Abnormal blood concentration changes in a 71-year-old female who survived a 10,000mg overdose of clozapine: a case report

BACKGROUND

Clozapine is a highly effective second-generation antipsychotic with few extrapyramidal reactions, making it a preferred choice among clinicians. However, instances of acute clozapine poisoning resulting from suicide attempts and misuse have been reported. Through our review of existing literature, we identified that we believe to be the highest recorded overdose of clozapine in elderly patients, resulting in a nonfatal outcome.

CASE PRESENTATION

The case report involves a 71-year-old female with a history of depression who ingested a dose of 10,000 mg of clozapine. Approximately 6 h after the overdose, the clozapine level was 5,200 μg/L, significantly surpassing the recommended therapeutic concentration range of 350-600 μg/L. After gastric lavage and hemoperfusion, the blood level dropped to 1847.11 μg/L. Notably, during therapeutic drugs monitoring (TDM), we found a perplexing spike in the patient's blood level to 5554.15 μg/L after the second hemoperfusion.

CONCLUSION

In this case we mainly focused on the abnormal fluctuations in the concentration of clozapine. We conducted a comprehensive analysis of potential factors contributing to this abnormal phenomenon in terms of the patient's age, clinical symptoms, various laboratory test indexes, and the pharmacokinetics of clozapine. Our findings underscore the importance of timely TDM and the precision of results in managing elderly patients experiencing high-dose clozapine poisoning.

The systemic inflammatory response syndrome in acute antipsychotic poisoning

The purpose of this study was to investigate the mutual effect of systemic inflammatory response syndrome (SIRS) accompanied with fibrinolysis, endotoxemia, and coagulation in severe cases of antipsychotic poisoning. A total of 199 patients were examined, of which 71 were men and 128 were women. The age of the patients was from 22 to 63 years, (45.3 ± 6.1 years on average). According to the results of the course of therapy, the patients were divided into two groups. In the blood plasma, the content of C-reactive protein, fibrinogen and its proteolysis products (oligopeptides, D-dimers), interleukin-6 were determined. In the first 1 to 3 days, in group 1, the level of interleukin-6 decreased and approached the normal level (P ≤ .05). The opposite trend continued throughout the observation of patients from group 2-their levels of interleukin-6 increased day by day (P ≤ .05). The concentration of D-dimer already in 1 day after admission to intensive care in patients from group 2 exceeded the norm by 14 times (P ≤ .05). The level of D-dimer correlated with the level of oligopeptides in blood plasma upon admission, as well as for 3 and 5 days after admission to intensive care: 0.36, 0.76 at P ≤ .05, 0.94 at P ≤ .01, respectively. Similar correlations were obtained for the content of oligopeptides in urine and the level of D-dimer: 0.55, 0.85 at P ≤ .05, 0.93 at P ≤ .01. In this regard, the most pronounced correlation is that between the SIRS score, plasma D-dimer level, and the plasma level of the D-dimer derivatives, oligopeptides.

Delayed-Onset Toxicity in an Adolescent Case Following Attempted Suicide with an Overdose of Paliperidone Intake

Paliperidone is a relatively novel atypical antipsychotic drug that is currently used to treat schizophrenia in adolescents and adults. The drug was generated by combining the active metabolite of risperidone, 9-hydroxyrisperidone, with osmotic controlled-release oral administration system (OROS) technology. Due to its specific design, the drug has been identified as a different form, albeit an active metabolite of risperidone. Such distinction mainly manifests itself during pharmacokinetic processes, because paliperidone is not affected by CYP2D6 metabolism. On the other hand, this drug is regularly released for a period of 24 hours. Even though it is possible to reach relevant literature on the efficacy and safety of paliperidone use in detail, limited data regarding its toxicity exists. A review of the literature in that sense, has revealed a scarce number of case reports and a retrospective study existing. Bearing in mind the specific form and design of the drug, we have hypothesized its toxicity might cause diverse clinical presentations, in the face of overdose or poisoning. This might in turn, prompt us to switch our usual evaluation and intervention practices. With this case report, we have aimed to discuss delayed onset toxicity with paliperidone overdose in an adolescent case, due to a suicide attempt with excessive intake of the medication.

