Propoxyphene-induced hypoglycemia in renal failure

A Case of Unintentional Methadone Overdose Followed by Hypoglycaemia

Methadone overdose is expected to result in intoxication simulating the other opioids. We report a case of hypoglycaemia following accidental methadone ingestion. A 21-year-old woman presented to a local accident and emergency department 10 hours after ingestion of 800 mg of methadone. She was found to have coma, respiratory suppression, hypotension, prolonged QTc and hypoglycaemia. The hypoglycaemia was reversed by dextrose replacement. The patient required intubation and inotropic support because of cardio-respiratory instability. She eventually recovered without consequence. To date, this is the first reported case of methadone overdose induced hypoglycaemia.

Severe hypoglycemia during methadone escalation in an 8-year-old child

This case report describes hypoglycemia during methadone escalation in an 8-year-old girl with acute lymphatic leukemia. After a significant increase in the methadone dosage, the blood glucose decreased from 12 mmol/l to 1 mmol/l. Nutrition and other medications were meticulously checked and no other apparent explanation was found. There are few reports from the adult palliative setting which describe this serious side effect. This is to our knowledge, the first described pediatric case.

Opioid-induced endocrinopathy in cancer patients: an underestimated clinical problem

The impact of both endogenous and exogenous opioids on the endocrine system has been known for many years. With the increased use of opioids in chronic pain treatment, the research focuses mainly on their effects on the endocrine system in patients with chronic non-malignant pain. Despite the wide dissemination of cancer, there has been little research on the possible effects of opioids on the endocrine system in cancer patients. For the growing number of cancer survivors and patients in long-term remission who take opioids, other aspects of endocrine disorders caused or exacerbated by opioids will have practical and clinical importance. Conversely, this problem may be less relevant for patients in active cancer treatment or in the advanced stage of disease. This article presents the available research on the effects of opioids on the endocrine system and the clinical consequences resulting from opioid use in cancer patients. Clinicians who use opioids in clinical practice should be aware of the existence of the endocrine symptoms of opioid therapy. There is still a need for more research in this area to maintain the best possible quality of life for cancer patients treated with opioid analgesics.

Tramadol and hypoglycaemia: comparison with other step 2 analgesic drugs

AIMS

The risk of hypoglycaemia with tramadol (TRM) is not well described. Our aim was to analyze spontaneous reports of hypoglycaemia registered in the French Pharmacovigilance database and to compare these data with two other step-2 analgesic drugs.

METHODS

Cases of hypoglycaemia associated with TRM, dextropropoxyphene (DXP) and codeine (COD) recorded between 1997 and November 2010 in the French pharmacovigilance database were compared.

RESULTS

Seventy-two cases of hypoglycaemia associated with DXP and 43 with TRM were retained for evaluation (the single case reported with COD was not further considered). Most patients were elderly people with no significant difference in age between DXP- and TRM-treated patients (71.2 ± 21 vs. 69.4 ± 22.5 years). Hypoglycaemia occurred after a median of 4 and 5 days with DXP and TRM treatment, respectively. The mean lowest serum glucose concentration was 2.1 ± 0.9 mmol l(-1) in the DXP group compared with 2.5 ± 1 mmol l(-1) in the TRM group (P = 0.072). At least, one risk factor of hypoglycaemia was found in most patients, with no significant difference between groups (58.3% in the DXP group and 58.1% in the TRM group). In particular, 31.9% patients from the DXP group had diabetes compared with 41.8 % from the TRM group (P = 0.28) and 18% of DXP patients had renal insufficiency compared with 16.3% of TRM patients (P = 0.8).

CONCLUSIONS

Our study confirms that TRM is associated with the occurrence of hypoglycaemia in elderly or predisposed patients, with characteristics similar to those previously reported with DXP.

