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Jeong S, Kim Y, Choe S, Kang H, Kim HM, Kang JS. A fatal case of desvenlafaxine and paroxetine poisoning. J Pharm Biomed Anal 2024; 245:116148. [PMID: 38652939 DOI: 10.1016/j.jpba.2024.116148] [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: 03/07/2024] [Revised: 04/11/2024] [Accepted: 04/13/2024] [Indexed: 04/25/2024]
Abstract
Desvenlafaxine (O-desmethylvenlafaxine) and paroxetine are antidepressants that inhibit serotonin reuptake. Despite their relatively safe profiles, several serious side effects, including serotonin syndrome, bleeding, mania, and high blood pressure, are observed. We report the confirmation of the death of a 41-year-old female, with an overdose of desvenlafaxine and paroxetine suspected as the main cause of death. To quantify the level of desvenlafaxine and paroxetine in whole blood and urine, solid phase extraction combined with liquid chromatography-tandem mass spectrometry was developed and validated. Calibration curves were linear with coefficients of determination (r2) >0.999 for desvenlafaxine and paroxetine. The limits of detection and the limits of quantification for both desvenlafaxine and paroxetine were 0.001 µg/mL and 0.02 µg/mL, respectively. Desvenlafaxine and paroxetine were detected in the postmortem samples, along with various psychiatric drugs, and the blood alcohol content level was below 0.010%. The concentrations of desvenlafaxine and paroxetine in the heart blood were 11.0 µg/mL and 2.1 µg/mL, respectively, indicating lethal concentrations. In the urine, the concentrations of desvenlafaxine and paroxetine were 87.7 µg/mL and 3.5 µg/mL, respectively. This is the first report to determine the blood concentration of desvenlafaxine in a fatal intoxication caused by an overdose of desvenlafaxine single formulation.
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Affiliation(s)
- Sujin Jeong
- National Forensic Service, Jeju-do 63309, Republic of Korea
| | - Yoseob Kim
- National Forensic Service, Jeju-do 63309, Republic of Korea
| | - Sanggil Choe
- National Forensic Service, Wonju 26460, Republic of Korea
| | - Hyunwook Kang
- Department of Forensic Medicine, College of Medicine, Jeju National University, Jeju-do 63241, Republic of Korea
| | - Hyung Min Kim
- College of Pharmacy, Chungnam National University, Daejeon 34134, Republic of Korea.
| | - Jong Seong Kang
- College of Pharmacy, Chungnam National University, Daejeon 34134, Republic of Korea.
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2
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Galust H, Hardin JR, Friedman NA, Seltzer JA, Clark RF. QRS Prolongation After Seizure in a Patient with Venlafaxine Overdose. J Emerg Med 2024; 66:e38-e40. [PMID: 37891066 DOI: 10.1016/j.jemermed.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/13/2023] [Accepted: 07/15/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Henrik Galust
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Jeremy R Hardin
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Nathan A Friedman
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Justin A Seltzer
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Richard F Clark
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
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3
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de Wit D, Franssen E, Verstoep N. Intralipid administration in case of a severe venlafaxine overdose in a patient with previous gastric bypass surgery. Toxicol Rep 2022; 9:1139-1141. [PMID: 36119942 PMCID: PMC9470933 DOI: 10.1016/j.toxrep.2022.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022] Open
Abstract
This case describes a patient with a history of bariatric surgery who was admitted to our hospital with a severe venlafaxine intoxication. Due to the altered anatomy of the gastrointestinal tract, the use of oral activated charcoal and large volumes of laxatives to prevent further uptake of venlafaxine was hampered. This resulted in massive absorption and a severe serotonergic syndrome. The patient was successfully treated with intravenous lipid emulsion. We describe a patient with bariatric surgery and a severe venlafaxine intoxication. The altered GI-tract hampered the use of activated charcoal and laxatives. This resulted in a serotonergic syndrome, successfully treated with Intralipid.
