1
|
Lu HR, Damiano BP, Kreir M, Rohrbacher J, van der Linde H, Saidov T, Teisman A, Gallacher DJ. The Potential Mechanisms behind Loperamide-Induced Cardiac Arrhythmias Associated with Human Abuse and Extreme Overdose. Biomolecules 2023; 13:1355. [PMID: 37759755 PMCID: PMC10527387 DOI: 10.3390/biom13091355] [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: 08/10/2023] [Revised: 09/01/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Loperamide has been a safe and effective treatment for diarrhea for many years. However, many cases of cardiotoxicity with intentional abuse of loperamide ingestion have recently been reported. We evaluated loperamide in in vitro and in vivo cardiac safety models to understand the mechanisms for this cardiotoxicity. Loperamide slowed conduction (QRS-duration) starting at 0.3 µM [~1200-fold (×) its human Free Therapeutic Plasma Concentration; FTPC] and reduced the QT-interval and caused cardiac arrhythmias starting at 3 µM (~12,000× FTPC) in an isolated rabbit ventricular-wedge model. Loperamide also slowed conduction and elicited Type II/III A-V block in anesthetized guinea pigs at overdose exposures of 879× and 3802× FTPC. In ion-channel studies, loperamide inhibited hERG (IKr), INa, and ICa currents with IC50 values of 0.390 µM, 0.526 µM, and 4.091 µM, respectively (i.e., >1560× FTPC). Additionally, in silico trials in human ventricular action potential models based on these IC50s confirmed that loperamide has large safety margins at therapeutic exposures (≤600× FTPC) and confirmed repolarization abnormalities in the case of extreme doses of loperamide. The studies confirmed the large safety margin for the therapeutic use of loperamide but revealed that at the extreme exposure levels observed in human overdose, loperamide can cause a combination of conduction slowing and alterations in repolarization time, resulting in cardiac proarrhythmia. Loperamide's inhibition of the INa channel and hERG-mediated IKr are the most likely basis for this cardiac electrophysiological toxicity at overdose exposures. The cardiac toxic effects of loperamide at the overdoses could be aggravated by co-medication with other drug(s) causing ion channel inhibition.
Collapse
Affiliation(s)
- Hua Rong Lu
- Global Safety Pharmacology, Janssen Research and Development, Turnhoutseweg 30, 2340 Beerse, Belgium; (B.P.D.); (J.R.); (H.v.d.L.); (T.S.); (A.T.); (D.J.G.)
| | | | - Mohamed Kreir
- Global Safety Pharmacology, Janssen Research and Development, Turnhoutseweg 30, 2340 Beerse, Belgium; (B.P.D.); (J.R.); (H.v.d.L.); (T.S.); (A.T.); (D.J.G.)
| | | | | | | | | | | |
Collapse
|
2
|
Wu PE, Juurlink DN. Loperamide Cardiac Toxicity – Pathophysiology, Presentation and Management. Can J Cardiol 2022; 38:1378-1383. [DOI: 10.1016/j.cjca.2022.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/02/2022] Open
|
3
|
Malinky CA, Lindsley CW, Han C. DARK Classics in Chemical Neuroscience: Loperamide. ACS Chem Neurosci 2021; 12:2964-2973. [PMID: 34346690 DOI: 10.1021/acschemneuro.1c00382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Loperamide, a popular and inexpensive over-the-counter antidiarrheal medicine, is a potent μ-opioid receptor agonist approved by the U.S. Food and Drug Administration (FDA). It has been on the market since 1976 and is relatively safe with no central nervous system-related side effects when used for a short period of time at the recommended therapeutic dose (2-8 mg/day). In recent years, loperamide has become notoriously known as the "poor man's methadone" for people with substance dependence due to the increase in loperamide overdoses from self-administered medication to treat opioid withdrawal symptoms. As a result, in 2018, the FDA decided to limit the available packaged dose of loperamide to stop prominent abuse. This review provides the synthesis and chemical properties of loperamide as well as the pharmacology and adverse effects of its use and the social effects of such abuse.
