Multiple organ failure after an overdose of less than 0.4 mg/kg of colchicine: role of coingestants and drugs during intensive care management

Colchicine: the good, the bad, the ugly and how to minimize the risks

Colchicine has an important role in managing various conditions, including gout, familial Mediterranean fever, amyloidosis, Behçet's syndrome, recurrent pericarditis and calcium pyrophosphate deposition disease. The adverse effect profile of colchicine is well understood. However, due to its narrow therapeutic index, colchicine has been associated with overdose and fatalities. When ingested in toxic amounts, the mainstay of management is supportive care. Strategies to minimize the risk of colchicine poisoning can focus on three broad causes: unauthorized access, intentional overdose and inappropriate dosing. Culturally safe and appropriate education about storage and appropriate use of colchicine is essential to minimize the risk of overdose.

Upadacitinib sustained-release tablets for the treatment of chronic refractory gouty arthritis: a case report and literature review

Background

Gouty arthritis (GA) is a crystal-related joint disease caused by the deposition of monosodium urate (MSU) crystals, directly associated with hyperuricemia resulting from purine metabolism disorder and/or reduced uric acid excretion. Acute attacks of typical gouty arthritis are generally relieved through the clinical use of NSAIDs, colchicine, or glucocorticoids. However, managing patients with chronic refractory gout poses challenges due to complications such as multiple tophi, gouty nephropathy, diabetes, and gastrointestinal bleeding. While there have been numerous studies on gout in recent years, research specifically regarding chronic refractory gout remains limited. The management of such cases still faces several unresolved issues, including recurrent disease flare-ups and poor patient compliance leading to inadequate drug utilization and increased risk of side effects. In this report, we present a case of successful improvement in chronic refractory gouty arthritis using the biologic agent upadacitinib sustained-release tablets.

Case presentation

Our case report involves a 53 years-old Asian patient with recurrent gouty arthritis who had a history of over 20 years without regular treatment, presenting with tophi and an increasing number of painful episodes. During hospitalization, various analgesics and anti-inflammatory drugs provided inadequate relief, requiring the use of steroids to alleviate symptoms. However, tapering off steroids proved challenging. We decided to add upadacitinib sustained-release tablets to the treatment regimen, which ultimately improved the patient's condition. After 6 months of follow-up, the patient has not experienced any further acute pain episodes.

Conclusion

This case highlights the potential therapeutic effect of upadacitinib sustained-release tablets during the acute phase of chronic refractory gouty arthritis.

Propofol-Related Infusion Syndrome: A Bibliometric Analysis of the 100 Most-Cited Articles

Propofol-related infusion syndrome (PRIS) is a rare, yet life-threatening sequelae to prolonged administration of the anesthetic propofol in mechanically intubated patients. The condition is characterized by progressive multi-system organ failure and eventual mortality; of note, the predominant characteristics of PRIS involve but are not limited to cardiovascular impairment and collapse, metabolic and lactic acidosis, rhabdomyolysis, hyperkalemia, and acute renal failure. While potent or extended doses of propofol have been found to be the primary precipitating factor of this condition, others such as age, critical illness, steroid therapy, and hyperlipidemia have been discovered to play a role as well. This bibliometric analysis was done to reflect the current relevance and understanding of PRIS in recent literature. The SCOPUS database was utilized to conduct a search for articles with keywords "propofol infusion syndrome" and "propofol syndrome" from February 24, 2001, until April 16, 2023, with parameters for article title, citation number, citation per year, author, institution, publishing journal, and country of origin. PRIS was first defined in 1990, just a year after its approval by the Food and Drug Administration for use as a sedative-hypnotic. Since then, interest in PRIS slowly rose up to 13 publications per year in 2013. Seven papers on the topic were published in Critical Care Medicine, six in Neurocritical Care, and four in Anesthesia. The most common institutions were Mayo Clinic, Northeastern University, and Tufts Medical Center. To our knowledge, this is the first bibliometric analysis to evaluate the most influential publications about PRIS. A majority of the research is case-based, possibly owing to the rarity of the condition. Our research suggests that confounding factors outside the precipitating dosage of propofol may be implicated in the onset and progression of PRIS. This study could therefore bring renewed interest to the topic and lead to additional research focused on fully understanding the pathophysiology of PRIS in order to promote the development of novel diagnostics and treatment.

