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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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Brettner F, Brettner F, Appelt W, Berlinger A, Perras J, Steindl D, Greb I. [Cardiac arrest after intoxication with an extremely high dose of venlafaxine. Bridge to recovery with extracorporeal life support]. DIE ANAESTHESIOLOGIE 2024; 73:408-411. [PMID: 38717642 DOI: 10.1007/s00101-024-01412-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 04/04/2024] [Accepted: 04/10/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Florian Brettner
- Klinik für Anästhesiologie und Intensivmedizin, ARDS und ECMO Zentrum München-Nymphenburg, Krankenhaus Barmherzige Brüder München, Romanstr. 93, 80639, München, Deutschland
| | - Franz Brettner
- Klinik für Anästhesiologie und Intensivmedizin, ARDS und ECMO Zentrum München-Nymphenburg, Krankenhaus Barmherzige Brüder München, Romanstr. 93, 80639, München, Deutschland.
| | - Werner Appelt
- Klinik für Anästhesiologie und Intensivmedizin, ARDS und ECMO Zentrum München-Nymphenburg, Krankenhaus Barmherzige Brüder München, Romanstr. 93, 80639, München, Deutschland
| | - Angelika Berlinger
- Klinik für Anästhesiologie und Intensivmedizin, ARDS und ECMO Zentrum München-Nymphenburg, Krankenhaus Barmherzige Brüder München, Romanstr. 93, 80639, München, Deutschland
| | - Jan Perras
- Intensivmedizin, BG Unfallklinik Murnau, Murnau, Deutschland
| | - David Steindl
- Giftnotruf, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Medizinische Klinik mit Schwerpunkt Nephrologie und internistische Intensivmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Ingo Greb
- Giftnotruf, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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Hoffmann M, Akbas S, Kindler R, Bettex D. Successful use of extracorporeal life support and hemadsorption in the context of venlafaxine intoxication requiring cardiopulmonary resuscitation: a case report. J Artif Organs 2024; 27:167-171. [PMID: 37115336 PMCID: PMC11126471 DOI: 10.1007/s10047-023-01399-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/08/2023] [Indexed: 04/29/2023]
Abstract
Venlafaxine is a serotonin and noradrenalin reuptake inhibitor prescribed as an antidepressant. Overdose clinically manifests with neurological, cardiovascular and gastrointestinal abnormalities based on, amongst others, serotonin syndrome and can be life-threatening due to cardiovascular collapse. Besides immediate decontamination via gastric lavage and inhibition of enteral absorption through active charcoal, successful hemadsorption with CytoSorb® has been reported. We present the case of a 17-year-old female who required extracorporeal life support (ECLS) for cardiovascular collapse as a result of life-threatening venlafaxine intoxication. Serial serum blood concentrations of venlafaxine/desmethylvenlafaxine on admission at a tertiary hospital (approx. 24 h after ingestion) and subsequently 6 h and 18 h thereafter, as well as on days 2 and 4, were measured. CytoSorb® was initiated 6 h after admission and changed three times over 72 h. The initial blood concentration of venlafaxine/desmethylvenlafaxine was 53.52 µmol/l. After 6 h, it declined to 30.7 µmol/l and CytoSorb® was initiated at this point. After 12 h of hemadsorption, the blood level decreased to 9.6 µmol/l. On day 2, it was down to 7.17 µmol/l and decreased further to 3.74 µmol/l. Additional continuous renal replacement therapy using CVVHD was implemented on day 5. The combination of hemadsorption, besides traditional decontamination strategies along maximal organ supportive therapy with ECLS, resulted in the intact neurological survival of the highest venlafaxine intoxication reported in the literature to date. Hemadsorption with CytoSorb® might help to reduce blood serum levels of venlafaxine. Swift clearance of toxic blood levels may support cardiovascular recovery after life-threatening intoxications.