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Affiliation(s)
- D. de Wit
- Department of Clinical Pharmacy, BovenIJ hospital, Amsterdam, the Netherlands
- Corresponding author.
| | - E.J.F. Franssen
- Department of Clinical Pharmacy, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - N. Verstoep
- Department of Intensive care, BovenIJ hospital, Amsterdam, the Netherlands
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The Use of Extracorporeal Life Support in a Patient Suffering from Venlafaxine Intoxication. A Case Report. ACTA ACUST UNITED AC 2020; 6:120-123. [PMID: 32426519 PMCID: PMC7216027 DOI: 10.2478/jccm-2020-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
Very few reports exist on serious cardiac complications associated with intake of serotonin-noradrenaline reuptake inhibitors. This paper describes and discusses the case of a patient who ingested a dose of 17.5 g venlafaxine. She developed a full serotonergic syndrome leading to multi-organ failure, including refractory cardiovascular shock, which was managed by early implantation of an extracorporeal life support (ECLS) system as a bridging strategy. This intervention was successful and resulted in full recovery of the patient.
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Paulis MG, Hafez EM, El-Tahawy NF, Aly MKM. Toxicological Assessment of Venlafaxine: Acute and Subchronic Toxicity Study in Rats. Int J Toxicol 2018; 37:327-334. [PMID: 29862856 DOI: 10.1177/1091581818777470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antidepressants are the most commonly prescribed drugs for psychiatric treatment, and venlafaxine (VEN) is one of the most popular options. Venlafaxine is a nontricyclic dual-acting serotonin-norepinephrine reuptake inhibitor. Although an increased incidence of acute toxicity and addiction has been reported, controlled studies examining its toxic effects on different organs are still lacking. This study investigated the possible toxic effects of VEN on the liver, kidney, and gastric tissues. Three groups of rats were administered saline, a single LD50 dose (350 mg/kg), or 100 mg/kg VEN daily, followed by increases in the dose of 50 mg/kg every 10 days for 30 days (about 10 times the therapeutic doses). The following parameters of liver and kidney injury were then assayed: alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transferase, prothrombin time, partial thromboplastin time, blood urea nitrogen, and serum creatinine. A histopathological examination was then conducted. Both acute and subchronic administration of VEN produced multiple clinical manifestations in the experimental animals, including seizures, coma, and even death. Moreover, the liver and renal function tests indicated injury in these tissues. Furthermore, the histopathological examination showed signs of organ toxicity after both acute and chronic VEN exposure. This study has shown that VEN has harmful effects on the liver, kidney, and stomach in either a single high dose (LD50) or repeated exposure to 10 times the therapeutic doses. As a result, strategies to increase awareness of these effects among physicians and the public are needed because this drug may be addictive.
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Affiliation(s)
- Melad G Paulis
- 1 Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Minia University, Menia, Egypt
| | - Essam M Hafez
- 1 Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Minia University, Menia, Egypt
| | - Nashwa F El-Tahawy
- 2 Department of Histology and Cell Biology, Faculty of Medicine, Minia University, Menia, Egypt
| | - Mohmed K M Aly
- 3 Psychiatry Department, Faculty of Medicine, Minia University, Menia, Egypt
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Abstract
Venlafaxine is a selective serotonin and norepinephrine reuptake inhibitor commonly used for the treatment of depression. Although listed as an adverse reaction, seizure activity associated with a therapeutic dose of venlafaxine has rarely been documented. A review of the literature reveals only 2 cases of venlafaxine-induced seizures, both of which were generalized tonic-clonic seizures in patients on doses at the higher end of the therapeutic range. We report the case of a 44-year-old woman undergoing antituberculosis therapy who suffered complex partial seizures after ingestion of a low therapeutic dose of venlafaxine extended release (ER). Her first seizure was observed soon after venlafaxine ER was titrated from 37.5 to 75 mg daily, with a total of 9 witnessed complex partial seizures. After titrating the dose of the venlafaxine ER back down to 37.5 mg daily and beginning lamotrigine anticonvulsant therapy, the patient exhibited no further seizures. The development of seizure activity under therapeutic dosing of venlafaxine should be brought to the attention of the health care prescriber. The potential for drug-drug interactions involving venlafazine, particularly in combination with multiple drugs, such as isoniazid and levofloxacin, needs to be recognized.
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Greene S, AufderHeide E, French-Rosas L. Toxicologic Emergencies in Patients with Mental Illness: When Medications Are No Longer Your Friends. Psychiatr Clin North Am 2017; 40:519-532. [PMID: 28800806 DOI: 10.1016/j.psc.2017.05.007] [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
Patients with psychiatric disorders are at risk for toxicologic emergencies. Psychotropic medications have numerous effects on the neurologic, cardiac, and other organ systems and interact with other medications, potentially leading to further side effects. It is important to become familiar with accepted psychiatric practice guidelines, common toxidromes, medical sequelae associated with prescribed medications, and the specific workup and treatment of overdoses of frequently prescribed psychotropics.
