
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Jiang YK, Wang RY, Wang X, Zhao HZ, Zhou LH, Huang LP, Yip CW, Cheng JH, Que CX, Jiang C, Zhu LP. Genetic polymorphisms of transient receptor potential melastatin 1 correlate with voriconazole-related visual adverse events. Mycoses 2020; 63:579-587. [PMID: 32222082 DOI: 10.1111/myc.13080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/14/2020] [Accepted: 03/19/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Causes of voriconazole-related visual adverse events (VVAE) remained controversial. OBJECTIVES We aimed to explore the relationship between voriconazole serum concentrations and VVAE as well as the potential influence of transient receptor potential melastatin 1 (TRPM1) on VVAE. PATIENTS/METHODS This prospective observational cohort study was done in two stages. Patients who received voriconazole for invasive fungal diseases were consecutively enrolled. Correlations between voriconazole trough levels and VVAE were explored in 76 patients. Genotyping was further conducted for 17 tag SNPs of TRPM1 in a larger population of 137 patients. Genotype distributions were compared between patients with and without VVAE. RESULT Of the 76 patients, a total of 229 steady-state voriconazole trough levels were evaluated, 69.9% of which were within the target range (1-5.5 mg/L). No correlations were found between voriconazole trough levels and VVAE. Of the total 137 patients, VVAE occurred in 37 (27.0%) patients, including visual hallucination (13.9%, 19/137) and visual disturbances (19.0%, 26/137). Significant difference in TRPM1 genotype distribution was only observed in patients with visual hallucination but not with visual disturbances. We found that rs890160 G/T genotype was under-presented (OR, 0.11; 95% CI, 0.01-0.84; P = .011) and rs1378847 C/C genotype was more frequently detected (OR, 8.89; 95% CI, 1.14-69.02; P = .013) in patients with visual hallucination when compared with those without. CONCLUSION Transient receptor potential melastatin 1 was genetically associated with voriconazole-related visual hallucination. The correlation was failed to found between voriconazole trough levels and VVAE.
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Affiliation(s)
- Ying-Kui Jiang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Rui-Ying Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Xuan Wang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Hua-Zhen Zhao
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ling-Hong Zhou
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Ping Huang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Ching-Wan Yip
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Hui Cheng
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Chun-Xing Que
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Chen Jiang
- Department of Pharmaceutics, School of Pharmacy, Shanghai Medical College, Fudan University, Shanghai, China
| | - Li-Ping Zhu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
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14
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Shi L, Sun LD, Odel JG. Colored floaters as a manifestation of digoxin toxicity. Am J Ophthalmol Case Rep 2018; 10:233-235. [PMID: 29780940 PMCID: PMC5956671 DOI: 10.1016/j.ajoc.2018.02.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 11/24/2017] [Accepted: 02/26/2018] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Since its report in one patient more than 70 years ago, digitalis-induced colored muscae volitantes have not surfaced again in the literature. We report here a case of digoxin induced colored floaters. OBSERVATIONS An 89-year-old man on 0.25 mg digoxin daily developed visual hallucinations and colored floaters. He had floaters in the past but now they were in various colors including yellow, green, blue and red, though predominantly in yellow. These "weirdly" shaped little particles wiggled around as if in a viscous solution and casted shadows in his vision. He also saw geometric shapes, spirals, and cross hatch patterns of various colors that moved and undulated, especially on wallpaper. Ophthalmic examination revealed reduced visual acuity, poor color vision especially in his left eye, along with central depression on Amsler grid and Humphrey visual field in his left eye. Discontinuation of digoxin resulted in complete resolution of his visual symptoms. On subsequent ophthalmic examination, the patient's visual acuity, field testing and color vision improved and he had normal Amsler grid test results. CONCLUSIONS AND IMPORTANCE Colored floaters may occur in patients taking cardiac glycosides but this association has not been explored. Unlike optical illusions and visual hallucinations, floaters are entoptic phenomena casting a physical shadow upon the retina and their coloring likely arise from retinal dysfunction. Colored floaters may be a more common visual phenomenon than realized.
