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Inoue F, Iga K, Maeda K, Sera S, Fujisaki N, Okazaki Y, Ichiba T, Chiba T, Namera A. Refractory seizures due to severe quetiapine poisoning. Clin Toxicol (Phila) 2023; 61:620-621. [PMID: 37655784 DOI: 10.1080/15563650.2023.2251674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Fumiya Inoue
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, 7-33 Motomachi, Naka-ku, Hiroshima City, Hiroshima 730-8518, Japan
| | - Kenichiro Iga
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Keisuke Maeda
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Satoshi Sera
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Noritomo Fujisaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima City, Hiroshima, Japan
| | - Takuyo Chiba
- Department of Emergency Medicine, International University of Health and Welfare, Narita city, Chiba, Japan
| | - Akira Namera
- Department of Forensic Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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A Real-World Study of Risk Factors for QTc Prolongation in Schizophrenia Patients Receiving Atypical Antipsychotics. J Clin Psychopharmacol 2022; 42:71-74. [PMID: 34928562 DOI: 10.1097/jcp.0000000000001501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The risk of sudden cardiac death in patients receiving atypical antipsychotics may be related to QTc prolongation. The aim of this study was to investigate the risk factors for QTc prolongation to prevent QTc prolongation and guide clinical practice. METHODS All electrocardiogram recordings of 913 schizophrenia patients who were receiving atypical antipsychotics were reviewed for prolonged QTc and associated conditions. Binary logistic regression analysis was used to investigate risk factors for QTc prolongation. RESULTS Logistic regression analysis demonstrated that sex (odds ratio [OR], 0.386; P = 0.010), age (OR, 1.047; P = 0.000), high-density lipoprotein (OR, 0.257; P = 0.014), and antipsychotics dose (OR, 1.040; P = 0.036) were significantly associated with QTc prolongation. CONCLUSIONS In patients with male sex, elder age, low high-density lipoprotein, or large antipsychotics dose, QTc should be monitored more frequently.
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Abstract
PURPOSE/BACKGROUND Quetiapine is a relatively new atypical antipsychotic with fewer adverse effects. It is increasingly prescribed to patients. The purpose of this study was to describe the cases of poisoning observed at the western France Poison Control Centre and identify potential risk factors that increase the severity of the cases. METHODS This was a retrospective study of self-poisoning with quetiapine as reported by the western France Poison Control Centre between 2007 and 2017. RESULTS There were 372 cases of quetiapine poisoning. Circumstances are known in 367 of 372 cases. There were 75 cases of null severity (grade 0), 133 cases of mild severity (grade 1), 85 cases of moderate severity (grade 2), and 79 cases of high severity (grade 3). Five deaths were listed in this series. The most commonly observed symptoms were neurological and cardiovascular in nature (drowsiness, coma, tachycardia, hypotension). Of these cases, 79.8% included voluntary ingestions. Among 302 cases with coagents, the most common coagents were benzodiazepines (56%), other psychotropic drugs (41%), and antidepressants (37%). An evaluated ingested dose 1500 mg or greater and 2 or more coagents increase the risk of severe poisoning. In particular, concomitant ingestion of benzodiazepines and antidepressants with quetiapine was associated with high severity (odds ratio, 2.478 [confidence interval, 1.3-4.723]; odds ratio, 1.820 [confidence interval, 1.010-3.316]). CONCLUSIONS Quetiapine may lead to severe poisoning for which there is currently no specific treatment. Patients and practitioners should be aware of this when quetiapine is prescribed, particularly when used in combination with other medications, and in order to deal with cases of poisoning.
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Tschirdewahn J, Eyer F. [Diagnostics and treatment of selected clinically relevant, acute drug intoxications]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:1313-1323. [PMID: 31578621 DOI: 10.1007/s00103-019-03024-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute drug poisoning due to accidental or self-damaging overdoses is responsible for 5-10% of emergency medical interventions in Germany. The treatment of asymptomatic to life-threatening courses requires extensive expertise. On the basis of a selective literature search, this article gives an overview of selected clinically relevant, acute drug poisonings with regard to epidemiology, symptomatology, diagnostics, and therapy.Intoxications with psychotropic drugs are the most common drug intoxications. Poisoning with tricyclic antidepressants causes anticholinergic, central nervous, and cardiovascular symptoms. Less toxic are selective serotonin reuptake inhibitors (SSRIs); the intoxication may be characterized by serotonin syndrome. Malignant neuroleptic syndrome is a severe complication of neuroleptic poisoning.Poisoning with analgesics is clinically relevant due to its high availability. For paracetamol poisoning, intravenous acetylcysteine is available as an antidote. Hemodialysis may be indicated for severe salicylate intoxication. Poisoning with nonsteroidal anti-inflammatory drugs is usually only associated with mild signs of intoxication.Poisoning with cardiac drugs (β-blockers and calcium antagonists) can cause life-threatening cardiovascular events. In addition to symptomatic therapy, insulin glucose therapy also plays an important role.The majority of acute drug poisonings can be treated adequately by symptomatic and partly intensive care therapy - if necessary with the application of primary and secondary toxin elimination. Depending on the severity of the intoxication, pharmacology-specific therapy must be initiated.