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Cooper JM, Brown JA, Cairns R, Isbister GK. Desvenlafaxine overdose and the occurrence of serotonin toxicity, seizures and cardiovascular effects. Clin Toxicol (Phila) 2016; 55:18-24. [DOI: 10.1080/15563650.2016.1223847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- J. M. Cooper
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - J. A. Brown
- New South Wales Poison Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
| | - R. Cairns
- New South Wales Poison Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
| | - G. K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- New South Wales Poison Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
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Castanares-Zapatero D, Gillard N, Capron A, Haufroid V, Hantson P. Reversible cardiac dysfunction after venlafaxine overdose and possible influence of genotype and metabolism. Forensic Sci Int 2016; 266:e48-e51. [DOI: 10.1016/j.forsciint.2016.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/18/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
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First MEPS/HPLC assay for the simultaneous determination of venlafaxine and O-desmethylvenlafaxine in human plasma. Bioanalysis 2014; 6:3025-38. [DOI: 10.4155/bio.14.222] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: A new high-performance liquid chromatography–fluorescence detection assay based on microextraction by packed sorbent as sample preparation approach is described to quantify venlafaxine (VEN) and its main metabolite [O-desmethylvenlafaxine (ODV)]in human plasma. Methods & results: Chromatographic separation of the target analytes (VEN and ODV) and internal standard (licarbazepine) was achieved in less than 6 min on a reverse-phase C18 column using isocratic elution. Calibration curves were linear in the ranges of 10–1000 ng ml-1 for VEN and 20–1000 ng ml-1 for ODV. The method was successfully applied to real plasma samples. Conclusion: This microextraction by packed sorbent/high-performance liquid chromatography–fluorescence detection assay offers a cost-effective tool that can be applied for therapeutic drug monitoring and also support other pharmacokinetic-based studies in humans.
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Vignali C, Morini L, Chen Y, Stramesi C, Groppi A. Distribution of venlafaxine and O -desmethylvenlafaxine in a fatal case. Forensic Sci Int 2014; 242:e48-e51. [PMID: 25086830 DOI: 10.1016/j.forsciint.2014.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/27/2014] [Accepted: 07/11/2014] [Indexed: 11/18/2022]
Affiliation(s)
- Claudia Vignali
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini, 12, 27100 Pavia, Italy.
| | - Luca Morini
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini, 12, 27100 Pavia, Italy
| | - Yao Chen
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini, 12, 27100 Pavia, Italy
| | - Cristiana Stramesi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini, 12, 27100 Pavia, Italy
| | - Angelo Groppi
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Forlanini, 12, 27100 Pavia, Italy
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Venlafaxine-induced orthostatic hypotension in a geriatric patient. Case Rep Psychiatry 2013; 2013:761567. [PMID: 23984153 PMCID: PMC3747447 DOI: 10.1155/2013/761567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 07/18/2013] [Indexed: 11/30/2022] Open
Abstract
Venlafaxine is not usually associated with risk of orthostatic hypotension. A 65-year-old US Caucasian female taking 225 mg/day of venlafaxine extended-release developed symptomatic orthostatic hypotension. The systolic and diastolic blood pressure dropped by 25 and 18 mm Hg, respectively, from supine position to standing position within 3 minutes. The patient was otherwise healthy and the orthostatic hypotension resolved with venlafaxine discontinuation. This was a probable venlafaxine adverse drug reaction according to the Naranjo scale. This case contributes to the scarce literature that indicates that clinicians need to be aware that occasionally venlafaxine can induce clinically significant orthostatic hypotension, particularly in geriatric patients. Our patient did not have orthostatic hypotension when she was taking venlafaxine at 60 years of age in higher venlafaxine doses (300 mg/day) but developed this adverse drug reaction when venlafaxine was restarted at the geriatric age. This case indicates that a history of prior tolerance to venlafaxine does not guarantee tolerance after 65 years of age. If a clinician decides to use venlafaxine in geriatric patients, the clinician should warn the patient about the risk of orthostatic hypotension and consider very slow titration and low doses.
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Lung D, Cuevas C, Zaid U, Ancock B. Venlafaxine pharmacobezoar causing intestinal ischemia requiring emergent hemicolectomy. J Med Toxicol 2011; 7:232-5. [PMID: 21373970 PMCID: PMC3151403 DOI: 10.1007/s13181-011-0144-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Derrick Lung
- California Poison Control System, San Francisco Division, University of California, San Francisco, San Francisco, CA 94143-1369, USA.