Patient Survival After Acute Voluntary Poisoning With a Huge Dose of Oxcarbazepine and Olanzapine

INTRODUCTION

Oxcarbazepine is a carbamazepine pre-drug with less drug interactions. Its adverse effects, including hyponatremia, somnolence and ataxia, are dose dependent. Olanzapine is an atypical antipsychotic drug most commonly used to manage psychoses and symptoms of irritability and aggressive behavior. Main side effects include extrapyramidal and anticholinergic symptoms, weight gain, and hyperglycemia.

CASE REPORT

In this manuscript a case of oxcarbazepine and olanzapine intoxication is discussed. A 45-year-old woman, previously diagnosed with bipolar disorder and chronic alcoholism, was presented two hours after ingestion of 30,000mg of oxcarbazepine and 140 mg of olanzapine, combined with alcohol. She was immediately treated with gastric lavage and administration of activated charcoal. During her hospitalization she was hemodynamically and respiratory stable with no neurological signs and symptoms except for somnolence. Another side effect was hyponatremia. She was discharged from our department in stable clinical condition after being evaluated by a psychiatrist.

CONCLUSION

Early approach is crucial for the management of drug intoxication. Late symptoms can be avoided through close monitoring of vital signs, mental status and laboratory values. Psychiatric consultation is essential for a better long-term outcome.

Antipsychotic drug poisoning monitoring of clozapine in urine by using coffee ring effect based surface-enhanced Raman spectroscopy

Antipsychotics are the drugs most often involved in drug poisoning cases, and therefore, therapeutic drug monitoring (TDM) is necessary for safe and effective medication administration of these drugs. In this study, a coffee ring effect-based surface-enhanced Raman spectroscopy (CRE-SERS) method was developed and successfully used to monitor antipsychotic poisoning by using urine samples for the first time. The established method exhibited excellent SERS performance since more hot spots were obtained in the "coffee ring". Using the optimized CRE-SERS method, the sensitivity was improved one order more than that of the conventional method with reasonable reproducibility. The antipsychotic drug clozapine (CLO) spiked into urine samples at 0.5-50 μg mL^-1 was quantitatively detected, at concentrations above the thresholds for toxicity. The CRE-SERS method allowed CLO and its metabolites to be ultimately distinguished from real poisoning urine samples. The coffee-ring effect would provide more opportunities for practical applications of the SERS-based method. The frequent occurrence of drug poisoning may have created a new area for the application of the CRE-SERS method. It is anticipated that the developed method will also have great potential for other drug poisoning monitoring.

Low-dose intravenous lipid emulsion for the treatment of severe quetiapine and citalopram poisoning

The treatment of quetiapine and/or citalopram poisoning is mainly supportive and involves gastric lavage, activated charcoal, intubation, and mechanical ventilation. Recently, however, there were reports of successful treatment with intravenous lipid emulsion. Here we report a case of a 19-year-old Caucasian girl who ingested approximately 6000 mg of quetiapine, 400 mg of citalopram, and 45 mg of bromazepam in a suicide attempt. The patient developed ventricular tachycardia and epileptic seizures 12 h after admission to the hospital. As the patient's condition deteriorated, we combined standard therapy (intubation, mechanical ventilation, and vasopressors) with low-dose intravenous lipid emulsion (ILE) (a total of 300 mL of 20 % lipid emulsion) and normalised her heart rhythm and stopped the seizures. She was discharged to the psychiatric ward after 48 h and home after a prolonged (2-month) psychiatric rehabilitation. Intravenous lipid emulsion turned out to be effective even in the lower dose range than previously reported for quetiapine poisoning in patients presenting with seizure and ventricular arrhythmia. To our knowledge, there are no case reports describing the use of ILE in treating citalopram poisoning.

Olanzapine overdose is associated with acute muscle toxicity

Olanzapine is an atypical antipsychotic that is reported to cause myopathy and raised creatine kinase (CK) levels. The prevalence and severity of acute myopathy after deliberate olanzapine ingestion are unclear. Therefore, we reviewed casenotes from 64 consecutive patients admitted to our institution after olanzapine overdose. Overall, serum CK was higher than five times the upper limit of normal in 17% of patients. The prevalence of raised CK values was positively correlated with the stated quantity of olanzapine ingested, suggesting a dose-dependent relationship for acute muscle toxicity. There was an apparent delay of 12 hours or more between olanzapine ingestion and the occurrence of maximum CK. Despite the high prevalence of acute muscle toxicity after olanzapine ingestion, none of the patients developed renal failure.