Collapse
Affiliation(s)
- Cori A. Malinky
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Craig W. Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Changho Han
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| |
Collapse
|
4
|
Abstract
INTRODUCTION Loperamide is an opioid available over the counter and in prescription form. Loperamide functions as a μ-agonist within the enteric nervous system to slow intestinal motility. Its antidiarrheal properties and primarily peripheral activity make loperamide an important tool in the management of inflammatory bowel disease. CASE REPORT A 42-year-old man was found unconscious in cardiac arrest, and emergency medical personnel restored normal sinus rhythm. Family reported complaints of abdominal pain and that he "went through a lot" of loperamide. In the emergency department, the patient exhibited symptoms consistent with an opioid overdose. Mental status improved after administration of naloxone, an opioid antagonist. An electrocardiogram revealed a prolonged QTc interval, which progressed into Torsades de Pointes rhythm during admission. The patient succumbed from hypoxic brain injury, and there was evidence of acute pancreatitis at autopsy. Loperamide and desmethylloperamide (loperamide metabolite) were detected in blood samples. Cause of death was ruled loperamide toxicity. DISCUSSION Because of reduced central nervous system activity and associated euphoria at therapeutic doses, loperamide abuse is rarely reported. This case demonstrates that an overdose on loperamide can occur in patients seeking symptom alleviation, and may mimic the presentation of opioid overdose.
Collapse
|
5
|
Cicci JD, Jagielski SM, Clarke MM, Rayson RA, Cavender MA. Loperamide overdose causing torsades de pointes and requiring Impella temporary mechanical support: a case report. Eur Heart J Case Rep 2019; 3:1-6. [PMID: 31911979 PMCID: PMC6939795 DOI: 10.1093/ehjcr/ytz150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/23/2019] [Accepted: 09/11/2019] [Indexed: 11/14/2022]
Abstract
Abstract
Background
Loperamide is a widely available oral μ-opioid receptor agonist, and loperamide abuse is increasing by those seeking intoxication. Loperamide has potent QTc-prolonging properties, placing patients at risk for ventricular arrhythmias and sudden cardiac death.
Case summary
A 23-year-old woman was found to be in pulseless ventricular fibrillation with a QTc of 554 ms and received multiple defibrillations and IV lidocaine. Her toxicology studies were negative. She subsequently experienced multiple episodes of torsades de pointes and was found to be in cardiogenic shock with a left ventricular ejection fraction of 5%. Following multiple defibrillations, an Impella® mechanical circulatory support device was placed, and she was given IV magnesium and IV lidocaine. After mechanical circulatory support was withdrawn, she experienced major bleeding and was found to have a deep vein thrombosis, bilateral radial artery thrombosis, and multiple pulmonary embolisms in the setting of heparin-induced thrombocytopenia. After stabilizing, she admitted to taking 80 tablets of loperamide 2 mg in pursuit of euphoria.
Discussion
Loperamide is an increasingly popular agent of abuse. Loperamide-associated ventricular arrhythmias are rare with normal doses but more common with high doses, chronic ingestion, or interacting medications. Loperamide cardiotoxicity may be prolonged due to a long half-life and accumulation. Loperamide abuse may be under-recognized, leading to delays in treatment. Intravenous fluids, magnesium supplementation, chronotropes, transcutaneous or transvenous pacing, and defibrillation may be helpful in mitigating loperamide-associated polymorphic ventricular tachycardia. Clinicians should monitor for drug interactions in patients taking loperamide and screen for electrocardiographic abnormalities in those taking chronic or high-dose loperamide.