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Affiliation(s)
- Matthias Hoffmann
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Samira Akbas
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Rahel Kindler
- Institute of Intensive Care Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Dominique Bettex
- Institute of Anesthesiology, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Ren J, Wang Y, Nie J, Sun L, Wu H, Li Y, Wu J. Venlafaxine-Associated Rhabdomyolysis: A Literature Review. J Clin Psychopharmacol 2024; 44:297-301. [PMID: 38506608 DOI: 10.1097/jcp.0000000000001838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
PURPOSE This systematic review aimed to investigate the clinical manifestations and characteristics of venlafaxine-associated rhabdomyolysis. METHODS A systematic search was conducted in PubMed, Elsevier, Science Direct, Embase, Springer Link, Wiley Online Library, CNKI, and Wanfang databases from the date of database inception to January 2023. Previously reported cases of venlafaxine-associated rhabdomyolysis were identified, and relevant data from these cases were collected for descriptive statistical analysis. Cases that met the inclusion criteria were evaluated to determine the correlation between adverse reactions and venlafaxine. RESULTS A total of 12 patients with venlafaxine-associated rhabdomyolysis were included. None of these patients had a history of muscle pain or discomfort. Of the 12 patients, 5 patients received venlafaxine at doses of ≤225 mg/d, whereas the remaining 7 patients received doses exceeding 225 mg/d. The main clinical symptoms included myalgia, muscle weakness, and renal injury. All 12 patients discontinued venlafaxine and received symptomatic care. CONCLUSIONS Venlafaxine, used either as a monotherapy or in combination with other drugs, may be associated with rhabdomyolysis. Creatine kinase levels may normalize or significantly decrease after discontinuation of venlafaxine and symptomatic treatment.
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Affiliation(s)
- Jieru Ren
- From the Department of Pharmacy, Shandong Second Provincial General Hospital, Jinan
| | - Ying Wang
- University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong, China
| | - Jing Nie
- From the Department of Pharmacy, Shandong Second Provincial General Hospital, Jinan
| | - Lei Sun
- From the Department of Pharmacy, Shandong Second Provincial General Hospital, Jinan
| | - Huina Wu
- From the Department of Pharmacy, Shandong Second Provincial General Hospital, Jinan
| | - Yamei Li
- From the Department of Pharmacy, Shandong Second Provincial General Hospital, Jinan
| | - Jiyong Wu
- From the Department of Pharmacy, Shandong Second Provincial General Hospital, Jinan
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Couderc S, Gabriel A, Decheiver S, N'Zoué Kanga S, Fikanni A, Flint H, Pihan F, Sahar A, Tifrea M, Tifrea A, Marsaud JP, Vandroux D. A Massive Venlafaxine Intoxication: Evolution of Cardiac Toxicity with Venlafaxine and O-Desmethylvenlafaxine Elimination Kinetics: A Grand Round. Ther Drug Monit 2024; 46:133-137. [PMID: 38158602 DOI: 10.1097/ftd.0000000000001167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 10/18/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND This study presents the case of a 19-year-old woman who attempted suicide by ingesting 11.25 g of venlafaxine (V). She was admitted to the hospital with severe biventricular dysfunction, progressing to cardiac arrest requiring extracorporeal circulatory life support for 11 days. The pharmacokinetics of venlafaxine during impaired cardiac output and the effect of its active metabolite, the O-desmethylvenlafaxine (ODV), are currently not very well understood. METHODS AND RESULTS Serum concentrations of V and ODV were monitored twice daily for 3 weeks. The maximum concentrations of venlafaxine and ODV were at 14 hours after ingestion, with 29,180 mcg/L for V and 5399 mcg/L for ODV. Half-lives increased, requiring 2 weeks to eliminate the drug. The left ventricular ejection fraction significantly improved when V + ODV was below 1000 mcg/L and remained altered until the ODV concentrations were lower than 400 mcg/L. CONCLUSIONS This report, with complete elimination kinetic of V and ODV in a monodrug intoxication, provides information about the modification of pharmacokinetics in the case of an overdose managed by extracorporeal circulatory life support, the cardiac toxicity of ODV, and the value of the toxic threshold for the active moiety.
