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Zhao X, Zhang R, Li W. A Strategy for Rescuing a Child From Clonazepam Poisoning: A Case Study. Ther Drug Monit 2024; 46:138-140. [PMID: 37876261 DOI: 10.1097/ftd.0000000000001148] [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: 05/23/2023] [Accepted: 08/15/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND This report describes the successful rescue of a 12-year-old girl who ingested large quantities of clonazepam tablets. METHODS The patient was promptly treated with flumazenil and hemoperfusion to alleviate the symptoms of central depression. Therapeutic drug monitoring was used to evaluate detoxification efficacy. The authors analyzed the rescue protocol for clonazepam poisoning based on the pathophysiology, clinical manifestations, and pharmacokinetics of clonazepam overdose. RESULTS The patient responded well to the treatment and was discharged from the hospital without adverse events. CONCLUSIONS This case study demonstrated the effectiveness and safety of combining flumazenil with hemoperfusion as a treatment for clonazepam poisoning. This study aimed to provide insights into more effective methods for treating clonazepam overdose and contribute to the ongoing issue of managing this condition.
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Affiliation(s)
- Xuemei Zhao
- Department of Pharmacy, Qingdao West Coast New Area People's Hospital, Qingdao, China
| | - Rui Zhang
- Department of Pharmacy, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China; and
| | - Wenjing Li
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, China
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Warlick H, Leon L, Patel R, Filoramo S, Knipe R, Joubran E, Levy A, Nguyen H, Rey J. Application of gabapentinoids and novel compounds for the treatment of benzodiazepine dependence: the glutamatergic model. Mol Biol Rep 2023; 50:1765-1784. [PMID: 36456769 DOI: 10.1007/s11033-022-08110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 11/09/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Current approaches for managing benzodiazepine (BZD) withdrawal symptoms are daunting for clinicians and patients, warranting novel treatment and management strategies. This review discusses the pharmacodynamic properties of BZDs, gabapentinoids (GBPs), endozepines, and novel GABAergic compounds associated with potential clinical benefits for BZD-dependent patients. The objective of this study was to review the complex neuromolecular changes occurring within the GABAergic and glutamatergic systems during the BZD tolerance and withdrawal periods while also examining the mechanism by which GBPs and alternative pharmacological therapies may attenuate withdrawal symptoms. METHODS AND RESULTS An elaborative literature review was conducted using multiple platforms, including the National Center for Biotechnology (NCBI), AccessMedicine, ScienceDirect, pharmacology textbooks, clinical trial data, case reports, and PubChem. Our literature analysis revealed that many distinctive neuroadaptive mechanisms are involved in the GABAergic and glutamatergic systems during BZD tolerance and withdrawal. Based on this data, we hypothesize that GBPs may attenuate the overactive glutamatergic system during the withdrawal phase by an indirect presynaptic glutamatergic mechanism dependent on the α2δ1 subunit expression. CONCLUSIONS GBPs may benefit individuals undergoing BZD withdrawal, given that the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor current significantly increases during abrupt BZD withdrawal in animal studies. This may be a conceivable explanation for the effectiveness of GBPs in treating both alcohol withdrawal symptoms and BZD withdrawal symptoms in some recent studies. Finally, natural and synthetic GABAergic compounds with unique pharmacodynamic properties were found to exert potential clinical benefits as BZD substitutes in animal studies, though human studies are lacking.
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Affiliation(s)
- Halford Warlick
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA.
| | - Lexie Leon
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Rudresh Patel
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Stefanie Filoramo
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Ryan Knipe
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Ernesto Joubran
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Arkene Levy
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Hoang Nguyen
- Dr. Kiran C. Patel College Of Osteopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Jose Rey
- College of Pharmacy, Nova Southeastern University, Davie, FL, USA
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Altered Behavioral Responses Show GABA Sensitivity in Muscleblind-Like 2-Deficient Mice: Implications for CNS Symptoms in Myotonic Dystrophy. eNeuro 2022; 9:ENEURO.0218-22.2022. [PMID: 36150891 PMCID: PMC9557336 DOI: 10.1523/eneuro.0218-22.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 01/17/2023] Open
Abstract
Considerable evidence from mouse models and human postmortem brain suggests loss of Muscleblind-like protein 2 (MBNL2) function in brain is a major driver of CNS symptoms in Myotonic dystrophy type 1 (DM1). Increased hypersomnia, fatigue, and surgical complications associated with general anesthesia suggest possible sensitivity to GABAergic inhibition in DM1. To test the hypothesis that MBNL2 depletion leads to behavioral sensitivity to GABAA receptor (GABAA-R) modulation, Mbnl2 knock-out (KO) and wild-type (WT) littermates were treated with the anesthetic sevoflurane, the benzodiazepine diazepam, the imidazopyridine zolpidem, and the benzodiazepine rescue agent, flumazenil (Ro 15-1788), and assessed for various behavioral metrics. Mbnl2 KO mice exhibited delayed recovery following sevoflurane, delayed emergence and recovery from zolpidem, and enhanced sleep time at baseline that was modulated by flumazenil. A significantly higher proportion of Mbnl2 KO mice also loss their righting reflex [loss of righting reflex (LORR)] from a standard diazepam dose. We further examined whether MBNL2 depletion affects total GABAA-R mRNA subunit levels and validated RNA-sequencing data of mis-spliced Gabrg2, whose isoform ratios are known to regulate GABA sensitivity and associated behaviors. While no other GABAA-R subunit mRNA levels tested were altered in Mbnl2 KO mouse prefrontal cortex, Gabrg2S/L mRNA ratio levels were significantly altered. Taken together, our findings indicate that loss of MBNL2 function affects GABAergic function in a mouse model of myotonic dystrophy (DM1).