Collapse
Affiliation(s)
- Jonathan D Cicci
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, CB 7600, Chapel Hill, NC 27514, USA
| | - Sarah M Jagielski
- UK Healthcare, 1000 S. Limestone, Room H110, Lexington, KY 40536, USA
| | - Megan M Clarke
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, CB 7600, Chapel Hill, NC 27514, USA
| | - Robert A Rayson
- Division of Cardiology, Department of Medicine, University of North Carolina, Burnett-Womack Building, 160 Dental Circle, CB# 7075, Chapel Hill, NC 27599, USA
| | - Matthew A Cavender
- Division of Cardiology, Department of Medicine, University of North Carolina, Burnett-Womack Building, 160 Dental Circle, CB# 7075, Chapel Hill, NC 27599, USA
| |
Collapse
|
6
|
Eggleston W, Palmer R, Dubé PA, Thornton S, Stolbach A, Calello DP, Marraffa JM. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila) 2019; 58:355-359. [DOI: 10.1080/15563650.2019.1681443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY, USA
- Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA
| | | | - Pierre-André Dubé
- Department of Environmental Health and Toxicology, Institut National de Santé Publique du Québec, Quebec, Canada
| | - Stephen Thornton
- Emergency Medicine, University of Kansas Medical Center, Kansas City, KS, USA
- Poison Control Center, University of Kansas Health System, Kansas City, KS, USA
| | - Andrew Stolbach
- Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Diane P Calello
- Rutgers New Jersey Medical School, Department of Emergency Medicine, New Jersey Poison Information and Education System, Newark, NJ, USA
| | - Jeanna M Marraffa
- Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA
| |
Collapse
|
7
|
Powell JW, Presnell SE. Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina. J Forensic Sci 2019; 64:1726-1730. [DOI: 10.1111/1556-4029.14115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 01/10/2023]
Affiliation(s)
- John W. Powell
- The Medical University of South Carolina Charleston SC29415
| | - Susan Erin Presnell
- Department of Pathology and Laboratory Medicine The Medical University of South Carolina Charleston SC29425-9080
| |
Collapse
|
8
|
Wu PE, Juurlink DN. Clinical Review: Loperamide Toxicity. Ann Emerg Med 2017; 70:245-252. [PMID: 28506439 DOI: 10.1016/j.annemergmed.2017.04.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 03/26/2017] [Accepted: 04/03/2017] [Indexed: 11/27/2022]
Abstract
Loperamide is a nonprescription opioid widely used for the treatment of diarrhea. Although it is relatively safe at therapeutic doses, increasing reports describe its misuse and abuse at very high doses either for euphoric effects or to attenuate symptoms of opioid withdrawal. Life-threatening loperamide toxicity can result from the relatively new clinical syndrome of loperamide-induced cardiac toxicity. These patients are often young and may present in cardiac arrest or with unheralded, recurrent syncope in conjunction with ECG abnormalities, including marked QT-interval prolongation, QRS-interval widening, and ventricular dysrhythmias. Features of conventional opioid toxicity may also be present. The mainstays of treatment include advanced cardiac life support and supportive care, although selected patients may be candidates for overdrive pacing, intravenous lipid emulsion, or extracorporeal membrane oxygenation. In patients who survive loperamide toxicity, consideration should be given to the treatment of an underlying opioid use disorder, if present.
Collapse
Affiliation(s)
- Peter E Wu
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; Division of Clinical Pharmacology and Toxicology and Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
| | - David N Juurlink
- Division of Clinical Pharmacology and Toxicology and Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical and Evaluative Sciences and Sunnybrook Research Institute, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Borron SW, Watts SH, Tull J, Baeza S, Diebold S, Barrow A. Intentional Misuse and Abuse of Loperamide: A New Look at a Drug with "Low Abuse Potential". J Emerg Med 2017; 53:73-84. [PMID: 28501383 DOI: 10.1016/j.jemermed.2017.03.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/22/2017] [Accepted: 03/08/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite its opioid properties, loperamide has long been thought to have low abuse potential due to its poor absorption from the gastrointestinal tract and limited potential to cross the blood-brain barrier. A recent patient reportedly taking loperamide to avoid heroin withdrawal symptoms, at doses approximately 100 times those recommended, directed our attention to this issue. OBJECTIVES 1) Investigate number of cases of intentional loperamide abuse and misuse reported to poison centers between 2009 and 2015; 2) Compile reports of clinical effects of loperamide abuse; and 3) Search for evidence of increasing Internet interest in the central opioid effects of loperamide. METHODS For the years 2009 thru 2015, we reviewed exposure calls related to misuse/abuse of loperamide in the Texas Poison Center Network's database and the National Poison Data System. We used Google trend analysis to detect evidence of increased Internet interest in the illicit use of loperamide. RESULTS Between 2009 and 2015, the number of misuse/abuse calls related to loperamide alone nearly doubled, with about one-third of cases occurring in teens and young adults in their 20s. Of particular concern are reports of significant cardiotoxic effects (∼18% of cases), including conduction defects and various dysrhythmias, sometimes leading to death. Google Trends analysis demonstrates an increasing number of searches for "loperamide high" and "loperamide withdrawal" beginning in 2011. CONCLUSIONS Loperamide misuse/abuse seems to be on the rise. Given its propensity to induce conduction disturbances and dysrhythmias at very high doses, emergency physicians should be vigilant for this form of drug abuse.