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Affiliation(s)
- Lynn Shi
- College of Physicians and Surgeons, Columbia University Medical Center, New York, N.Y., United States
- Department of Ophthalmology, Columbia University Medical Center, New York, N.Y., United States
| | - Linus D. Sun
- Department of Ophthalmology, Columbia University Medical Center, New York, N.Y., United States
| | - Jeffrey G. Odel
- Department of Ophthalmology, Columbia University Medical Center, New York, N.Y., United States
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15
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Landfried B, Samardzija M, Barben M, Schori C, Klee K, Storti F, Grimm C. Digoxin-induced retinal degeneration depends on rhodopsin. Cell Death Dis 2017; 8:e2670. [PMID: 28300845 PMCID: PMC5386584 DOI: 10.1038/cddis.2017.94] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 02/09/2017] [Accepted: 02/10/2017] [Indexed: 12/13/2022]
Abstract
Na,K-ATPases are energy consuming ion pumps that are required for maintaining ion homeostasis in most cells. In the retina, Na,K-ATPases are especially important to sustain the dark current in photoreceptor cells needed for rapid hyperpolarization of rods and cones in light. Cardiac glycosides like digoxin inhibit the activity of Na,K-ATPases by targeting their catalytic alpha subunits. This leads to a disturbed ion balance, which can affect cellular function and survival. Here we show that the treatment of wild-type mice with digoxin leads to severe retinal degeneration and loss of vision. Digoxin induced cell death specifically in photoreceptor cells with no or only minor effects in other retinal cell types. Photoreceptor-specific cytotoxicity depended on the presence of bleachable rhodopsin. Photoreceptors of Rpe65 knockouts, which have no measurable rhodopsin and photoreceptors of Rpe65R91W mice that have <10% of the rhodopsin found in retinas of wild-type mice were not sensitive to digoxin treatment. Similarly, cones in the all-cone retina of Nrl knockout mice were also not affected. Digoxin induced expression of several genes involved in stress signaling and inflammation. It also activated proteins such as ERK1/2, AKT, STAT1, STAT3 and CASP1 during a period of up to 10 days after treatment. Activation of signaling genes and proteins, as well as the dependency on bleachable rhodopsin resembles mechanisms of light-induced photoreceptor degeneration. Digoxin-mediated photoreceptor cell death may thus be used as an inducible model system to study molecular mechanisms of retinal degeneration.
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Affiliation(s)
- Britta Landfried
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland
| | - Marijana Samardzija
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland
| | - Maya Barben
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland.,Neuroscience Center Zürich (ZNZ), University of Zürich, Zürich, Switzerland
| | - Christian Schori
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland.,Center for Integrative Human Physiology (ZIHP), University of Zürich, Zürich, Switzerland
| | - Katrin Klee
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland.,Center for Integrative Human Physiology (ZIHP), University of Zürich, Zürich, Switzerland
| | - Federica Storti
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland
| | - Christian Grimm
- Lab for Retinal Cell Biology, Department of Ophthalmology, University of Zürich, Zürich, Switzerland.,Neuroscience Center Zürich (ZNZ), University of Zürich, Zürich, Switzerland.,Center for Integrative Human Physiology (ZIHP), University of Zürich, Zürich, Switzerland
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Dettoraki M, Moschos MM. The Role of Multifocal Electroretinography in the Assessment of Drug-Induced Retinopathy: A Review of the Literature. Ophthalmic Res 2016; 56:169-177. [PMID: 27351191 DOI: 10.1159/000446321] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/19/2016] [Indexed: 11/19/2022]
Abstract
Multifocal electroretinography (mfERG) is an objective, noninvasive examination for the assessment of visual function. It enables the stimulation of multiple retinal areas simultaneously and recording of each response independently, providing a topographic measure of retinal electrophysiological activity in the central 40-50° of the retina. A clinical application of mfERG represents the assessment of retinal toxicity associated with systemic medications. Drug-induced retinopathy represents a disease that, although not common, requires early recognition: if not detected early, it may progress and cause irreversible retinal dysfunction with subsequent visual impairment. This review aims to evaluate the use of mfERG in the assessment of retinal dysfunction associated with various systemic pharmacological agents based on the currently available literature. The most commonly recognized systemic medications affecting retinal function are included, such as chloroquine and hydroxychloroquine, vigabatrin, deferoxamine, ethambutol, interferon-α, tamoxifen, digoxin, sildenafil, canthaxanthin, amiodarone and nefazodone. The role of mfERG in the early diagnosis of retinal toxicity and the evaluation of disease severity is reviewed, as well as its clinical value in monitoring disease progression or recovery after drug cessation.
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Affiliation(s)
- Maria Dettoraki
- Department of Ophthalmology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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