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Affiliation(s)
- Julia Tschirdewahn
- Abteilung für Klinische Toxikologie & Giftnotruf München, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - Florian Eyer
- Abteilung für Klinische Toxikologie & Giftnotruf München, Universitätsklinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
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Klučka J, Juřenčák T, Kosinová M, Petr Š, Kratochvíl M, Sedláčková Y, Tomáš N, Pelclová D, Jabandžiev P. Intralipid infusion in paediatric patient with quetiapine and lamotrigine intoxication. MONATSHEFTE FUR CHEMIE 2019. [DOI: 10.1007/s00706-019-02423-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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6
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Giuntoli L, Dalmastri V, Cilloni N, Orsi C, Stalteri L, Demelas V, Giuliani G, Gordini G, De Ponti F, La Manna G. Severe quetiapine voluntary overdose successfully treated with a new hemoperfusion sorbent. Int J Artif Organs 2019; 42:516-520. [DOI: 10.1177/0391398819837686] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Quetiapine overdose, although rare, is mainly linked with tachycardia, QTc-interval prolongation, somnolence, coma, hyperglycemia, and eventually hepatotoxicity and myocarditis. Extracorporeal techniques for quetiapine removal might be helpful, but only a few cases are reported in the literature. We here describe the case of a 27-year-old healthy woman, admitted to our Intensive Care Unit after voluntary quetiapine intake and successfully treated with CytoSorb hemoperfusion in combination with continuous renal replacement therapy (CRRT), in order to accelerate quetiapine elimination. This is the first published experience about the potential application of hemoadsorption therapies, as CytoSorb sorbent, in large overdoses of quetiapine and this approach might be feasible to rapidly remove the substance from blood, stabilizing the patient condition.
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Affiliation(s)
- Lorenzo Giuntoli
- Department of Emergency-Urgency Medicine, Intensive Care Unit, Maggiore Hospital, Bologna, Italy
| | - Vittorio Dalmastri
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
| | - Nicola Cilloni
- Department of Emergency-Urgency Medicine, Intensive Care Unit, Maggiore Hospital, Bologna, Italy
| | - Claudio Orsi
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
| | - Lucia Stalteri
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
| | - Valentina Demelas
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Giuliani
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Gordini
- Department of Emergency-Urgency Medicine, Intensive Care Unit, Maggiore Hospital, Bologna, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
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Arens AM, Kearney T. Adverse Effects of Physostigmine. J Med Toxicol 2019; 15:184-191. [PMID: 30747326 DOI: 10.1007/s13181-019-00697-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/12/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Physostigmine is a tertiary amine carbamate acetylcholinesterase inhibitor. Its ability to cross the blood-brain barrier makes it an effective antidote to reverse anticholinergic delirium. Physostigmine is underutilized following the publication of patients with sudden cardiac arrest after physostigmine administration in patients with tricyclic antidepressant (TCA) overdoses. We completed a narrative literature review to identify reported adverse effects associated with physostigmine administration. DISCUSSION One hundred sixty-one articles and a total of 2299 patients were included. Adverse effects occurred in 415 (18.1%) patients. Hypersalivation (206; 9.0%) and nausea and vomiting (96; 4.2%) were the most common adverse effects. Fifteen (0.61%) patients had seizures, all of which were self-limited or treated successfully without complication. Symptomatic bradycardia occurred in 8 (0.35%) patients including 3 patients with bradyasystolic arrests. Ventricular fibrillation occurred in one (0.04%) patient with underlying coronary artery disease. Of the 394 patients with TCA overdose, adverse effects were described in 14 (3.6%). Adverse effects occurred in 7.7% of patients treated with an overdose of an anticholinergic agent compared with 20.6% of patients with non-anticholinergic agents. Five (0.22%) fatalities were identified. CONCLUSIONS In conclusion, significant adverse effects associated with the use of physostigmine were infrequently reported. Seizures were self-limited or resolved with benzodiazepines, and all patients recovered neurologically intact. Physostigmine should be avoided in patients with QRS prolongation on EKG, and caution should be used in patients with a history of coronary artery disease and overdoses with QRS prolonging medications. Based upon our review, physostigmine is a safe antidote to treat anticholinergic overdose.