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Affiliation(s)
- Sylvain Couderc
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France; and
| | - Anthony Gabriel
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Sarah Decheiver
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France; and
| | - Sita N'Zoué Kanga
- Department of Pharmacology and Toxicology, CHU Dupuytren, Limoges, France; and
| | - Amine Fikanni
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Harry Flint
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Franck Pihan
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Abdallah Sahar
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Marius Tifrea
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | - Andrea Tifrea
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
| | | | - David Vandroux
- Cardio-surgical Intensive Care Unit, CHU Dupuytren, Limoges, France
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Ollier M, Giles S, Gosselin S. The Occasional intralipid emulsion therapy. CANADIAN JOURNAL OF RURAL MEDICINE 2023; 28:195-200. [PMID: 37861604 DOI: 10.4103/cjrm.cjrm_62_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Mary Ollier
- Departement of Family Medicine Temerty School of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Giles
- Northern Ontario School of Medicine University, Thunder Bay, Ontario, Canada
| | - Sophie Gosselin
- Centre Intégré De Santé Et Services Sociaux De La Montérégie-Centre; Centre Antipoison Du Québec; Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
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7
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Manolis TA, Manolis AA, Melita H, Manolis AS. Neuropsychiatric disorders in patients with heart failure: not to be ignored. Heart Fail Rev 2022:10.1007/s10741-022-10290-2. [DOI: 10.1007/s10741-022-10290-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
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8
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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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Chiew AL, Buckley NA. The serotonin toxidrome: shortfalls of current diagnostic criteria for related syndromes. Clin Toxicol (Phila) 2021; 60:143-158. [PMID: 34806513 DOI: 10.1080/15563650.2021.1993242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Serotonin syndrome (toxicity) describes adverse drug effects from toxic amounts of intra-synaptic central nervous system serotonin. A wide range of drugs have been implicated to cause serotonin toxicity, not all justifiably. The plausible agents all have a final common pathway resulting in a substantial increase in central nervous system serotonergic neurotransmission. Serotonin toxicity is characterized by neuromuscular excitation, mental status changes, and autonomic dysregulation. Signs and symptoms represent a spectrum of toxicity (mild to life-threatening) related to increasing serotonin concentrations. As there is no consensus on the threshold for "toxicity" or diagnostic criteria, the true incidence of serotonin toxicity is unknown. The incidence in overdose is easier to quantify and is reasonably common in serotonergic antidepressant overdoses. In a large case series of overdoses, moderate serotonin toxicity occurred in 14% of poisonings with a selective serotonin reuptake inhibitor. While half those ingesting a monoamine oxidase inhibitor in combination with a serotonergic agent in overdose exhibit at least moderately severe serotonin toxicity. In contrast, the incidence of serotonin toxicity in those on therapeutic serotonergic agents appears to be very low. OBJECTIVES To provide a narrative review of the current diagnostic criteria, utilizing case reports of fatalities to evaluate how many meet the various diagnostic criteria and propose practical solutions to resolve controversies in diagnosis. METHODS A review of serotonin toxicity diagnostic criteria in the English literature was completed by searching Embase and PubMed from January 1990 to July 2021 for the keywords "serotonin syndrome/toxicity" paired with "diagnostic criteria" or "diagnosis." Also, fatal cases of serotonin toxicity identified from