Two fatal intoxications by colchicine taken for saffron. Clinical, medico-legal and forensic toxicological implications

Although fatal colchicine intoxications are rare and mostly related to suicidal intake or accidental overdose, other hypotheses should be considered when dealing with colchicine poisoning. We present a case of double, acute, and subacute, fatal colchicine intoxication in a married couple. The 70-year-old male victim suddenly died after vomiting and diarrhea. The next day his wife showed aggravating gastrointestinal symptoms and was hospitalized with a diagnosis of septic shock. A complete postmortem examination on the man was performed, together with histopathological analysis. Toxicological examination performed through liquid chromatography coupled to mass spectrometry revealed a colchicine blood peripheral concentration of 33 ng/mL. A few days after hospitalization, the woman showed a colchicine plasma concentration of 32 ng/mL. Despite veno-venous hemofiltration, she ultimately died of septic shock and multi-organ failure. Death scene investigation revealed that, a few days before the death of the male victim, the couple had collected wild saffron and had eaten a presumed saffron risotto. The integrated analysis of circumstantial, clinical, postmortem and toxicological data allowed to establish that the couple had died of a fatal accidental intoxication due to the ingestion of natural colchicine, mistaken for saffron. The death of the male was deemed caused by acute cardiovascular collapse induced by acute intoxication, while the female had suffered a subacute poisoning by antimitotic agent, resulting in immunosuppression and systemic infection. Toxicological analyses, promptly performed on the man for forensic purposes, directed the investigations and suggested the clinical diagnosis on the woman.

Severe hypertriglyceridemia and colchicine intoxication following suicide attempt

Colchicine overdose is uncommon but potentially life threatening. Due to its serious adverse systemic effects, overdose must be recognized and treated. We report a case of an 18-year-old female who ingested 18 mg (~0.4 mg/kg) of colchicine in a suicide attempt. The patient's clinical manifestations included abdominal cramps, vomiting, pancytopenia, hypocholesterolemia, and rhabdomyolysis. Two unique manifestations of toxicity in this patient were profound and persistent, severe hypertriglyceridemia and electrolyte imbalance, mainly hypophosphatemia, with no other evident cause except the colchicine intoxication. Following intensive supportive treatment, including ventilator support, N-acetylcysteine, granulocyte colony stimulating factor, electrolyte repletion, and zinc supplementation, the patient made a complete recovery. Colchicine intoxication is a severe, life-threatening situation that should be followed closely in intensive care units. Severe changes in body functions can rapidly develop, as previously described in the literature. To our knowledge, this extremely elevated triglyceride level has never been reported without the administration of propofol, and requires further evaluation.

Progressive Organ Failure After Ingestion of Wild Garlic Juice

BACKGROUND

Wild garlic and related plants are increasingly sought after by fans of natural products. They can be confused with other plants containing colchicine and cause potentially fatal intoxications.

CASE REPORT

We report a case of accidental poisoning by Colchicum autumnale, which was mistaken for wild garlic (Allium ursinum). The patient initially presented with mild gastrointestinal symptoms, but progressed rapidly to agranulocytosis, paraparesis, and delirium before the causative agent was identified. The laboratory tests revealed rhabdomyolysis, coagulopathy, alteration of liver tests, and prerenal azotemia. Botanical examination confirmed the incriminated plant (Colchicum autumnale). Serum and urine analysis confirmed the presence of colchicine. The patient required intensive support therapy, and she fully recovered within 8 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Colchicine poisoning should be considered in the differential diagnosis of patients presenting with gastroenteritis after ingestion of wild garlic.

Colchicine as an anti-inflammatory and cardioprotective agent

INTRODUCTION

Colchicine has been successfully used for the treatment of neutrophilic disorders such as familial Mediterranean fever (FMF), Behçet disease (BD) and gout. There is a growing interest in its cardiovascular effects.

AREAS COVERED

A MEDLINE/PubMed search for English articles published from January 1972 to June 2015 was completed using the following terms: therapy, pharmacokinetics, efficiency, side effects, toxicity, heart, colchicine, inflammation, FMF, amyloidosis, BD, gout, cardiovascular disorders, pericarditis, arrhythmias, inflammation, neutrophils, platelets.