Collapse
Affiliation(s)
- Stephen W Borron
- Division of Medical Toxicology, Department of Emergency Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas; West Texas Regional Poison Center, University Medical Center of El Paso, El Paso, Texas
| | - Susan H Watts
- Department of Emergency Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Jonathan Tull
- Department of Emergency Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Salvador Baeza
- West Texas Regional Poison Center, University Medical Center of El Paso, El Paso, Texas
| | - Stephanie Diebold
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Alison Barrow
- Department of Emergency Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| |
Collapse
|
10
|
“Poor man’s methadone” can kill the poor man. Extra-medical uses of loperamide: a review. Forensic Toxicol 2017. [DOI: 10.1007/s11419-017-0365-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
11
|
Loperamide misuse and abuse. J Am Pharm Assoc (2003) 2017; 57:S45-S50. [DOI: 10.1016/j.japh.2016.12.079] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 12/23/2016] [Accepted: 12/26/2016] [Indexed: 02/04/2023]
|
12
|
Eggleston W, Clark KH, Marraffa JM. Loperamide Abuse Associated With Cardiac Dysrhythmia and Death. Ann Emerg Med 2017; 69:83-86. [DOI: 10.1016/j.annemergmed.2016.03.047] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Indexed: 10/21/2022]
|
13
|
Abstract
Loperamide is widely available as an inexpensive, over-the-counter remedy commonly used for management of diarrhea. Although an opioid, at therapeutic doses it acts primarily on the gastrointestinal tissues; however, larger than recommended amounts facilitate central nervous system (CNS) penetration. Such high doses of loperamide have recently gained popularity among users of opioids to manage withdrawal symptomatology and, less frequently, to achieve psychoactive effects. Chronic loperamide use can result in development of tolerance and, upon abrupt cessation of use, withdrawal. With increasing prevalence of use, side-effects are noted, one particularly being life-threatening cardiac arrhythmias. Users are often not forthcoming and routine drug screens do not detect loperamide, so providers need to be alert to such practices in order to recognize intoxication, be able to screen for use, and facilitate entry into treatment.
Collapse
Affiliation(s)
- Cornel N Stanciu
- a Resident Physician, Department of Psychiatric Medicine, Brody School of Medicine , East Carolina University , Greenville , NC , USA
| | - Samantha A Gnanasegaram
- a Resident Physician, Department of Psychiatric Medicine, Brody School of Medicine , East Carolina University , Greenville , NC , USA
| |
Collapse
|
14
|
VAUGHN PATRICIA, SOLIK MICHELLEMK, BAGGA SHIV, PADANILAM BENZYJ. Electrocardiographic Abnormalities, Malignant Ventricular Arrhythmias, and Cardiomyopathy Associated With Loperamide Abuse. J Cardiovasc Electrophysiol 2016; 27:1230-1233. [DOI: 10.1111/jce.13052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/12/2016] [Accepted: 07/20/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - SHIV BAGGA
- St. Vincent Medical Group; Indianapolis Indiana USA
| | | |
Collapse
|
15
|
Orr KK, Matson KL, Cowles BJ. Nonprescription Medication Use by Infants and Children: Product Labeling Versus Evidence-Based Medicine. J Pharm Pract 2016. [DOI: 10.1177/0897190007299671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nonprescription or over-the-counter (OTC) medication use has been an increasing market over the past years. In addition to adult use of these medications, children also account for this trend. Although relatively safe when used according to package labeling and professional direction, serious adverse drug events and toxicity associated withOTC use among infants and children are becoming more common. The purpose of this review is to help the health care practitioner select and counsel on pediatric OTC products based on labeling and efficacy data in 3 main areas: cough and cold, analgesics, and treatment of gastroenteritis.