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Affiliation(s)
- Ann M Arens
- Minnesota Poison Control System, Minneapolis, MN, USA. .,Hennepin Healthcare, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, MC-R2, Minneapolis, MN, 55415, USA.
| | - Tom Kearney
- California Poison Control System, San Francisco Division, San Francisco, CA, USA.,San Francisco School of Pharmacy, University of California, San Francisco, CA, USA
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Taylor L, Graudins A. Extended-release quetiapine overdose is associated with delayed onset of toxicity compared to immediate-release quetiapine overdose. Emerg Med Australas 2018; 31:562-568. [PMID: 30485698 DOI: 10.1111/1742-6723.13205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/04/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES There are currently no studies comparing toxicity after extended-release (XR) and immediate-release (IR) quetiapine overdose. To compare the time course of toxicity of XR and IR quetiapine overdose. METHODS Retrospective analysis of toxicology unit consultations from July 2013 to April 2016. Information extracted included demographics, type of ingestion (IR, XR, mixed formulation, dose, tablet count, time to presentation, sedative co-ingestants), lowest Glasgow coma score (GCS), time to lowest GCS, fastest pulse, lowest systolic blood pressure, and time to recovery from sedation. RESULTS There were 256 presentations in 210 patients. Females 86% (n = 181), median age 30.5 years (IQR 23-43). Median quetiapine dose for the whole cohort was 2 g (IQR 1-5). Sedating co-ingestants were seen in 61% of presentations. Comparison of IR (n = 43) and XR quetiapine (n = 23) ingestions without sedating co-ingestants revealed a larger median ingested dose for XR formulation: 5.7 g versus 1.75 g (P = 0.004) and larger median tablet strength (XR 200 mg vs IR 100 mg, P < 0.001). Median time to lowest GCS: XR 7 h (IQR 4.9-11) versus IR 3.8 h (IQR 2.4-5.7), P < 0.001. Median time to peak pulse: XR 9 h (IQR 3-12) versus IR 2.5 h (IQR 1.5-5), P = 0.01. Median time to recovery from sedation: XR quetiapine 20 h (IQR 12-39) versus 12 h (IQR 5.5-22), P < 0.05. Median duration of intubation: XR 47 h versus 17 h for IR, P = 0.04). CONCLUSION XR quetiapine overdoses without sedating co-ingestants were associated with a doubling of time to peak sedation and pulse, and had longer recovery from sedation. The absence of sedation or tachycardia 12 h post-overdose of XR quetiapine seems a reasonable timeframe to rule out significant poisoning.
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Affiliation(s)
- Lucy Taylor
- Monash Emergency Research Collaborative, Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andis Graudins
- Monash Emergency Research Collaborative, Department of Medicine, Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Health Clinical Toxicology Unit, Monash Emergency Medicine Service, Dandenong Hospital, Melbourne, Victoria, Australia
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10
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Delayed-Onset Seizure in a Mild Quetiapine Overdose: Report of a Case and Review of the Literature. Case Rep Psychiatry 2018; 2018:7623051. [PMID: 29888020 PMCID: PMC5977051 DOI: 10.1155/2018/7623051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/26/2018] [Accepted: 04/10/2018] [Indexed: 11/17/2022] Open
Abstract
Among atypical antipsychotics, quetiapine is commonly prescribed and considered to have a favorable side effect and safety profile. Here, we report the case of a patient who developed a generalized tonic-clonic seizure 28 hours following ingestion of 1,400 mg of quetiapine. Review of the literature identifies delayed-onset seizure as a potential complication of quetiapine overdose. Unique to this case, delayed-onset seizures occurred in a patient with a relatively low dose of quetiapine and no obvious toxidrome, suggesting that this reaction may be an important consideration in the management of quetiapine overdose. The pharmacokinetics and pharmacodynamics of quetiapine may explain this unusual phenomenon.