a recent systematic review were independently examined to determine what diagnostic criteria were met and whether serotonin toxicity or another cause was most likely. REVIEW OF DIAGNOSIS CRITERIA Serotonin toxicity is a clinical diagnosis, four diagnostic criteria (Sternbach, Serotonin Syndrome Scale, Radomski, and Hunter) have been proposed. However, the Serotonin Syndrome Scale has not been validated in patients with serotonin toxicity and only utilized in those on a serotonergic agent. The remaining three criteria are utilized more widely but have undergone little refinement or validation. REVIEW OF FATAL CASES Shortfalls with diagnostic criteria can be illustrated by examining case fatalities. Of 55 fatal cases reviewed, 12 (22%) were unlikely to be serotonin toxicity. Sternbach and Radomski criteria were met by 25 (45%), 20 (36%) had insufficient data reported and 10 (18%) met an exclusion criterion. Few had sufficient information reported to determine whether Hunter Criteria were met, with only 13 (24%) documented as meeting the criteria, the remaining 42 (76%) had insufficient data. RESOLVING SHORTFALLS IN CURRENT DIAGNOSTIC CRITERIA As serotonin toxicity is a clinical diagnosis, issues arise when basing the diagnosis on symptom criteria alone, without considering whether the drug/s ingested increase central nervous system serotonin or whether there is an alternative diagnosis. This has resulted in case reports and government warnings for drugs that cannot plausibly cause significant serotonin toxicity (e.g., ondansetron and antipsychotics). We propose when assessing for a serotonin toxidrome, both the causative agent(s) and clinical scenario is considered to determine the likelihood of serotonin toxicity. Then the clinical features assessed, those with a moderate to high prior probability (e.g., serotonergic drug-drug interaction, overdose, recent initiation or increase in dose of serotonergic agent/s) could be diagnosed based on the Hunter criteria. However, those with a low probability (e.g., stable therapeutic doses of a serotonergic agent) require more specific and stringent criteria. Finally, we propose a minimum dataset for case reports/series of serotonin toxicity. CONCLUSIONS More complete and accurate reporting of serotonin toxicity cases is required in the future, to avoid further misleading associations that are physiologically implausible.
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Affiliation(s)
- Angela L Chiew
- Clinical Toxicology Unit, Prince of Wales Hospital, Randwick, Australia.,NSW Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Westmead, Australia.,Clinical Pharmacology and Toxicology Research Group, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Forsberg S, Abazi L, Forsman P. Successful use of extended cardiopulmonary resuscitation followed by extracorporeal oxygenation after venlafaxine-induced takotsubo cardiomyopathy and cardiac arrest: a case report. J Med Case Rep 2021; 15:485. [PMID: 34579764 PMCID: PMC8477521 DOI: 10.1186/s13256-021-03031-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 07/27/2021] [Indexed: 11/18/2022] Open
Abstract
Background Severe venlafaxine intoxication may cause arrhythmias, cardiac failure, and even cardiac arrest. Case presentation A 48-year-old caucasian male with an extensive psychiatric history ingested a high dose of venlafaxine causing a serum venlafaxine concentration of 12.6 mg/L 24 hours after ingestion. Seven hours post-ingestion, he experienced tonic–clonic seizures, and 8 hours later, takotsubo cardiomyopathy was recognized followed by cardiac arrest. The patient was resuscitated with prolonged cardiopulmonary resuscitation including ongoing automatic external compressions during helicopter transportation to a tertiary hospital for extracorporeal membrane oxygenation treatment. Despite a cardiopulmonary resuscitation duration of 2 hours, 36 hours of extracorporeal membrane oxygenation, and a total of 30 days of intensive care, the patient made a full recovery. Conclusion In cases of intoxication-induced cardiac arrests among otherwise young and healthy patients, prolonged cardiopulmonary resuscitation and extracorporeal circulation can be a life-saving bridge to recovery.
