Adverse Drug Interaction Between Kratom and Amitriptyline With Gastrointestinal and Mild Hepatic Effects

Kratom (Mitragyna speciosa) is a tropical evergreen plant native to Southeast Asia, where it has been used historically for its various psychoactive and analgesic properties. In recent years, the popularity of kratom has surged in the United States as a supplement for treating opioid withdrawal/addiction, anxiety, depression, and chronic pain, among others. However, much of Kratom processing and sales remain largely unregulated, with little clinical research to demonstrate the effects of kratom on physiologic processes such as potential drug interactions. Here, we present a case of Kratom interaction with Amitriptyline in a patient recovering from Opioid Use Disorder.

Pilot Study on QTc Interval in Dogs Treated with Domperidone

Domperidone is used as an immunomodulatory drug for Leishmania infantum infection and disease in dogs. However, a pro-arrhythmic side effect, caused by prolonged QT intervals, is reported in humans. This pilot study evaluated the corrected QT (QTc) interval in dogs treated with domperidone for preventive or therapeutic management of leishmaniosis. The electrocardiogram and blood concentration of creatinine, urea nitrogen, sodium, potassium, and chloride were evaluated seven days before the start and on the last day of therapy in 17 dogs receiving domperidone for four weeks. In two dogs, the QTc interval was measured before and 2 h, 3 h, and 12 h after administration of the drug on the first day of treatment. After treatment, QTc measures and chloride concentrations increased significantly, although the QTc value slightly exceeded the upper reference limit only in one dog, and chloride concentrations were always normal. Creatinine concentrations significantly decreased after therapy. In the two dogs monitored at different times on the first day of treatment, QTc values were always normal. Domperidone caused a slight prolongation of QTc interval, and further studies should be made for a risk assessment in dogs with cardiac diseases, electrolytic imbalance, and in those receiving drugs increasing QT interval or competing with domperidone metabolism.

Tongue Hematoma With Necrosis

Spontaneous tongue hematoma is a known rare adverse side effect associated with warfarin therapy. There is a long list of drug-to-drug interactions with warfarin that may contribute to a rise in international normalized ratio (INR) levels, increasing the risk of bleeding. We present a case of an elderly female patient who presented with oral dysphagia and spontaneous oral cavity bleeding while on warfarin therapy. She was found to have tongue hematoma and necrosis. A week prior she started treatment with topical miconazole for oral candidiasis and a few days later topical clarithromycin was added. Treatment given was mainly supportive with intravenous vitamin K, fresh frozen plasma, and aminocaproic acid. Full recovery was achieved. It is our intention to raise awareness of a rare adverse side effect related to warfarin therapy that may have been precipitated with the use of medications known to contribute to INR elevation. As learning points, we emphasize close monitoring of INR levels when using known drug-to-drug interactions with warfarin and also consider replacing warfarin for a direct oral anticoagulant if no contraindication is present.

Adverse Side Effects of Crizotinib in the Treatment of Anaplastic Lymphoma Kinase-Mutated Non-small Cell Lung Cancer: A Systematic Review

Lung cancer is the leading cause of cancer deaths worldwide, with the majority consisting of non-small cell lung cancer (NSCLC). Genetic mutations present an opportunity for targeted therapy, in addition to current mainstay treatments such as chemotherapy and radiotherapy. Overall, 5% of NSCLCs have an anaplastic lymphoma kinase (ALK) mutation, often prevalent in a younger population. Crizotinib is an ALK inhibitor that was approved to treat ALK-mutated advanced NSCLC. While common side effects such as nausea, fatigue, and diarrhea are mostly well tolerated, adverse side effects can lead to treatment discontinuation or adjustment or can be fatal. This systematic review used articles searched on Google Scholar and PubMed which were assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa Scale. This yielded nine papers consisting of randomized controlled trials and cohort studies. Side effects resulting in cessation of treatment or dose reduction included liver dysfunction, nausea, neutropenia, and QT prolongation. This review showed that crizotinib has a better side effect profile than chemotherapy in ALK-positive NSCLC, even though toxicities leading to treatment withdrawal are present. Adverse effects were tackled by dose reduction, temporary withdrawal from treatment, and close monitoring.