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Chan BS, Becker T, Chiew AL, Abdalla AM, Robertson TA, Liu X, Roberts MS, Buckley NA. Vasoplegic Shock Treated with Methylene Blue Complicated by Severe Serotonin Syndrome. J Med Toxicol 2018; 14:100-103. [PMID: 29134498 PMCID: PMC6013734 DOI: 10.1007/s13181-017-0637-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Management of severe vasoplegic shock in overdose can be very challenging. We describe a case of severe refractory vasodilatory shock in poisoning where methylene blue (MB) was used with success. However, the patient subsequently developed severe Serotonin Syndrome (SS) as a result of an interaction between serotonergic drugs and MB. CASE REPORT A 15-year-old male developed severe vasoplegic shock 1.5 hours after overdosing on several different medications including quetiapine slow release, quetiapine immediate release, desvenlafaxine slow release, venlafaxine, amlodipine, ramipril, fluoxetine, promethazine and lithium. His vasoplegic shock was resistant to high doses of noradrenaline and vasopressin. MB was administered 6.5 hours post ingestion and within 1 hour there was an improvement in his hemodynamic status and reduction of catecholamine requirements. Twelve hours post ingestion, he developed severe Serotonin Syndrome that lasted 5 days as a result of interaction between MB, a reversible monoamine oxidase inhibitor (MAO-I), and the antidepressants taken in overdose. MB had a calculated half-life of 38 hours. CONCLUSION MB is a useful additional strategy for severe drug induced vasodilatory shock and may be potentially life-saving. Clinicians should be aware that it can interact with other drugs and cause life-threatening Serotonin Syndrome. Lower doses or shorter durations may be wise in patients at risk of this interaction.
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Affiliation(s)
- Betty S Chan
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia.
| | - Therese Becker
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Angela L Chiew
- Clinical Toxicology Unit & Emergency Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Ahmed M Abdalla
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Tom A Robertson
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Xin Liu
- Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Michael S Roberts
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
- Therapeutics Research Centre, Diamantina Institute, The University of Queensland, Translational Research Institute, Brisbane, Australia
| | - Nicholas A Buckley
- Department of Clinical Pharmacology, University of Sydney, Sydney, New South Wales, Australia
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Lehmann DF, Eggleston WD, Wang D. Validation and Clinical Utility of the hERG IC50:C max Ratio to Determine the Risk of Drug-Induced Torsades de Pointes: A Meta-Analysis. Pharmacotherapy 2018; 38:341-348. [PMID: 29380488 DOI: 10.1002/phar.2087] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Use of the QT interval corrected for heart rate (QTc) on the electrocardiogram (ECG) to predict torsades de pointes (TdP) risk from culprit drugs is neither sensitive nor specific. The ratio of the half-maximum inhibitory concentration of the hERG channel (hERG IC50) to the peak serum concentration of unbound drug (Cmax ) is used during drug development to screen out chemical entities likely to cause TdP. PURPOSE To validate the use of the hERG IC50:Cmax ratio to predict TdP risk from a culprit drug by its correlation with TdP incidence. DATA SOURCES Medline (between 1966 and March 2017) was accessed for hERG IC50 and Cmax values from the antihistamine, fluoroquinolone, and antipsychotic classes to identify cases of drug-induced TdP. Exposure to a culprit drug was estimated from annual revenues reported by the manufacturer. STUDY SELECTION Inclusion criteria for TdP cases were provision of an ECG tracing that demonstrated QTc prolongation with TdP and normal serum values of potassium, calcium, and magnesium. Cases reported in patients with a prior rhythm disturbance and those involving a drug interaction were excluded. DATA EXTRACTION AND SYNTHESIS The Meta-Analysis of Observational Studies in Epidemiology checklist was used for epidemiological data extraction by two authors. MAIN OUTCOME AND MEASURE Negligible risk drugs were defined by an hERG IC50:Cmax ratio that correlated with less than a 5% chance of one TdP event for every 100 million exposures (relative risk [RR] 1.0). RESULTS The hERG IC50:Cmax ratio correlated with TdP risk (0.312; 95% confidence interval 0.205-0.476, p<0.0001), a ratio of 80 (RR 1.0). The RR from olanzapine is on par with loratadine; ziprasidone is comparable with ciprofloxacin. Drugs with an RR greater than 50 include astemizole, risperidone, haloperidol, and thioridazine. CONCLUSIONS The hERG IC50:Cmax ratio was correlated with TdP incidence for culprit drugs. This validation provides support for the potential use of the hERG IC50:Cmax ratio for clinical decision making in instances of drug selection where TdP risk is a concern.
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Affiliation(s)
- David F Lehmann
- Department of Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - William D Eggleston
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York.,Department of Pharmacy Practice, Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, New York
| | - Dongliang Wang
- Department of Public Health and Preventive Medicine, SUNY Upstate Medical University, Syracuse, New York
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Maldonado JR. Acute Brain Failure: Pathophysiology, Diagnosis, Management, and Sequelae of Delirium. Crit Care Clin 2017; 33:461-519. [PMID: 28601132 DOI: 10.1016/j.ccc.2017.03.013] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Delirium is the most common psychiatric syndrome found in the general hospital setting, with an incidence as high as 87% in the acute care setting. Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances. The development of delirium is associated with increased morbidity, mortality, cost of care, hospital-acquired complications, placement in specialized intermediate and long-term care facilities, slower rate of recovery, poor functional and cognitive recovery, decreased quality of life, and prolonged hospital stays. This article discusses the epidemiology, known etiological factors, presentation and characteristics, prevention, management, and impact of delirium.