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Affiliation(s)
- Sune Forsberg
- Department of Anaesthesiology and Intensive Care, Norrtälje Hospital, Norrtälje, Sweden. .,Centre for Resuscitation Science, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. .,Swedish Poisons Information Centre, Stockholm, Sweden.
| | - Lis Abazi
- Department of Anaesthesiology and Intensive Care, Norrtälje Hospital, Norrtälje, Sweden.,Centre for Resuscitation Science, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Pär Forsman
- ECMO Centre Karolinska, Karolinska University Hospital, Stockholm, Sweden
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Prakash S, Rathore C, Rana K, Prakash A. Fatal serotonin syndrome: a systematic review of 56 cases in the literature. Clin Toxicol (Phila) 2020; 59:89-100. [PMID: 33196298 DOI: 10.1080/15563650.2020.1839662] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Serotonin syndrome (SS) is a drug-induced potentially life-threatening clinical condition. There is a paucity of data on the risk factors, clinical course, and complications associated with fatal SS. OBJECTIVE To characterize the epidemiological profile, clinical features, and risk factors associated with fatal SS through a systematic review. METHODS We performed a systematic review of MEDLINE and Google Scholar for case reports, case series, or cohort studies of fatal SS. RESULTS Initial database search identified 2326 articles of which 46 (56 patients) were included in the final analysis. The mean age was 42.3 years (range 18-87 years) with female predominance (57%). North America and Europe constitute 80% of the reported fatal SS. The symptoms evolved very rapidly, within 24 h after the administration of serotonergic drugs in 59% of the cases. Fever (61%) was the most common symptom, followed by seizure (36%) and tremors (30%). The mean temperature in the reported cases (25 patients) was 41.6 ± 1.3 °C (range 38.3-43.5 °C). SS was reported to occur with the maintenance dosage of serotonergic agents, after initiation of the drug for the first time, and addition of the drugs for the development of another unrelated illness. Creatine kinase (CK) activities were elevated (>3 times of the upper limit of normal) in eighteen patients, and it was very high (>25,000 IU/L) in four patients. Presence of high grade fever, seizures, and high CK activities may be associated with severe SS. Nine patients (16%) received 5-HT2A antagonists as a therapy. About 50% of patients died within 24 h of the onset of symptoms. CONCLUSIONS While fatal SS is rare, frequently observed features include hyperthermia, seizures, and high CK activities. Cyproheptadine use appears infrequent for these patients.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Kaushik Rana
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, India
| | - Anurag Prakash
- Parul Institute of Medical Sciences & Research, Parul University, Waghodia, Vadodara, India
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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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13
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Stefani M, Roberts DM, Brett J. High-dose insulin euglycemic therapy to treat cardiomyopathy associated with massive venlafaxine overdose. Clin Toxicol (Phila) 2020; 58:299-300. [DOI: 10.1080/15563650.2019.1638930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Maurizio Stefani
- St. Vincent’s Clinical School, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Darren M. Roberts
- St. Vincent’s Clinical School, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Jonathan Brett
- St. Vincent’s Clinical School, University of NSW, Darlinghurst, New South Wales, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
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Singh H, DuBois B, Al-Jammali Z, Barrett T. Pharmacogenomics in the clinic: genetic polymorphism contributing to venlafaxine-associated heart failure. Pharmacogenomics 2019; 20:1175-1178. [PMID: 31799914 DOI: 10.2217/pgs-2019-0083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Harleen Singh
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Portland, OR 97201, USA.,Department of Internal Medicine, The Veterans Affairs Portland Health Care System, Portland, OR 97239, USA
| | - Barent DuBois
- QPS LLC, Pencader Corporate Center,110 Executive drive, Newark, DE 19702, USA
| | - Zain Al-Jammali
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Portland, OR 97201, USA
| | - Thomas Barrett
- Department of Internal Medicine, The Veterans Affairs Portland Health Care System, Portland, OR 97239, USA
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Schoretsanitis G, Haen E, Hiemke C, Endres K, Ridders F, Veselinovic T, Gründer G, Paulzen M. Pharmacokinetic correlates of venlafaxine: associated adverse reactions. Eur Arch Psychiatry Clin Neurosci 2019; 269:851-857. [PMID: 30923938 DOI: 10.1007/s00406-019-01005-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 03/21/2019] [Indexed: 01/03/2023]