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Vinetti M, Haufroid V, Capron A, Classen JF, Marchandise S, Hantson P. Severe acute cardiomyopathy associated with venlafaxine overdose and possible role of CYP2D6 and CYP2C19 polymorphisms. Clin Toxicol (Phila) 2011; 49:865-9. [DOI: 10.3109/15563650.2011.626421] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Marco Vinetti
- Cliniques St-Luc, Université catholique de Louvain, Intensive Care,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | - Vincent Haufroid
- Université catholique de Louvain, Louvain Centre for Toxicology and Applied Pharmacology,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | - Arnaud Capron
- Université catholique de Louvain, Louvain Centre for Toxicology and Applied Pharmacology,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | - Jean-François Classen
- Université catholique de Louvain, Louvain Centre for Toxicology and Applied Pharmacology,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | | | - Philippe Hantson
- Cliniques St-Luc, Université catholique de Louvain, Intensive Care,
Avenue Hippocrate 10, Brussels, 1200 Belgium
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Malfroy S, Tassin C, Attof R, Perdrix JP, Piriou V. Choc cardiogénique après intoxication médicamenteuse volontaire à la venlafaxine. ACTA ACUST UNITED AC 2011; 30:857-8. [DOI: 10.1016/j.annfar.2011.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 07/06/2011] [Indexed: 11/28/2022]
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Kingbäck M, Karlsson L, Zackrisson AL, Carlsson B, Josefsson M, Bengtsson F, Ahlner J, Kugelberg FC. Influence of CYP2D6 genotype on the disposition of the enantiomers of venlafaxine and its major metabolites in postmortem femoral blood. Forensic Sci Int 2011; 214:124-34. [PMID: 21840145 DOI: 10.1016/j.forsciint.2011.07.034] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 07/05/2011] [Accepted: 07/18/2011] [Indexed: 11/18/2022]
Abstract
Venlafaxine (VEN) is an antidepressant drug mainly metabolized by the cytochrome P450 (CYP) enzyme CYP2D6 to the active metabolite O-desmethylvenlafaxine (ODV). VEN is also metabolized to N-desmetylvenlafaxine (NDV) via CYP3A4. ODV and NDV are further metabolized to N,O-didesmethylvenlafaxine (DDV). VEN is a racemic mixture of the S- and R-enantiomers and these have in vitro displayed different degrees of serotonin and noradrenaline reuptake inhibition. The aim of the study was to investigate if an enantioselective analysis of VEN and its metabolites, in combination with genotyping for CYP2D6, could assist in the interpretation of forensic toxicological results in cases with different causes of deaths. Concentrations of the enantiomers of VEN and metabolites were determined in femoral blood obtained from 56 autopsy cases with different causes of death. The drug analysis was done by liquid chromatography tandem mass spectrometry (LC/MS/MS) and the CYP2D6 genotyping by PCR and pyrosequencing. The mean (median) enantiomeric S/R ratios of VEN, ODV, NDV and DDV were 0.99 (0.91), 2.17 (0.93), 0.92 (0.86) and 1.08 (1.03), respectively. However, a substantial variation in the relationship between the S- and R-enantiomers of VEN and metabolites was evident (S/R ratios ranging from 0.23 to 17.6). In six cases, a low S/R VEN ratio (mean 0.5) was associated with a high S/R ODV ratio (mean 11.9). Genotyping showed that these individuals carried two inactive CYP2D6 genes indicating a poor metabolizer phenotype. From these data we conclude that enantioselective analysis of VEN and ODV can predict if a person is a poor metabolizer genotype/phenotype for CYP2D6. Knowledge of the relationship between the S- and R-enantiomers of this antidepressant drug and its active metabolite is also important since the enantiomers display different pharmacodynamic profiles.