Collapse
Affiliation(s)
- Katherine Kelly Orr
- Department of Pharmacy Practice at the University of Rhode Island College of Pharmacy, Kingston,
| | - Kelly L. Matson
- Department of Pharmacy Practice at the University of Rhode Island College of Pharmacy, Kingston
| | - Brian J. Cowles
- Department of Pharmacy Practice at the University of Rhode Island College of Pharmacy, Kingston
| |
Collapse
|
16
|
Loperamide Induced Torsades de Pointes: A Case Report and Review of the Literature. Case Rep Med 2016; 2016:4061980. [PMID: 26989420 PMCID: PMC4775784 DOI: 10.1155/2016/4061980] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Accepted: 02/01/2016] [Indexed: 01/08/2023] Open
Abstract
Abuse of over the counter drugs often gets overlooked by health care providers. Loperamide is one such over the counter drug that is often abused by drug addicts. We present here a case of a young male attaining euphoria from taking massive doses of loperamide. He developed Torsades de Pointes and subsequent cardiac arrest. We found similarities in the progression of myocardial electrical conduction abnormalities among loperamide and other previously known arrhythmogenic drugs. We intend to raise concern over the ease of availability of such drugs over the counter and increase the index of suspicion for over the counter drug abuse from our experience.
Collapse
|
17
|
|
18
|
MacDonald R, Heiner J, Villarreal J, Strote J. Loperamide dependence and abuse. BMJ Case Rep 2015; 2015:bcr-2015-209705. [PMID: 25935922 DOI: 10.1136/bcr-2015-209705] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Loperamide is a common over-the-counter antidiarrheal considered safe in a broad range of dosages and thought devoid of abuse potential. We describe the first case of a patient with loperamide dependence due to misuse of its opiate-like effects achieved by chronic massive oral ingestions. A 26-year-old man who was taking 800 mg of loperamide per day presented requesting detoxification referral. Loperamide has potential for euphoric effects and information on how to facilitate such effects is easily available. It is important for physicians to be aware of the potential for misuse of and dependence on loperamide, with symptoms mimicking opiate use.
Collapse
Affiliation(s)
- Ryan MacDonald
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Jason Heiner
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joshua Villarreal
- Department of Pharmacy, University of Washington Medical Center, Seattle, Washington, USA
| | - Jared Strote
- Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
19
|
Spinner HL, Lonardo NW, Mulamalla R, Stehlik J. Ventricular Tachycardia Associated with High-Dose Chronic Loperamide Use. Pharmacotherapy 2015; 35:234-8. [DOI: 10.1002/phar.1540] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Hannah L. Spinner
- Department of Pharmacy; University of Utah Health Care; Salt Lake City Utah
| | - Nick W. Lonardo
- Department of Pharmacy; University of Utah Health Care; Salt Lake City Utah
| | - Roja Mulamalla
- Division of Cardiovascular Medicine; University of Utah Health Care; Salt Lake City Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine; University of Utah Health Care; Salt Lake City Utah
| |
Collapse
|
20
|
Loperamide overdose-induced catatonia: potential role of brain opioid system and P-glycoprotein. Acta Neuropsychiatr 2014; 26:58-60. [PMID: 25142101 DOI: 10.1017/neu.2013.45] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Catatonic features are observed in several psychiatric illnesses but can also be found following substance misuse. Loperamide is an anti-diarrhoeal medication that acts on opioid receptors in the intestine, reducing peristalsis. It is normally unable to pass through the intestinal wall or the blood-brain barrier; however, high dosages can in fact induce the effects on the central nervous system. CASE REPORT We describe the case of a 20-year-old man who presented with severe catatonia following excessive intake of loperamide, fully remitted with lorazepam. CONCLUSION We speculate on a possible increase of loperamide's bioavailability after overdose owing to reduced expression and functioning of P-glycoprotein.