Abstract
To address the potential correlation between plasma concentrations of venlafaxine (VEN), its active metabolite O-desmethylvenlafaxine (ODVEN) and the active moiety, AM, (ODVEN + VEN) and adverse drug reactions (ADR) in a large naturalistic sample of in- and outpatients. We compared plasma concentrations of VEN, ODVEN and AM and dose-adjusted (C/D) levels as well the ODVEN/VEN ratios between patients complaining ADRs, following the Udvalg for Kliniske Undersogelser side effect rating scales (UKU) (n = 114) and patients without ADRs (control group, n = 688) out of a naturalistic database. We also investigated potential pharmacokinetic correlates of the four UKU categories by comparing patients complaining ADRs with those who did not. Based on previous literature we applied different ODVEN/VEN ratio values as cut-offs to split our sample into two groups at a time and compare frequencies of ADRs between the groups. No differences for demographic and pharmacokinetic variables including plasma and C/D concentrations as well as ODVEN/VEN ratios were observed between study groups. Neither the comparisons between females and males nor between elderly and non-elderly patients revealed significant differences (p > 0.05 in all cases). No differences were also reported exploring the patients complaining ADRs from the 4 UKU categories separately. After applying various ODVEN/VEN cut-offs, groups did not display differences in frequencies of ADRs (p > 0.05 in all cases). Our findings do not demonstrate a direct link between venlafaxine metabolism measures and ADRs. Therefore, additional dimensions are needed to be considered in future trials aiming to disentangle the involved aspects of ADRs in patients receiving venlafaxine.
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Affiliation(s)
- Georgios Schoretsanitis
- Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA.
| | - Ekkehard Haen
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Christoph Hiemke
- Department of Psychiatry and Psychotherapy, Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of Mainz, Mainz, Germany
| | - Katharina Endres
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Florian Ridders
- Clinical Pharmacology, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.,Department of Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Tanja Veselinovic
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany.,JARA: Translational Brain Medicine, Aachen, Germany
| | - Gerhard Gründer
- Department of Molecular Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Paulzen
- Department of Psychiatry, Psychotherapy and Psychosomatics, RWTH Aachen University, Aachen, Germany.,JARA: Translational Brain Medicine, Aachen, Germany.,Alexianer Hospital Aachen, Aachen, Germany
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Quand les vêtements demeurent la seule matrice disponible…. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2019. [DOI: 10.1016/j.toxac.2019.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Identify the relationships between depression, anxiety, and heart failure (HF).• Assess methods for accurately diagnosing depression and anxiety disorders in patients with HF.• Evaluate current evidence for treatment of anxiety and depression in patients with HF. BACKGROUND In patients with heart failure (HF), depression and anxiety disorders are common and associated with adverse outcomes such as reduced adherence to treatment, poor function, increased hospitalizations, and elevated mortality. Despite the adverse impact of these disorders, anxiety and depression remain underdiagnosed and undertreated in HF patients. METHODS We performed a targeted literature review to (1) identify associations between depression, anxiety, and HF, (2) examine mechanisms mediating relationships between these conditions and medical outcomes, (3) identify methods for accurately diagnosing depression and anxiety disorders in HF, and (4) review current evidence for treatments of these conditions in this population. RESULTS Both depression and anxiety disorders are associated with the development and progression of HF, including increased rates of mortality, likely mediated through both physiologic and behavioral mechanisms. Given the overlap between cardiac and psychiatric symptoms, accurately diagnosing depression or anxiety disorders in HF patients can be challenging. Adherence to formal diagnostic criteria and utilization of a clinical interview are the best courses of action in the evaluation process. There is limited evidence for the efficacy of pharmacologic and psychotherapy in patients with HF. However, cognitive-behavioral therapy has been shown to improve mental health outcomes in patients with HF, and selective serotonin reuptake inhibitors appear safe in this cohort. CONCLUSIONS Depression and anxiety disorders in HF patients are common, underrecognized, and linked to adverse outcomes. Further research to improve detection and develop effective treatments for these disorders in HF patients is badly needed.