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Effective Preparation of [ 18F]Flumazenil Using Copper-Mediated Late-Stage Radiofluorination of a Stannyl Precursor. Molecules 2022; 27:molecules27185931. [PMID: 36144667 PMCID: PMC9505495 DOI: 10.3390/molecules27185931] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/05/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
(1) Background: [18F]Flumazenil 1 ([18F]FMZ) is an established positron emission tomography (PET) radiotracer for the imaging of the gamma-aminobutyric acid (GABA) receptor subtype, GABAA in the brain. The production of [18F]FMZ 1 for its clinical use has proven to be challenging, requiring harsh radiochemical conditions, while affording low radiochemical yields. Fully characterized, new methods for the improved production of [18F]FMZ 1 are needed. (2) Methods: We investigate the use of late-stage copper-mediated radiofluorination of aryl stannanes to improve the production of [18F]FMZ 1 that is suitable for clinical use. Mass spectrometry was used to identify the chemical by-products that were produced under the reaction conditions. (3) Results: The radiosynthesis of [18F]FMZ 1 was fully automated using the iPhase FlexLab radiochemistry module, affording a 22.2 ± 2.7% (n = 5) decay-corrected yield after 80 min. [18F]FMZ 1 was obtained with a high radiochemical purity (>98%) and molar activity (247.9 ± 25.9 GBq/µmol). (4) Conclusions: The copper-mediated radiofluorination of the stannyl precursor is an effective strategy for the production of clinically suitable [18F]FMZ 1.
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Abstract
BACKGROUND Anxiety disorders are highly prevalent affecting up to 33.7% of people over a lifetime. Although many treatment options are available, they are often associated with unacceptable side-effect profiles and approximately one in three patients are treatment resistant. Allopregnanolone, a neuroactive steroid acting as a positive allosteric modulator at the GABAA receptor, is synthesised in response to stress and acts to negatively modulate the hypothalamic-pituitary-adrenal axis. FINDINGS After chronic exposure to and withdrawal from allopregnanolone, an increase in α4β2δ GABAA receptors results in a reduced inhibitory effect of allopregnanolone, resulting in decreased inhibition and, therefore, increased neuronal excitability. The relationship between allopregnanolone and increased α4β2δ GABAA receptors has been demonstrated in animal models during methamphetamine withdrawal and puberty, events both associated with stress. The effect of allopregnanolone during these events is anxiogenic, a paradoxical action to its usual anxiolytic effects. Flumazenil, the GABAA receptor antagonist, has been shown to cause receptor internalisation of α4β2δ GABAA receptors, which may results in anxiolysis. CONCLUSION We propose that chronic stress and chronic exposure to and withdrawal from allopregnanolone in anxiety disorders result in alterations in GABAA receptor function, which can be corrected by flumazenil. As such, flumazenil may exhibit anxiolytic properties in patients with increased α4β2δ GABAA receptor expression.
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Affiliation(s)
- Alexander T Gallo
- Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia
| | - Gary K Hulse
- Division of Psychiatry, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia.,Fresh Start Recovery Programme, Subiaco, WA, Australia
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Casari R, Metastasio A, Zamboni L, Biasioli M, Campagnari S, Lugoboni F. Addiction of High Dose of Benzodiazepine: Verona Detox Approach With Flumazenil. Front Psychiatry 2022; 13:857376. [PMID: 35432044 PMCID: PMC9008883 DOI: 10.3389/fpsyt.2022.857376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Since the 1990s there has been evidence of the significant role Flumazenil (FLU) has in benzodiazepines (BZD) detoxes. The Verona Detox approach has been developed for high dose BZD and Z-drug detoxification via continuous subcutaneous infusion of FLU, a selective BZD receptor antagonist acting on the BZD subunit of the GABA-A receptor. Flumazenil is licensed in the United Kingdom and other countries to treat only BZD overdose although numerous studies have demonstrated its effectiveness in rapidly resetting GABA-A receptors, quickly reducing tolerance and dependence from BZD, and providing a safe and rapid detox from benzodiazepines. OBJECTIVE The aim of this article is to provide all healthcare professional who are interested in BZD detoxification with an approach and clear practical information on how to administer FLU. METHOD In this article we outline the approach in detail, describing all medical and nursing procedures day by day. This detox treatment is indicated for patients abusing from at least 5 Defined Daily Dose (DDD) of BZDs or Z-drugs. The process lasts 7 days, and is conducted under medical supervision (daily reviews) and continuous nursing (24/7). During this period, 7mg of FLU is administered (1 mg/24) through an elastomeric pump, via continuous subcutaneous infusion. CONCLUSION To this day, the largest database of FLU detoxification was published by our group, showing how this treatment is safe, with very little side effects even in patients with significant medical comorbidities.
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Affiliation(s)
- Rebecca Casari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | | | - Lorenzo Zamboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy.,Department of Neurosciences, University of Verona, Verona, Italy
| | - Martino Biasioli
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Simone Campagnari
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
| | - Fabio Lugoboni
- Unit of Addiction Medicine, Department of Internal Medicine, Integrated University Hospital of Verona, Verona, Italy
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