Collapse
|
21
|
Daniulaityte R, Carlson R, Falck R, Cameron D, Perera S, Chen L, Sheth A. "I just wanted to tell you that loperamide WILL WORK": a web-based study of extra-medical use of loperamide. Drug Alcohol Depend 2013. [PMID: 23201175 PMCID: PMC3633632 DOI: 10.1016/j.drugalcdep.2012.11.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
AIMS Many websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users. METHODS A website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use. RESULTS There has been an increase in discussions related to loperamide's use by non-medical opioid users, especially in 2010-2011 Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as "poor man's" methadone. Typical doses ranged 70-100mg per day, much higher than an indicated daily dose of 16mg. CONCLUSIONS This study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a "leading edge" data source in identifying emerging drug use practices.
Collapse
Affiliation(s)
- Raminta Daniulaityte
- Center for Interventions, Treatment, and Addictions Research, Department of Community Health, Boonshoft School of Medicine, Wright State University, Dayton, OH 45435, United States.
| | - Robert Carlson
- Center for Interventions, Treatment, and Addictions Research (CITAR) Department of Community Health, Boonshoft School of Medicine, Wright State University
| | - Russel Falck
- Center for Interventions, Treatment, and Addictions Research (CITAR) Department of Community Health, Boonshoft School of Medicine, Wright State University
| | - Delroy Cameron
- Ohio Center of Excellence in Knowledge-Enabled Computing (Kno.e.sis), Wright State University: http://knoesis.org
| | - Sujan Perera
- Ohio Center of Excellence in Knowledge-Enabled Computing (Kno.e.sis), Wright State University: http://knoesis.org
| | - Lu Chen
- Ohio Center of Excellence in Knowledge-Enabled Computing (Kno.e.sis), Wright State University: http://knoesis.org
| | - Amit Sheth
- Ohio Center of Excellence in Knowledge-Enabled Computing (Kno.e.sis), Wright State University: http://knoesis.org
| |
Collapse
|
22
|
|
23
|
Vandenbossche J, Huisman M, Xu Y, Sanderson-Bongiovanni D, Soons P. Loperamide and P-glycoprotein inhibition: assessment of the clinical relevance. J Pharm Pharmacol 2011; 62:401-12. [PMID: 20604828 DOI: 10.1211/jpp.62.04.0001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Loperamide is a peripherally acting mu opioid receptor agonist and an avid substrate for P-glycoprotein. This may give rise to drug-drug interactions and increased risk for central adverse effects. The objective of this study was to re-evaluate the predictability of non-clinical data using loperamide as a probe P-glycoprotein substrate. We searched the literature for papers containing data on drug-drug interactions of loperamide-containing products in humans. We also reviewed the internal worldwide safety database of Johnson & Johnson for spontaneous case reports suggestive of a central opioid effect after coadministration of loperamide with a P-glycoprotein inhibitor or substrate. KEY FINDINGS Only one of the ten studies in our review supported the finding that inhibition of P-glycoprotein is associated with clinically relevant signs or symptoms of central nervous system (CNS) depression/opioid toxicity of loperamide. None of the 25 spontaneous case reports of interest were suggestive of signs or symptoms of CNS depression/opioid toxicity due to coadministration of loperamide and a P-glycoprotein inhibitor or substrate. SUMMARY Based on a review of the literature and a cumulative review of the spontaneous case reports, there is insufficient evidence that an interaction between loperamide and a P-glycoprotein inhibitor or substrate is associated with clinical symptoms of CNS depression/opioid toxicity when loperamide is taken at the recommended dose.