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Affiliation(s)
- Christopher M. Celano
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | - Ana C. Villegas
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| | | | - Hanna K. Gaggin
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Jeff C. Huffman
- Harvard Medical School, Boston, MA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
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Ott M, Mannchen JK, Jamshidi F, Werneke U. Management of severe arterial hypertension associated with serotonin syndrome: a case report analysis based on systematic review techniques. Ther Adv Psychopharmacol 2019; 9:2045125318818814. [PMID: 30886699 PMCID: PMC6413434 DOI: 10.1177/2045125318818814] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 08/01/2018] [Indexed: 12/14/2022] Open
Abstract
Serotonin syndrome is thought to arise from serotonin excess. In many cases, symptoms are mild and self-limiting. But serotonin syndrome can become life threatening, when neuromuscular hyperexcitability spins out of control. Uncontainable neuromuscular hyperexcitability may lead to cardiovascular complications, linked to extreme changes in blood pressure. Currently, there is little guidance on how to control blood pressure in hyperserotonergic states. We report a case with treatment-resistant arterial hypertension, followed by a clinical review (using systematic review principles and techniques) of the available evidence from case reports published between 2004 and 2016 to identify measures to control arterial hypertension associated with serotonin syndrome. We conclude that classic antihypertensives may not be effective for the treatment of severe hypertension associated with serotonin syndrome. Benzodiazepines may lower blood pressure. Patients with severe hypertension not responding to benzodiazepines may benefit from cyproheptadine, propofol or both. In severe cases, higher cyproheptadine doses than currently recommended may be necessary.
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Affiliation(s)
- Michael Ott
- Department of Public Health and Clinical
Medicine – Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Julie K. Mannchen
- Department of Public Health and Clinical
Medicine – Family Medicine, Umeå University, Umeå, Sweden
| | | | - Ursula Werneke
- Sunderby Research Unit, Department of Clinical
Sciences – Psychiatry, Umeå University, Umeå, Sweden
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Manolis TA, Manolis AA, Manolis AS. Cardiovascular Safety of Psychiatric Agents: A Cautionary Tale. Angiology 2018; 70:103-129. [PMID: 29874922 DOI: 10.1177/0003319718780145] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Psychiatric agents are among the most commonly prescribed medications. Despite the advent of newer generation agents, patients receiving them still experience cardiovascular (CV) side effects. However, these agents may have heterogeneous properties, calling for an individualized approach based on efficacy and also on the particular side effect profile of each specific agent. Proarrhythmic effects arising from drug-induced long-QT syndrome and consequent potentially life-threatening polymorphic ventricular arrhythmias in the form of torsade de pointes, the metabolic syndrome contributing to atherosclerosis and acute coronary syndromes, and drug-induced orthostatic hypotension raise major concerns. Of course, it is also crucial that fear of potential CV adverse effects does not deprive psychiatric patients of appropriate drug therapy. Modification of CV risk factors in psychiatric patients together with optimal management of their CV diseases and appropriate selection of psychotropic agents with greater efficacy and least CV toxicity are of paramount importance in mitigating CV risks and enhancing safety. Identifying patients at high risk of CV complications and close monitoring of all patients receiving these agents are crucial steps to prevent and manage such complications. All these issues are herein reviewed, relevant guidelines are discussed, and schemas are depicted that illustrate the interrelated connections among the psychotropic agents and their CV effects.