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Affiliation(s)
- José R Maldonado
- Psychosomatic Medicine Service, Emergency Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Suite 2317, Stanford, CA 94305-5718, USA.
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Schwarz ES, Kopec KT, Wiegand TJ, Wax PM, Brent J. Should We Be Using the Poisoning Severity Score? J Med Toxicol 2017; 13:135-145. [PMID: 28283941 DOI: 10.1007/s13181-017-0609-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 02/18/2017] [Accepted: 02/22/2017] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Despite the existence of a number of severity-of-illness classifications for other areas of medicine, toxicology research lacks a well-accepted method for assessing the severity of poisoning. The Poisoning Severity Score (PSS) was developed in the 1990s in Europe as a scoring system for poisonings reported to a poison center in order to describe a patient's most severe symptomatology. We reviewed the literature to describe how the PSS is utilized and describe its limitations. DISCUSSION We searched the medical literature in all languages using PUBMED, EMBASE, and SCOPUS from inception through August 2013 using predefined search terms. Out of 204 eligible publications, 40 met our criteria for inclusion in this review. There has been a paucity of published studies from North America that used the PSS. In some cases, the PSS was misapplied or modified from standard scoring, making a bottom line appraisal of the validity or reliability of the original version of the instrument challenging. The PSS has several subjective criteria, is time consuming to score, and is likely to be of little use with some types of poisonings, limiting its clinical utility. CONCLUSION The PSS was developed as a tool to document encounters with poisoned patients. However, it is used infrequently and, when applied, has been misused or modified from its original form. In its current form, it has limited clinical utility and likely cannot be broadly applied to many exposures due to their unique clinical circumstances. With better global collaboration among medical toxicologists, it is possible that a modified score could be developed for use clinically or as a research instrument.
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Affiliation(s)
- Evan S Schwarz
- Division of Emergency Medicine, Washington University School of Medicine, 660 South Euclid, Campus Box 8072, Saint Louis, MO, 63110, USA.
| | - Kathryn T Kopec
- Department of Emergency Medicine, Carolinas Medical Center, Medical Education Building, Third Floor 1000 Blythe Blvd, Charlotte, NC, 28203, USA
| | - Timothy J Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Box 655, Rochester, NY, 14642, USA
| | - Paul M Wax
- Department of Emergency Medicine, University of Texas Southwestern School of Medicine, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Jeffrey Brent
- University of Colorado School of Medicine, 12605 E. 16th Ave, Aurora, CO, 80045, USA
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Lai J, Lu Q, Huang T, Hu S, Xu Y. Convulsive syncope related to a small dose of quetiapine in an adolescent with bipolar disorder. Neuropsychiatr Dis Treat 2017; 13:1905-1908. [PMID: 28790826 PMCID: PMC5529712 DOI: 10.2147/ndt.s137923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Quetiapine, an atypical antipsychotic, has been extensively used in patients with bipolar disorder. Overdose of quetiapine can result in severe complications, such as coma, seizure, respiratory depression, arrhythmia, and even death. However, the paucity of toxicological evaluation in adolescence causes more potential risks in this population. Herein, we present a case of hypotension and convulsive syncope after exposure to a small dose of quetiapine in a 16-year-old who was diagnosed with bipolar disorder. After cessation of quetiapine, no additional convulsive movements were reported. This case indicates that even in young patients without predisposing factors, close monitoring of adverse effects should be warranted for safety concerns, especially at the initiation of quetiapine treatment.