Collapse
Affiliation(s)
- Joris Vandenbossche
- Clinical Pharmacology, Johnson & Johnson Pharmaceutical Research & Development, Beerse, Belgium.
| | | | | | | | | |
Collapse
|
24
|
Niemi M, Tornio A, Pasanen MK, Fredrikson H, Neuvonen PJ, Backman JT. Itraconazole, gemfibrozil and their combination markedly raise the plasma concentrations of loperamide. Eur J Clin Pharmacol 2006; 62:463-72. [PMID: 16758263 DOI: 10.1007/s00228-006-0133-z] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2005] [Accepted: 03/23/2006] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Loperamide is biotransformed in vitro by the cytochromes P450 (CYP) 2C8 and 3A4 and is a substrate of the P-glycoprotein efflux transporter. Our aim was to investigate the effects of itraconazole, an inhibitor of CYP3A4 and P-glycoprotein, and gemfibrozil, an inhibitor of CYP2C8, on the pharmacokinetics of loperamide. METHODS In a randomized crossover study with 4 phases, 12 healthy volunteers took 100 mg itraconazole (first dose 200 mg), 600 mg gemfibrozil, both itraconazole and gemfibrozil, or placebo, twice daily for 5 days. On day 3, they ingested a single 4-mg dose of loperamide. Loperamide and N-desmethylloperamide concentrations in plasma were measured for up to 72 h and in urine for up to 48 h. Possible central nervous system effects of loperamide were assessed by the Digit Symbol Substitution Test and by subjective drowsiness. RESULTS Itraconazole raised the peak plasma loperamide concentration (Cmax) 2.9-fold (range, 1.2-5.0; P < 0.001) and the total area under the plasma loperamide concentration-time curve (AUC(0-infinity)) 3.8-fold (1.4-6.6; P < 0.001) and prolonged the elimination half-life (t(1/2)) of loperamide from 11.9 to 18.7 h (P < 0.001). Gemfibrozil raised the Cmax of loperamide 1.6-fold (0.9-3.2; P < 0.05) and its AUC(0-infinity) 2.2-fold (1.0-3.7; P < 0.05) and prolonged its t(1/2) to 16.7 h (P < 0.01). The combination of itraconazole and gemfibrozil raised the Cmax of loperamide 4.2-fold (1.5-8.7; P < 0.001) and its AUC(0-infinity) 12.6-fold (4.3-21.8; P < 0.001) and prolonged the t(1/2) of loperamide to 36.9 h (P < 0.001). The amount of loperamide excreted into urine within 48 h was increased 3.0-fold, 1.4-fold and 5.3-fold by itraconazole, gemfibrozil and their combination, respectively (P < 0.05). Itraconazole, gemfibrozil and their combination reduced the plasma AUC(0-72) ratio of N-desmethylloperamide to loperamide by 65%, 46% and 88%, respectively (P < 0.001). No significant differences were seen in the Digit Symbol Substitution Test or subjective drowsiness between the phases. CONCLUSION Itraconazole, gemfibrozil and their combination markedly raise the plasma concentrations of loperamide. Although not seen in the psychomotor tests used, an increased risk of adverse effects should be considered during concomitant use of loperamide with itraconazole, gemfibrozil and especially their combination.
Collapse
Affiliation(s)
- Mikko Niemi
- Department of Clinical Pharmacology, Helsinki University Central Hospital, PO Box 340, FI-00029, HUS, Finland.
| | | | | | | | | | | |
Collapse
|
25
|
Chanzy S, Moretti S, Mayet H, Routon MC, De Gennes C, Msélati JC. [Loss of consciousness in a child due to loperamide]. Arch Pediatr 2004; 11:826-7. [PMID: 15234380 DOI: 10.1016/j.arcped.2004.03.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2003] [Accepted: 03/20/2004] [Indexed: 11/18/2022]
Abstract
Loperamide is an antidiarrheal peripheral opiate agonist, with rare neurological secondary effects. We report the case of a 26-month-old child who had impaired consciousness under treatment by loperamide, and was treated successfully with naloxone. Limitations of the use of loperamide in young children are underlined. Naloxone may be used in case of impaired consciousness, for a diagnostic as well as therapeutic purpose.