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Affiliation(s)
- Maria Kingbäck
- Division of Drug Research, Clinical Pharmacology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
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Cognitive Deterioration After Venlafaxine Overdose. J Emerg Med 2011; 40:e103-6. [DOI: 10.1016/j.jemermed.2009.04.059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2008] [Revised: 01/13/2009] [Accepted: 04/11/2009] [Indexed: 11/23/2022]
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Abstract
Tricyclic antidepressants (TCAs) are among the most effective antidepressants available, although their poor tolerance at usual recommended doses and toxicity in overdose make them difficult to use. While selective serotonin reuptake inhibitors (SSRIs) are better tolerated than TCAs, they have their own specific problems, such as the aggravation of sexual dysfunction, interaction with coadministered drugs, and for many, a discontinuation syndrome. In addition, some of them appear to be less effective than TCAs in more severely depressed patients. Increasing evidence of the importance of norepinephrine in the etiology of depression has led to the development of a new generation of antidepressants, the serotonin and norepinephrine reuptake inhibitors (SNRIs). Milnacipran, one of the pioneer SNRIs, was designed from theoretic considerations to be more effective than SSRIs and better tolerated than TCAs, and with a simple pharmacokinetic profile. Milnacipran has the most balanced potency ratio for reuptake inhibition of the two neurotransmitters compared with other SNRIs (1:1.6 for milnacipran, 1:10 for duloxetine, and 1:30 for venlafaxine), and in some studies milnacipran has been shown to inhibit norepinephrine uptake with greater potency than serotonin (2.2:1). Clinical studies have shown that milnacipran has efficacy comparable with the TCAs and is superior to SSRIs in severe depression. In addition, milnacipran is well tolerated, with a low potential for pharmacokinetic drug-drug interactions. Milnacipran is a first-line therapy suitable for most depressed patients. It is frequently successful when other treatments fail for reasons of efficacy or tolerability.
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Affiliation(s)
- Siegfried Kasper
- Department of Psychiatry and Psychotherapy, Medical, University of Vienna, Austria
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Convulsiones tardías tras intoxicación por topiramato, venlafaxina y quetiapina. Med Clin (Barc) 2010; 135:191-2. [DOI: 10.1016/j.medcli.2009.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 05/15/2009] [Indexed: 11/23/2022]
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Wijnen PAHM, Limantoro I, Drent M, Bekers O, Kuijpers PMJC, Koek GH. Depressive effect of an antidepressant: therapeutic failure of venlafaxine in a case lacking CYP2D6 activity. Ann Clin Biochem 2009; 46:527-30. [PMID: 19822698 DOI: 10.1258/acb.2009.009003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Understanding the mechanisms of drug metabolism and interactions can help to prevent side-effects. Not only drug interactions, environmental factors, disease processes and ageing are factors in the inter-individual metabolic capacity variance but also genetic factors probably play an important role, as is illustrated in the case presented. Besides therapeutic drug monitoring, genotyping some important cytochrome P450 (CYP450) enzymes was of additional value in explaining why the patient developed severe adverse effects and, moreover, did not experience any therapeutical effect of venlafaxine. Results indicated that the patient was a poor metabolizer for CYP2D6, the most important phase I enzyme to metabolize venlafaxine. This corroborates that polymorphisms in the CYP450 gene influence the metabolic activity of the corresponding enzymes, thus affecting the subsequent serum drug levels and their metabolites. This case highlights the potential benefit of both clinical and genetic risk stratification (pharmacogenetics) prior to treatment, either for setting the individual dose or for making a decision about using a particular drug.
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Affiliation(s)
- P A H M Wijnen
- Department of Clinical Chemistry, ILD Care Center, Maastricht, The Netherlands
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Abstract
Objectives: To compare the efficacy and pharmacologic, pharmacokinetic, drug interaction and adverse effect profiles of duloxetine and venlafaxine. Methods: A systematic review of the literature pertaining to duloxetine and venlafaxine was conducted using a computer-aided search of MEDLINE and EMBASE for the period January 1988 to May 2008 with the following search terms: venlafaxine and duloxetine and depression, clinical studies, pharmacology, drug interactions, pharmacokinetics, adverse effects, safety, case reports and review articles. Results: Duloxetine and venlafaxine have comparable efficacy and share similar pharmacologic profiles but differ somewhat in their pharmacokinetic profiles, drug interactions and adverse effects. Both agents block the reuptake of serotonin and norepinephrine and both are substrates for the cytochrome P450 2D6 isoenzyme; however, duloxetine inhibits these enzymes to a moderate extent, whereas venlafaxine is only a weak inhibitor. Furthermore, duloxetine is more extensively bound to protein than venlafaxine. Venlafaxine is more likely to elevate blood pressure in a dose-related manner. Both duloxetine and venlafaxine have the potential to cause hepatic injury. Conclusions: Although venlafaxine and duloxetine have similar efficacy in the treatment of depression, differences in their adverse effects and pharmacokinetic profiles suggest that one agent may be preferred over the other in certain patient groups.