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Affiliation(s)
- Jianbo Lai
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine.,Key Laboratory of Mental Disorder Management in Zhejiang Province
| | - Qiaoqiao Lu
- Department of Internal Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Tingting Huang
- Department of Internal Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaohua Hu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine.,Key Laboratory of Mental Disorder Management in Zhejiang Province
| | - Yi Xu
- Department of Psychiatry, First Affiliated Hospital, Zhejiang University School of Medicine.,Key Laboratory of Mental Disorder Management in Zhejiang Province
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16
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Klein L, Bangh S, Cole JB. Intentional Recreational Abuse of Quetiapine Compared to Other Second-generation Antipsychotics. West J Emerg Med 2016; 18:243-250. [PMID: 28210359 PMCID: PMC5305132 DOI: 10.5811/westjem.2016.10.32322] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 09/30/2016] [Accepted: 10/15/2016] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Case reports and poison center data have demonstrated that the second-generation antipsychotic quetiapine is being obtained and used for recreational abuse. The purpose of this study was to describe the relative rates of single-substance abuse for different atypical antipsychotics and compare their demographic and clinical features. METHODS We conducted a 10-year retrospective analysis of the National Poison Data System (NPDS) database (2003 - 2013). Trained nurses and pharmacists with specialty training in toxicology prospectively collect all NPDS data at poison control centers around the United States. We queried the NPDS for all cases of single-substance second-generation antipsychotic exposures coded as "intentional abuse." The data provided by the NPDS regarding rates and clinical features of quetiapine abuse and the abuse of all other second-generation antipsychotics were compared and described descriptively. RESULTS During the study period, 2,118 cases of quetiapine abuse and 1,379 cases of other second-generation antipsychotic abuse were identified. Quetiapine abuse was more common than the abuse of other second-generation antipsychotics, compromising 60.6% of all abuse cases during the study period. After quetiapine, the next most frequently abused medications were risperidone (530 cases, 15.2%) and olanzapine (246 cases, 7.0%). For all second-generation antipsychotics including quetiapine, central nervous system clinical effects were most common, including drowsiness, confusion, and agitation. Other serious clinical effects observed with second-generation antipsychotic abuse included hypotension, respiratory depression, and seizures. CONCLUSION Quetiapine abuse is relatively common, and is abused far more often than any other second-generation antipsychotic. Emergency physicians should be aware of the clinical effects that may occur after second-generation antipsychotic abuse.
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Affiliation(s)
- Lauren Klein
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Stacey Bangh
- Minnesota Poison Control System, Minneapolis, Minnesota
| | - Jon B Cole
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota; Minnesota Poison Control System, Minneapolis, Minnesota
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Suicide attempt during late pregnancy with quetiapine: nonfatal outcome despite severe intoxication. J Clin Psychopharmacol 2015; 35:343-4. [PMID: 25830593 DOI: 10.1097/jcp.0000000000000308] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Mattson ME, Albright VA, Yoon J, Council CL. Emergency Department Visits Involving Misuse and Abuse of the Antipsychotic Quetiapine: Results from the Drug Abuse Warning Network (DAWN). SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2015; 9:39-46. [PMID: 26056465 PMCID: PMC4444129 DOI: 10.4137/sart.s22233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/15/2015] [Accepted: 03/16/2015] [Indexed: 12/03/2022]
Abstract
Case reports in medical literature suggest that the atypical antipsychotic quetiapine, a medication not previously considered to have abuse potential, is now being subject to misuse and abuse (MUA; ie, taken when not prescribed for them or used in a way other than instructed by their health professional). Here we present systematic, nationally representative data from the 2005 to 2011 Drug Abuse Warning Network (DAWN) for prevalence of emergency department (ED) visits among the U.S. general population involving quetiapine and related to MUA, suicide attempts, and adverse reactions. Nationally, quetiapine-related ED visits increased 90% between 2005 and 2011, from 35,581 ED visits to 67,497. DAWN data indicate that when used without medical supervision for recreational/self-medication purposes, quetiapine poses health risks for its users, especially among polydrug users and women. These findings suggest that the medical and public health communities should increase vigilance concerning this drug and its potential for MUA.
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Affiliation(s)
- Margaret E Mattson
- Substance Abuse and Mental Health Services Administration, Rockville, MD, USA
| | | | - Joanna Yoon
- Health Resources and Services Administration, Rockville, MD, USA
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QTc interval prolongation and torsade de pointes associated with second-generation antipsychotics and antidepressants: a comprehensive review. CNS Drugs 2014; 28:887-920. [PMID: 25168784 DOI: 10.1007/s40263-014-0196-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We comprehensively reviewed published literature to determine whether it supported the link between corrected QT (QTc) interval prolongation and torsade de pointes (TdP) for the 11 second-generation antipsychotics and seven second-generation antidepressants commonly implicated in these complications. Using PubMed and EMBASE, we identified four thorough QT studies (one each for iloperidone, ziprasidone, citalopram, and escitalopram), 40 studies specifically designed to assess QTc interval prolongation or TdP, 58 publications based on data from efficacy and safety trials, 18 toxicology studies, and 102 case reports. Thorough QT studies, QTc prolongation-specific studies, and studies based on efficacy and safety trials did not link drug-associated QTc interval prolongation with TdP. They only showed that the drugs reviewed caused varying degrees of QTc interval prolongation, and even that information was not clear and consistent enough to stratify individual drugs for this risk. The few toxicology studies provided valuable information but their findings are pertinent only to situations of drug overdose. Case reports were most informative about the drug-QTc interval prolongation-TdP link. At least one additional well established risk factor for QTc prolongation was present in 92.2 % of case reports. Of the 28 cases of TdP, six (21.4 %) experienced it with QTc interval <500 ms; 75 % of TdP cases occurred at therapeutic doses. There is little evidence that drug-associated QTc interval prolongation by itself is sufficient to predict TdP. Future research needs to improve its precision and broaden its scope to better understand the factors that facilitate or attenuate progression of drug-associated QTc interval prolongation to TdP.