Clozapine intoxication due to cessation of smoking and infection

We report on a patient on clozapine treatment who was admitted to our hospital with pneumonia. He had stopped smoking a few weeks before admission. The serum clozapine rose to a toxic level, most likely due to the combination of infection and smoking cessation. Physicians and pharmacists are often not aware of risk factors for decreased metabolism of clozapine.

Clozapine re-trial in a patient with repeated life threatening pneumonias

BACKGROUND AND AIM OF THE WORK

There has been an increasing amount of evidence to suggest a link between Clozapine and pneumonia. Whilst an exact mechanism for disease causation has not been identified excess salivation, impaired swallowing and abnormalities within the immune system have all been implicated. Within forensic services there is often a need to treat complex patients with Clozapine, even when a past history of pneumonia is present.

METHODS

We present a case report on a forensic inpatient who has suffered repeated episodes of Clozapine associated pneumonia and highlight methods for good practice.

RESULTS

Where appropriate, Clozapine can still be used in complex patients who have suffered previous pneumonias and have additional risk factors for chest infections, provided that robust risk reduction, infection surveillance and treatment interventions are employed.

CONCLUSIONS

Practical measures can be employed to enable safe treatment of forensic patients with Clozapine, this includes risk factors for chest infections being carefully controlled such as asthma, Chronic Obstructive Airways Disease or diabetes. Patients should be carefully monitored for signs of infection by way of regular physical examinations and appropriate tests when required. Should signs of pneumonia arise the dose of Clozapine may need to be reduced and the infection aggressively treated with antibiotic medication.

Black esophagus: acute esophageal necrosis in fatal haloperidol intoxication

Herein, we present a case of 53-year-old psychotic woman with acute esophageal necrosis (black esophagus), who was found lying on the floor in the living room of her flat. Pillboxes of antipsychotic drugs were located in the bin. External examination of the body was unremarkable. On internal examination, we found acute esophageal necrosis. Histologically, there was complete epithelial necrosis with focal involvement of muscularis mucosae, dense infiltrate of leukocytes, and ulcerations without any viable cells. There was no evidence of underlying organic diseases or trauma. Toxicological analysis revealed a fatal blood level of antipsychotics (haloperidol, zotepine, and chlorprothixene). Death of the deceased was attributed to fatal intoxication with three various types of antipsychotics. As far we know, this is the first described association between so-called black esophagus and fatal blood level of neuroleptics.

The toxicology and comorbidities of fatal cases involving quetiapine

The use of quetiapine in Australia has increased rapidly in recent years. Anecdotal and post-marketing surveillance reports indicate an increase in quetiapine misuse in prisons as well as an increase in its availability on the black-market. This study examined a cohort of quetiapine-associated deaths occurring in Victoria, Australia, between 2001 and 2009, to determine the prevalence of deaths associated with this drug and to determine whether misuse represents a legitimate concern. Case details were extracted from the National Coronial Information System. There were 224 cases with an average age of 43 years of age (range 15-87 years). The cause of death was mostly drug toxicity (n = 114, 51 %), followed by natural disease (n = 60, 27 %), external injury (n = 31, 14 %) and unascertained causes (n = 19, 8 %). Depression and/or anxiety were common, observed in over a third of the cohort (80 cases, 36 %). About 20 % of cases did not mention a psychiatric diagnosis at all which raises the question of whether quetiapine had been prescribed correctly in these cases. Cardiovascular disease was the most commonly reported illness after mental disease. Quetiapine ranged in concentration from the limit of reporting (0.01 mg/L) to 110 mg/L. The median concentration of quetiapine was much lower in the natural disease deaths (0.25 mg/L) compared with drug caused deaths (0.7 mg/L). The most commonly co-administered drug was diazepam in 81 (36 %) cases. There were a small number of cases where quetiapine contributed to a death where it had not apparently been prescribed, including the death of a 15 year old boy and one of a 34 year old female. Overall, misuse of quetiapine did not appear to be a significant issue in this cohort; use of the drug only occasionally led to fatalities when used in excess or concomitantly with interacting drugs. However, considering that it is a recent social concern, it is possible that analysis of cases post 2009 would reveal more cases of quetiapine abuse. Close monitoring of quetiapine is therefore advised to prevent adverse outcomes, particularly in vulnerable populations such as substance abusers.