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Affiliation(s)
| | | | - Antonis S Manolis
- 3 Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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20
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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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Napp LC, Vogel-Claussen J, Schäfer A, Haverich A, Bauersachs J, Kühn C, Tongers J. First-in-Man Fully Percutaneous Complete Bypass of Heart and Lung. JACC Cardiovasc Interv 2017; 10:e231-e233. [PMID: 29198456 DOI: 10.1016/j.jcin.2017.07.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/27/2017] [Accepted: 07/11/2017] [Indexed: 11/26/2022]
Affiliation(s)
- L Christian Napp
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
| | - Jens Vogel-Claussen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Andreas Schäfer
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jörn Tongers
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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22
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Kumar M, Nayak PK. Psychological sequelae of myocardial infarction. Biomed Pharmacother 2017; 95:487-496. [PMID: 28866415 DOI: 10.1016/j.biopha.2017.08.109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 01/10/2023] Open
Abstract
Patient with myocardial infarction (MI) are often affected by psychological disorders such as depression, anxiety, and post-traumatic stress disorder. Psychological disorders are disabling and have a negative influence on recovery, reduce the quality of life and causes high mortality rate in MI patients. Despite tremendous advancement in technologies, screening scales, and treatment strategies, psychological sequelae of MI are currently understudied, underestimated, underdiagnosed, and undertreated. Depression is highly prevalent in MI patients followed by anxiety and post-traumatic stress disorder. Pathophysiological factors involved in psychopathologies observed in patients with MI are sympathetic over-activity, hypothalamic-pituitary-adrenal axis dysfunction, and inflammation. Numerous preclinical and clinical studies evidenced a positive association between MI and psychopathologies with a common molecular pathophysiology. This review provides an update on diagnostic feature, prevalence, pathophysiology, clinical outcomes, and management strategies of psychopathologies associated with MI. Moreover, preclinical research findings on molecular mechanisms involved in post-MI psychopathologies and future therapeutic strategies have been outlined in the review.
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Affiliation(s)
- Mukesh Kumar
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh, India.
| | - Prasanta Kumar Nayak
- Department of Pharmaceutical Engineering and Technology, Indian Institute of Technology (Banaras Hindu University), Varanasi, Uttar Pradesh, India.
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23
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Celano CM, Villegas A, Albanese A, Huffman JC. Heart Failure: Psychological and Pharmacological Considerations. Psychiatr Ann 2016. [DOI: 10.3928/00485713-20161102-01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Anxiety and its associated disorders are common in patients with cardiovascular disease and may significantly influence cardiac health. Anxiety disorders are associated with the onset and progression of cardiac disease, and in many instances have been linked to adverse cardiovascular outcomes, including mortality. Both physiologic (autonomic dysfunction, inflammation, endothelial dysfunction, changes in platelet aggregation) and health behavior mechanisms may help to explain the relationships between anxiety disorders and cardiovascular disease. Given the associations between anxiety disorders and poor cardiac health, the timely and accurate identification and treatment of these conditions is of the utmost importance. Fortunately, pharmacologic and psychotherapeutic interventions for the management of anxiety disorders are generally safe and effective. Further study is needed to determine whether interventions to treat anxiety disorders ultimately impact both psychiatric and cardiovascular health.
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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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Mermet C, Capaldo L, Bouchet S, Saint-Léger M, De Guillebon S, Labadie M. Intoxication à la venlafaxine responsable d’un syndrome sérotoninergique sévère chez une patiente déficitaire en cytochrome P450 2D6. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2016.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cooper CM, Baron JM. Case records of the Massachusetts General Hospital. Case 4-2015. A 49-year-old man with obtundation followed by agitation and acidosis. N Engl J Med 2015; 372:465-73. [PMID: 25629745 DOI: 10.1056/nejmcpc1410940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hantson P, Batista M, Fonseca S, Ferreira I, Haufroid V, Capron A, Bonbled F, Cosyns JP. Acute heart failure after venlafaxine overdose: Post-mortem myocardial examination in two cases. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2014. [DOI: 10.1016/j.toxac.2014.09.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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XXXIV International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 27–30 May 2014, Brussels, Belgium. Clin Toxicol (Phila) 2014. [DOI: 10.3109/15563650.2014.906213] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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