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Meli M, Rauber-Lüthy C, Hoffmann-Walbeck P, Reinecke HJ, Prasa D, Stedtler U, Färber E, Genser D, Kupferschmidt H, Kullak-Ublick GA, Ceschi A. Atypical antipsychotic poisoning in young children: a multicentre analysis of poisons centres data. Eur J Pediatr 2014; 173:743-50. [PMID: 24370666 DOI: 10.1007/s00431-013-2241-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 12/05/2013] [Accepted: 12/09/2013] [Indexed: 11/24/2022]
Abstract
UNLABELLED Although paediatric patients frequently suffer from intoxications with atypical antipsychotics, the number of studies in young children, which have assessed the effects of acute exposure to this class of drugs, is very limited. The aim of this study was to achieve a better characterization of the acute toxicity profile in young children of the atypical antipsychotics clozapine, olanzapine, quetiapine, and risperidone. We performed a multicentre retrospective analysis of cases with atypical antipsychotics intoxication in children younger than 6 years, reported by physicians to German, Austrian, and Swiss Poisons Centres for the 9-year period between January 1, 2001 and December 31, 2009. One hundred and six cases (31 clozapine, 29 olanzapine, 12 quetiapine, and 34 risperidone) were available for analysis. Forty-seven of the children showed minor, 28 moderate, and 2 severe symptoms. Twenty-nine cases were asymptomatic. No fatalities were recorded. Symptoms predominantly involved the central nervous and cardiovascular systems. Minor reduction in vigilance (Glasgow Coma Scale score >9) (62 %) was the most frequently reported symptom, followed by miosis (12 %) and mild tachycardia (10 %). Extrapyramidal motor symptoms were observed in one case (1 %) after ingestion of risperidone. In most cases, surveillance and supportive care were sufficient to achieve a good outcome, and all children made full recovery. CONCLUSIONS Paediatric antipsychotic exposure can result in significant poisoning; however, in most cases only minor or moderate symptoms occurred and were followed by complete recovery. Symptomatic patients should be monitored for central nervous system depression and an electrocardiogram should be obtained.
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Affiliation(s)
- Marianne Meli
- Division of Science, Swiss Toxicological Information Centre, Associated Institute of the University of Zurich, Freiestrasse 16, Zurich, CH-8032, Switzerland
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Rauber-Lüthy C, Hofer KE, Bodmer M, Kullak-Ublick GA, Kupferschmidt H, Ceschi A. Gastric pharmacobezoars in quetiapine extended-release overdose: A case series. Clin Toxicol (Phila) 2013; 51:937-40. [DOI: 10.3109/15563650.2013.856442] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Müller D, Desel H. Common causes of poisoning: etiology, diagnosis and treatment. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:690-9; quiz 700. [PMID: 24194796 DOI: 10.3238/arztebl.2013.0690] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 07/31/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND In 2011, German hospitals treated approximately 205 000 patients suffering from acute poisoning. Change is seen over time both in the types of poisoning that occur and in the indications for specific treatment. METHODS This article is based on a selective review of the literature, with special attention to the health reports of the German federal government, the annual reports of the GIZ-Nord Poisons Center (the poison information center for the four northwestern states of Germany, i.e. Bremen, Hamburg, Lower Saxony and Schleswig-Holstein), and the recommendations of international medical associations. RESULTS From 1996 to 2011, the GIZ-Nord Poisons Center answered more than 450 000 inquiries, most of which involved exposures to medical drugs, chemicals, plants, foods, or cosmetics. Poisoning was clinically manifest in only a fraction of these cases. Ethanol intoxication is the commonest type of acute poisoning and suicide by medical drug overdose is the commonest type of suicide by poisoning. Death from acute poisoning is most commonly the result of either smoke inhalation or illegal drug use. Severe poisoning is only rarely due to the ingestion of chemicals (particularly detergents and cleaning products), cosmetics, or plant matter. Medical procedures that are intended to reduce the absorption of a poison or enhance its elimination are now only rarely indicated. Antidotes (e.g., atropine, 4-dimethylaminophenol, naloxone, toluidine blue) are available for only a few kinds of poisoning. Randomized clinical trials of treatment have been carried out for only a few substances. CONCLUSION Most exposures to poisons can be treated with general emergency care and, if necessary, with symptomatic intensive-care measures. Poison information centers help ensure that cases of poisoning are dealt with efficiently. The data they collect are a useful aid to toxicological assessment and can serve as a point of departure for research projects.