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Affiliation(s)
- Sylvia Zerjav
- British Columbia Mental Health and Addictions Services, Coquitlam (Zerjav); the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver (Zerjav); the Fraser Health Authority, Vancouver (Tse); and the Department of Psychiatry, Prince George Regional Hospital, Prince George (Scott), British Columbia. Contact
| | - Gordon Tse
- British Columbia Mental Health and Addictions Services, Coquitlam (Zerjav); the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver (Zerjav); the Fraser Health Authority, Vancouver (Tse); and the Department of Psychiatry, Prince George Regional Hospital, Prince George (Scott), British Columbia. Contact
| | - Michael J.W. Scott
- British Columbia Mental Health and Addictions Services, Coquitlam (Zerjav); the Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver (Zerjav); the Fraser Health Authority, Vancouver (Tse); and the Department of Psychiatry, Prince George Regional Hospital, Prince George (Scott), British Columbia. Contact
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Alexandrino-Silva C, Nadalini Mauá FH, de Andrade AG, de Toledo Ferraz Alves TC. Hypotension caused by therapeutic doses of venlafaxine: case report and proposed pathophysiological mechanisms. J Psychopharmacol 2008; 22:214-6. [PMID: 18208934 DOI: 10.1177/0269881107076403] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although venlafaxine is usually associated with modest increases in blood pressure and not so often clinical hypertension, there are a few reported cases of hypotension related to overdoses of this specific antidepressant. The case study of a young female patient with a history of Major Depressive Disorder who initiated treatment with venlafaxine 75 mg/day and developed hypotension when the dosage was titrated up to 225 mg/day is described. The patient did not present comorbid diseases nor use other medication. A temporal association and a dose-dependent relationship between the hypotension and the use of venlafaxine is shown. To the best of the knowledge of the authors,this is the first case report that specifically associates regular doses of venlafaxine with the presence of hypotension. A pathophysiological mechanism is proposed, involving the participation of presynaptic alpha2-adrenergic receptors and the presence of a possible genetic polymorphism of cytochrome P4502D6, which is associated with lower drug metabolization, to explain the relationship between venlafaxine in regular dosage and development of hypotension.
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Dean AJ, McDermott BM, Marshall RT. Psychotropic medication utilization in a child and adolescent mental health service. J Child Adolesc Psychopharmacol 2006; 16:273-85. [PMID: 16768635 DOI: 10.1089/cap.2006.16.273] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVES This study aimed to identify rates and correlates of psychotropic drug utilization in children and adolescents in inpatient and outpatient settings. METHODS A retrospective chart review examined 122 inpatient and 126 outpatient charts from a metropolitan child and youth mental health service in Brisbane, Australia. RESULTS Inpatients received more psychotropic medication than outpatients (71% vs. 25%; p < 0.01). Patients receiving medication were older, had longer hospital admissions, and more complex presentations, including history of abuse or suicide attempts and more diagnoses (all p < 0.01). Selective serotonin reuptake inhibitors (SSRIs) were the most frequently used drug class (44% inpatients; 14% outpatients), primarily indicated for mood disorders (31%). SSRIs and newer antidepressants (ADs) were used more frequently in patients with a high suicide risk (p < 0.01). Atypical antipsychotics (APs) were also used (inpatients 23%; outpatients 3%), primarily for behavioral disturbances. Half of those receiving medication (51%) received polypharmacy (>1 concurrent drug), with up to four drugs used at one time. Rates of polypharmacy were highest among patients receiving antipsychotics. CONCLUSIONS Use of psychotropic medication is frequent in this population. Future research should initially focus on inpatients and intensive treatment settings and examine both safety and efficacy of interventions for depression in young people, atypical antipsychotics for behavioral disturbances, and polypharmacy.
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Affiliation(s)
- Angela J Dean
- Kids in Mind Research, Mater Child and Youth Mental Health Service, South Brisbane, QLD 4001, Australia.