EXPERT OPINION

By targeting neutrophils, endothelial cells and platelets, inhibiting mitosis, vascular hyperplasia and fibrosis, colchicine improves outcomes of pericarditis, myocardial ischemia and coronary interventions. Studies in neutrophilic rheumatic diseases and cardiovascular disorders demonstrated that oral colchicine at doses of 0.5 - 2.5 mg/daily is useful for treating pericarditis, myocardial ischemia and coronary occlusion. In rheumatic and cardiovascular disorders, therapeutic doses of the drug reduce C-reactive protein to levels below 2 mg/L, prevent myocardial damage and preserve normal values of atrial and ventricular impulse generation. One of the drug's frequent side effects is diarrhea, which is treated by diet modification or temporary discontinuation of the therapy. Certain drugs (macrolides, statins), comorbidities and certain genetic factors increase risk of colchicine toxicity.

Fatal colchicine poisoning by accidental ingestion of Colchicum persicum: a case report

Colchicine poisoning can occur not only by taking dosage form but also by ingesting a plant containing colchicine. A 39-year-old man presented to the emergency room with nausea, vomiting, and diarrhea 9 hours after ingestion of wild garlic. Symptoms attributed to food poisoning, and he received supportive cares and discharged. However, he was admitted to the hospital because of severe gastrointestinal presentations 4 hours later. He received treatments based on the diagnosis of acute gastroenteritis. The patient was in a fair condition during 30 hours of hospitalization until he suddenly developed respiratory distress and unfortunately died with cardiopulmonary arrest. The deceased body referred to our legal medicine center for determining cause of death and investigating possible medical staff malpractices. Postmortem examination, autopsy, macropathology and micropathology study, and postmortem toxicological analysis were performed. All results were submitted to the medical committee office for decision. The unknown cause of death was disclosed after determination of colchicine in the plant and botanical identification as Colchicum persicum. The committee determined the most probable cause of death as acute cardiopulmonary complications induced by colchicine poisoning and the manner of death as accidental. The medical staff was acquitted of the malpractice.

Hemophagocytic lymphohistiocytosis and pelger-huët anomaly associated with colchicine intoxication

Colchicine is frequently used in the treatment of familial Mediterranean fever (FMF). First symptoms of colchicine intoxication are gastrointestinal disturbances, such as abdominal cramps, diarrhea, pancytopenia and so on. Herein, we report a female FMF patient with pancytopenia and hemophagocytic lymphohitiocytosis (HLH), following colchicine intoxication for committing suicide. To our knowledge, this is the first reported case of a patient with HLH associated with colchicine intoxication.

Rugged and accurate quantitation of colchicine in human plasma to support colchicine poisoning monitoring by using turbulent-flow LC–MS/MS analysis

Background: Colchicine is a common drug used in inflammatory diseases. The narrow therapeutic index requires fast and reliable techniques for its quantitation. An online, automated sample preparation using TurboFlow™ technology combined with triple-stage quadrupole MS detection was applied to identify colchicine in human plasma and follow intoxications. Methodology: Plasma samples (200 µl) were mixed with deuterated colchicine and protein precipitation ZnSO4 solutions. After centrifugation, supernatants were extracted onto a Cyclone P TurboFlow column and eluted onto a narrowbore Hypersil™ GOLD column with a methanol/water gradient. Analytes were monitored in SRM mode (positive electrospray). Results: Total run time was 9.5 min. Calibration curves ranged from 0.342 to 17.1 ng/ml, with significant linearity (R2 >0.99). Inter- and intra-assay precisions were <16.8% and accuracy was 84.4–110%. Conclusion: This method is suitable for monitoring intoxication in patients undergoing chronic treatment and is routinely applied to toxicological samples.

2011 recommendations for the diagnosis and management of gout and hyperuricemia

Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care practices; thus, primary care physicians have a significant opportunity to improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant new evidence has accumulated, and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence-based strategy for rating quality of evidence and grading the strength of recommendation formulated for use in clinical practice. A total of 26 key recommendations, 10 for diagnosis and 16 for management, of patients with gout were evaluated, resulting in important updates for patient care. The presence of monosodium urate crystals and/or tophus and response to colchicine have the highest clinical diagnostic value. The key aspect of effective management of an acute gout attack is initiation of treatment within hours of symptom onset. Low-dose colchicine is better tolerated and is as effective as a high dose. When urate-lowering therapy (ULT) is indicated, the xanthine oxidase inhibitors allopurinol and febuxostat are the options of choice. Febuxostat can be prescribed at unchanged doses for patients with mild-to-moderate renal or hepatic impairment. The target of ULT should be a serum uric acid level that is ≤ 6 mg/dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option. This article is a summary of the 2011 clinical guidelines published in Postgraduate Medicine. This article provides a streamlined, accessible overview intended for quick review by primary care physicians, with the full guidelines being a resource for those seeking additional background information and expanded discussion.