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Affiliation(s)
- Dieter Müller
- GIZ-Nord Poisons Center, University Medical Center Göttingen-Georg-August-Universität
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Bartos M, Knudsen K. Use of intravenous lipid emulsion in the resuscitation of a patient with cardiovascular collapse after a severe overdose of quetiapine. Clin Toxicol (Phila) 2013; 51:501-4. [DOI: 10.3109/15563650.2013.803229] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sayyah M, Majzoob S, Sayyah M. Metabolic and toxicological considerations for obsessive-compulsive disorder drug therapy. Expert Opin Drug Metab Toxicol 2013; 9:657-73. [PMID: 23521155 DOI: 10.1517/17425255.2013.783011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Obsessive-compulsive disorder (OCD) affects the daily life of the patients. Chronic nature of this disease and the need for long-term high-dose drug therapy for its maintenance increase the risk of metabolic and toxicological complications. AREAS COVERED In this concise article, the metabolic and toxicological aspects of major medication categories prescribed in OCD, such as serotonin-specific reuptake inhibitors, tricyclic antidepressant (clomipramine), serotonin-norepinephrine reuptake inhibitors, and atypical antipsychotics indicated in OCD (both Food and Drug Administration-approved and off-label) are discussed. EXPERT OPINION The most critical point in pharmacotherapy of OCD is the need for the high-dose and long-term use of drugs. In OCD, generally the higher doses of applicable drugs than those used in depression are required, often exceeding the recommended maximum dose. Moreover, such high doses should be given for at least 10 - 12 weeks to ensure the adequate treatment duration for the clinical effects to emerge. This long-term high-dose maintenance therapy increases the risk of drug toxicity and adverse effects. Physicians should take extra care in periodical assessment of signs and symptoms of metabolic and toxicological complications in patients. Subjective symptoms reported by patients should be carefully assessed and not attributed to obsessive nature of the patients.
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Affiliation(s)
- Mohammad Sayyah
- Pasteur Institute of Iran, Department of Physiology and Pharmacology, Tehran, Iran
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Rhabdomyolysis following Acute Extended-Release Quetiapine Poisoning: A Case Report. Case Rep Psychiatry 2013; 2012:347421. [PMID: 23304601 PMCID: PMC3530860 DOI: 10.1155/2012/347421] [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: 10/26/2012] [Accepted: 11/24/2012] [Indexed: 11/18/2022] Open
Abstract
Background. During the past few years, there have been a number of case reports concerning rhabdomyolysis following quetiapine poisoning; however, there has been none concerning the medication in its extended-release form. Methods. We present the case report of a 48-year-old man presenting a major depressive disorder and borderline personality disorder, who after voluntary intoxication with 12000 mg of quetiapine extended-release developed signs of acute rhabdomyolysis. Results. The rhabdomyolysis was confirmed by the laboratory and the clinical findings, with elevated levels of creatinine, creatine phosphokinase, and CRP. Discussion. We would like to pinpoint the importance of this complication and our concern of prescribing it for psychiatric patients with chronic somatic comorbidities.
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Papazisis G, Mastrogianni O, Chatzinikolaou F, Vasiliadis N, Raikos N. Sudden cardiac death due to quetiapine overdose. Psychiatry Clin Neurosci 2012; 66:535. [PMID: 23066774 DOI: 10.1111/j.1440-1819.2012.02385.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
The topic of central nervous system intoxicants encompasses a multitude of agents. This article focuses on three classes of therapeutic drugs, with specific examples in which overdoses require admission to the intensive care unit. Included are some of the newer antidepressants, the atypical neuroleptic agents, and selected anticonvulsant drugs. The importance of understanding pertinent physiology and applicable supportive care is emphasized.
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Affiliation(s)
- Matthew W Hedge
- Department of Emergency Medicine, Detroit Receiving Hospital, Children's Hospital of Michigan Regional Poison Control Center, Wayne State University, Hutzel Building, 4707 Street Antoine, Suite 302, Detroit, MI 48201, USA.
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Lannemyr L, Knudsen K. Severe overdose of quetiapine treated successfully with extracorporeal life support. Clin Toxicol (Phila) 2012; 50:258-61. [DOI: 10.3109/15563650.2012.665456] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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