["Serious" adverse drug reactions with tramadol: a 2010-2011 pharmacovigilance survey in France]

OBJECTIVE

Tramadol is a weak opioid used as a step 2 analgesic, approved in France for moderate to severe pain. After dextropropoxyphene withdrawal, a national pharmacovigilance follow-up of tramadol was decided by the French Drug Agency.

METHODS

All Serious Adverse Drug Reactions (SADR) notified with tramadol to the French PharmacoVigilance Centres (CRPV) and pharmaceutical companies between August 1(st), 2010 and July 31(th), 2011 were analyzed.

RESULTS

During the study period, 296 cases of SADR were notified to CRPV and 59 to pharmaceutical companies. Apart from opiate-related SADR, tramadol induced serotoninergic SADR, including seizures or serotoninergic syndromes. Several « unlabelled » SADR were also identified: some of them, like hyponatremia or hypoglycemia, are poorly known by health professionals. Other were never published: peripheral edema or pancreatitis.

CONCLUSION

This study shows that besides well-known opioid or serotoninergic ADR, tramadol can also induce 2 other relatively unknown ADR: hypoglycemia and hyponatremia.

[Severe hypoglycemia induced by tramadol: two new cases of an unlisted side effect]

INTRODUCTION

Tramadol is a weak opioid analgesic used as a step two analgesic, approved in France for the treatment of moderate to severe pain in adult patients. The most common side effects are gastrointestinal and neurologic. Hypoglycaemia is an almost unknown side effect.

CASE REPORTS

We report two patients who presented with severe hypoglycaemia related to oral administration of tramadol in non diabetic patients. The underlying mechanisms of hypoglycaemia induced by tramadol are unclear. The only weak opioid analgesic drug reported to cause hypoglycaemia is propoxyphene, which has been widely used in France. The recent withdrawal of dextropropoxyphene in France might increase the prescriptions of tramadol and healthcare professionals should be aware of the risk of hypoglycaemia.

CONCLUSION

The risk of hypoglycaemia should be added to the summary of product characteristics of tramadol.

Drug-induced hypoglycaemia: an update

Drugs are the most frequent cause of hypoglycaemia in adults. Although hypoglycaemia is a well known adverse effect of antidiabetic agents, it may occasionally develop in the course of treatment with drugs used in everyday clinical practice, including NSAIDs, analgesics, antibacterials, antimalarials, antiarrhythmics, antidepressants and other miscellaneous agents. They induce hypoglycaemia by stimulating insulin release, reducing insulin clearance or interfering with glucose metabolism. Several drugs may also potentiate the hypoglycaemic effect of antidiabetic agents. Administration of these agents to individuals with diabetes mellitus is of most concern. Many of these drugs, and depending on clinical setting, may also induce hyperglycaemia. Drug-induced hepatotoxicity and nephrotoxicity may lead in certain circumstances to hypoglycaemia. Some drugs may also induce hypoglycaemia by causing pancreatitis. Drug-induced hypoglycaemia is usually mild but may be severe. Effective clinical management can be handled through awareness of this drug-induced adverse effect on blood glucose levels. Herein, we review pertinent clinical information on the incidence of drug-induced hypoglycaemia and discuss the underlying pathophysiological mechanisms, and prevention and management.

Recurrent hypoglycemia in a hemodialysis patient related to propoxyphene treatment

There are various etiologies for hypoglycemia in patients with chronic renal failure, and its pathogenesis is complex. Concomitant use of medications is the most common cause. We report a rare case of an 82-year-old woman with type 2 diabetes mellitus in end-stage renal disease undergoing maintenance hemodialysis, who experienced recurrent symptomatic hypoglycemia during treatment with propoxyphene for pain relief. Hypoglycemia occurred simultaneously with elevated levels of serum immunoreactive insulin and C-peptide. After discontinuing propoxyphene, hypoglycemia mitigated and the level of insulin returned to normal range. Our case reminds us that propoxyphene-induced hypoglycemia should not be ignored, especially in hemodialysis patients with cold sweats, agitation and depressed consciousness.