Uncommon Extrapyramidal Reaction to Ondansetron

We describe the case of a 77-year-old man, who was admitted for the initiation of chemotherapy for stage IV small cell lung cancer without cerebral metastases. On the first day post-admission, the patient developed altered mental status and right-sided weakness after premedication with ondansetron and dexamethasone. Symptoms resolved spontaneously within 90 minutes. An ischemic event was suspected despite unremarkable brain imaging. Prophylactic anticoagulation and statins were initiated. Five days later, a second episode of altered mental status, anisocoria, facial paresis, and severe dysarthria occurred following ondansetron administration. Bloodwork revealed significant hyponatremia (116 mEq/L), suggesting Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH), despite this suspicion, there was no further investigation to confirm this diagnosis due to rapid symptom reversal after biperiden administration, implicating an adverse reaction to ondansetron. Ondansetron and metoclopramide were discontinued, hyponatremia was corrected, and no further episodes occurred during the hospital stay. This case highlights the necessity of awareness for adverse reactions of ondansetron that can mimic cerebrovascular events and the need for a thorough revision of medication in complex cases.

Association Between the Immune Checkpoint Inhibitor Durvalumab and Myasthenia Gravis: A Comprehensive Review

Immune checkpoint inhibitors (ICIs), including Imfinzi (durvalumab), have revolutionized cancer treatment by stimulating the body's immune system to target cancerous cells. Although pharmaceuticals offer therapeutic benefits, several drugs have been associated with immune-related adverse events (irAEs), including the uncommon but serious condition known as myasthenia gravis (MG). This review synthesizes data from pertinent research to offer a thorough evaluation of the literature on the underlying mechanisms, clinical manifestations, and therapeutic approaches for durvalumab-induced MG. The incidence of MG in patients on durvalumab and other ICIs is typically low, with less than 1% documented, despite the potential for severe problems associated with the disease. Durvalumab disrupts immunological tolerance by stimulating autoreactive T-cells and inducing the production of autoantibodies. The clinical consequences of MG need meticulous monitoring, prompt identification, and suitable management to efficiently control the condition. Medical practitioners must carefully weigh the positive effects of ICIs against the possible hazards, emphasizing the necessity for more extensive investigation to improve patient results and establish uniform treatment protocols.

Analysis of Adverse Events and Medical Errors in Long-Term Hormone Treatments for Endometriosis: A Study Based on the US Food and Drug Administration Event Reporting System

Purpose

To investigate adverse events and medical errors, as well as their possible risk factors, of combined oral contraceptives and progestins used in patients with endometriosis.

Patients and Methods

Reports between January 1, 2014 and September 30, 2021 about patients with endometriosis in US Food and Drug Administration Adverse Event Reporting System were analyzed. Disproportional analysis was performed with the Gamma-Poisson Shrinker model to detect overreported drug-event pairs. Logistic regression analysis was utilized to explore potential risk factors.

Results

There were 823 reports on long-term hormone treatments and 6247 reports on other drugs after removing duplicates, most of which were reported by consumers and were from the United States. Procedural complications and product issues were common among long-term hormone treatment users, while some other new adverse events emerged in subgroup analysis of different dosage forms of progestin. Polytherapy was negatively associated with off label use (adjusted OR = 0.47, 95% CI 0.22-0.94) and product use in unapproved indication (adjusted OR = 0.36, 95% CI 0.15-0.76) for combined oral contraceptive users. Combined oral contraceptive users aged greater than or equal to 30 were less likely to have product use issue (adjusted OR = 0.33, 95% CI 0.12-0.82) but were at higher risk of pulmonary embolism (adjusted OR = 4.04, 95% CI 1.35-17.43).

Conclusion

Long-term hormone treatment products in this study are generally safe for endometriosis, while newly detected signals need to be validated by further exploration. Patients' tolerance and fertility desire should be considered when preparing treatment plans.

Vacuolar Interface Dermatitis as a Histologic Reaction Pattern of Sjögren's Syndrome: A Case Report

Sjögren's syndrome (SS) has been widely known for its dry mouth and dry eyes presentation. Extraglandular disease manifestations may be protean and pose a challenge for clinicians, especially when the typical known manifestations are absent. Skin involvement of SS is variable, and cutaneous signs and symptoms may be the initial presentation of this syndrome. Vacuolar interface dermatitis has been linked to dermatomyositis and systemic lupus erythematosus, but rarely to SS. Herein, we present the case of an 87-year-old man who presented for widespread itchy erythematous scaly plaques that were refractory to topical corticosteroids as well as discontinuation of possible offending medications. A biopsy demonstrated vacuolar interface dermatitis in the setting of strongly positive anti-SSA. Hydroxychloroquine treatment was effective in resolving the plaques.