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Blier P. Dual serotonin and noradrenaline reuptake inhibitors: Focus on their differences. Int J Psychiatry Clin Pract 2006; 10 Suppl 2:22-32. [PMID: 24921679 DOI: 10.1080/13651500600645612] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
There are three non-tricyclic dual serotonin (5-HT) and noradrenaline (NA) reuptake inhibitors (SNRIs) currently used in human therapeutics for psychiatric disorders. These medications differ in their in vitro potency to inhibit 5-HT and NA reuptake with differential ratios of activity. Using in vivo studies carried out in laboratory animals, which better reflect human physiology than experiments using lysed tissue in a test tube, venlafaxine is about three times more potent on 5-HT than NA reuptake, duloxetine five times, and milnacipran is about twice more potent on NA than 5-HT reuptake. Sustained administration of SNRIs induces different adaptive effects on presynaptic 5-HT and NA receptors controlling the function of 5-HT and NA neurons, suggesting that they may differentially affect transmission of these two neuronal systems. In the treatment of depression, SNRIs appear to have similar effectiveness and when compared to selective 5-HT reuptake inhibitors, they generally exert a superior antidepressant effect. Taken together, these observations suggest that individual patients not responding to a SNRI may present a favourable response to another agent within that family. SNRIs have different pharmacokinetic properties and exert distinct effects on the activity of liver metabolic enzymes. These features of SNRIs can help clinicians tailor treatment to individual patients.
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Affiliation(s)
- Pierre Blier
- University of Ottawa Institute of Mental Health Research, Ottawa, Canada
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Stahl SM, Grady MM, Moret C, Briley M. SNRIs: their pharmacology, clinical efficacy, and tolerability in comparison with other classes of antidepressants. CNS Spectr 2005; 10:732-47. [PMID: 16142213 DOI: 10.1017/s1092852900019726] [Citation(s) in RCA: 309] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The class of serotonin and norepinephrine reuptake inhibitors (SNRIs) now comprises three medications: venlafaxine, milnacipran, and duloxetine. These drugs block the reuptake of both serotonin (5-HT) and norepinephrine with differing selectivity. Whereas milnacipran blocks 5-HT and norepinephrine reuptake with equal affinity, duloxetine has a 10-fold selectivity for 5-HT and venlafaxine a 30-fold selectivity for 5-HT. All three SNRIs are efficacious in treating a variety of anxiety disorders. There is no evidence for major differences between SNRIs and SSRIs in their efficacy in treating anxiety disorders. In contrast to SSRIs, which are generally ineffective in treating chronic pain, all three SNRIs seem to be helpful in relieving chronic pain associated with and independent of depression. Tolerability of an SNRI at therapeutic doses varies within the class. Although no direct comparative data are available, venlafaxine seems to be the least well-tolerated, combining serotonergic adverse effects (nausea, sexual dysfunction, withdrawal problems) with a dose-dependent cardiovascular phenomenon, principally hypertension. Duloxetine and milnacipran appear better tolerated and essentially devoid of cardiovascular toxicity.
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Affiliation(s)
- Stephen M Stahl
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
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House C, Zebrowska G. Death Following Moclobemide and Venlafaxine Overdose. CANADIAN SOCIETY OF FORENSIC SCIENCE JOURNAL 2005. [DOI: 10.1080/00085030.2005.10757583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Précourt A, Dunewicz M, Grégoire G, Williamson DR. Multiple complications and withdrawal syndrome associated with quetiapine/venlafaxine intoxication. Ann Pharmacother 2004; 39:153-6. [PMID: 15562144 DOI: 10.1345/aph.1e073] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report a case of quetiapine/venlafaxine intoxication associated with multiple complications and to review their possible relationship with these 2 drugs. CASE SUMMARY A 53-year-old white man was admitted to the hospital for loss of consciousness secondary to voluntary intoxication with venlafaxine and quetiapine. Several complications were attributable to this intoxication including seizures, prolonged coma, respiratory depression, neuroleptic malignant syndrome, prolonged QRS and QTc intervals, and a possible venlafaxine withdrawal syndrome. DISCUSSION Quetiapine could be responsible for the neuroleptic malignant syndrome presented in this case. Moreover, venlafaxine intoxication, fever, autonomic instability, and myoclonus presented serotonin syndrome as a differential diagnosis. Potential causes of seizures and prolongation of the QRS and QTc intervals are reviewed. Finally, prolonged coma and late venlafaxine withdrawal are discussed with regard to the pharmacodynamics and pharmacokinetics of drug elimination in the context of intoxication. CONCLUSIONS Clinicians should be aware of possible complications following intoxication with atypical antipsychotics and anti-depressants, including protracted altered mental status.
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Affiliation(s)
- Andréanne Précourt
- Department of Pharmacy Services, Hôpital Ste-Justine, Montréal, Québec, Canada
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