Collapse
Affiliation(s)
- S Chanzy
- Service de pédiatrie et néonatologie, centre hospitalier d'Orsay, BP 27, 91401 Orsay, France.
| | | | | | | | | | | |
Collapse
|
26
|
Crowe A, Wong P. Potential roles of P-gp and calcium channels in loperamide and diphenoxylate transport. Toxicol Appl Pharmacol 2003; 193:127-37. [PMID: 14613723 DOI: 10.1016/s0041-008x(03)00372-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This study examined the accumulation and transport of two related systemic opioids used as antidiarrhoeal drugs and compared their rates of transport with known P-glycoprotein (P-gp) substrates used in our in vitro environment. Cellular uptake and efflux and transcellular transport were all determined using Caco-2 cells after exposure to loperamide or diphenoxylate, with or without a range of efflux inhibitors. Bidirectional transport studies of 5 microM loperamide showed efflux to be fivefold higher than influx (42 x 10(-6) compared to 8 x 10(-6) cm/s); however, this decreased to twofold at 10 microM and was abolished using 100 microM loperamide. An uptake pathway was also discovered when P-gp was inhibited which, in the presence of Ca(2+) channel blockers, was amplified, providing a potential mechanism for central nervous system effects to be increased upon blockage of L-type calcium channels, quite separate from any P-gp inhibition. Diphenoxylate transport, however, showed little sign of P-gp-mediated efflux. Diphenoxylate accumulated readily within cells, yet transport through cells was very low. Additionally, efflux inhibitors had little impact on transport or accumulation, suggesting that diphenoxylate was not a substrate for an efflux mechanism.
Collapse
Affiliation(s)
- Andrew Crowe
- School of Pharmacy, Curtin University of Technology, GPO Box U1987, Perth, Western Australia, 6845, Australia.
| | | |
Collapse
|
27
|
Abstract
BACKGROUND Although US poison control centres manage approximately 30,000 adverse drug reactions each year, the extent of voluntary reporting of these events to the US Food and Drug Administration (FDA) MedWatch spontaneous surveillance programme is unknown. METHODS A survey was mailed to directors of all 72 US poison control centres during April 1999 to determine their practices and opinions on reporting adverse drug reactions. The survey requested information on the poison control centre staff's practices in reporting adverse drug reactions to the FDA MedWatch programme during 1998. RESULTS A total of 56 fully completed surveys were returned. Of the respondents, 30 had not directly submitted adverse drug reaction reports to the FDA, 22 had submitted 10 or less, and 4 had submitted a total of 47 during 1998. Reasons given for not routinely reporting adverse drug reactions included adverse drug reactions reporting is not part of the regular routine (20%), lack of time to complete forms (15%), inability to determine causality (13%), most reactions are already reported and not unique (10%), reporting to the FDA is too much work (9%), and responsibility rests with the attending physician (7%). Direct reporting to MedWatch of any cases of adverse drug reactions was more likely when the poison control centre was certified by the American Association of Poison Control Centers (p < 0.05; odds ratio = 5.1; 95% confidence interval 1.1 to 23.5); however, this practice was not associated with documenting deaths associated with adverse drug reactions, having more than 75% of the staff of the Poison Information Specialists composed of pharmacists or nurses, or managing greater than 20,000 or 34,000 human exposure cases during 1998. Approximately half of the poison control centres directly or indirectly reported some adverse drug reactions to the FDA by virtue of contacting the manufacturer or cooperating with postmarketing surveillance. CONCLUSION Poison control centres represent an underutilised source of reporting to MedWatch, but several internal and external obstacles limit the direct reporting of adverse drug reactions routinely.
Collapse
Affiliation(s)
- P A Chyka
- University of Tennessee, Department of Pharmacy Practice and Pharmacoeconomics and Southern Poison Center, Memphis, USA.
| | | |
Collapse
|
28
|
Hamilton RJ, Goldfrank LR. Poison center data and the Pollyanna phenomenon. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1997; 35:21-3. [PMID: 9022647 DOI: 10.3109/15563659709001160] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
|