[Acute poisoning with sertindole--a case report]

The paper presents a case of acute, accidental sertindole poisoning. Intoxication had a stormy clinical course with symptoms of cardiovascular, respiratory and nervous system. A relatively small dose of ingested preparation and severe overdose course may indicate a low therapeutic drug index.

Nonfatal suicidal overdose of olanzapine in an adolescent

The atypical antipsychotic olanzapine is increasingly being used for various psychiatric conditions. There are few reports of olanzapine overdose in adolescent population. We report a case of 16-year-old adolescent who ingested 750 mg olanzapine, the highest reported nonlethal dose of olanzapine in adolescents. He presented with tachycardia, hypotension, generalized myoclonus, hyperpyrexia, muscular rigidity, leukocytosis and elevated creatine phosphokinase (CPK) levels. He recovered from the toxicity with minimal intervention.

Cognitive skills underlying driving in patients discharged following self-poisoning with central nervous system depressant drugs

BACKGROUND

Central nervous system-depressant (CNS-Ds) drugs can impair cognitive functions and driving. They are also the most common drugs taken in overdose in hospital-treated episodes of self-poisoning. In Australia most of these patients are discharged within 48 h, while they still have possible subclinical drug effects. We aimed to determine whether patients treated for self-poisoning with CNS-Ds are impaired in the Trail-Making Test (TMT, parts A and B), a neuropsychological test that is known to correlate with driving performance.

METHODS

This study was a conducted from November 2008 to April 2011 in a referral center for poisonings in New South Wales, Australia. One hundred seven patients discharged from the clinical toxicology unit following treatment for self-poisoning of CNS-Ds (benzodiazepines, atypical antipsychotics, or opioids) and a control group of 68 discharged following self-poisoning of non-CNS-depressant drugs (acetaminophen or nonsedating antidepressants) were tested with the TMT (parts A and B). Due to the known association of impaired TMT with driving impairment and increased risk of traffic accidents, performance less than the 10th percentile for age was defined as significant impairment in each part of the TMT. The odds ratio (OR) for impairment in each part was calculated in multivariate logistic regression (MLR) models adjusted for gender, education, IQ, and the presence of a major psychiatric illness. A secondary MLR analysis was conducted only for those patients (78 CNS-D and 54 control group participants) who were directly discharged home, after excluding those who were transferred for further psychiatric care.

RESULTS

The odds of impairment in the CNS-D group was 2.8 times that of the control group on the TMT-A (38 [35.5%] vs. 11 [16.2%]: adjusted OR = 2.76, 95% confidence interval [CI]: 1.28-5.97), and 4.6 times on the TMT-B (67 [62.6%] vs. 22 [32.4%]: adjusted OR = 4.63, 95% CI: 2.06-10.42). The results were similar in the subgroup of patients discharged home, and the odds of impairment in the CNS-D group was 3.3 times that of the control group on the TMT-A (25 [32.1%] vs. 7 [13.0%]: adjusted OR = 3.30, 95% CI: 1.28-8.52), and 3.6 times on the TMT-B (46 [59.0%] vs. 17 [31.5%]: adjusted OR = 3.64, 95% CI: 1.44-9.20). TMT-B impairment in the CNS-D group remained significant even after adjusting for TMT-A performance.

CONCLUSIONS

Patients with CNS-D overdose may have significant impairment in cognitive skills underlying driving at the time of discharge from hospitals. Clinicians should warn these patients that their driving skills might still be impaired, even if they are considered clinically recovered and advise them not to drive during the first 1 to 2 days following discharge.

Focal parietal necrosis of the sigmoid due to atypical neuroleptics: a case report

We present the case of a 26-year-old man with schizoid personality disorder who suffered from a very focal and transparietal necrosis of the sigmoid after an overdose of atypical neuroleptics. This is a singular, rather unknown and potentially lethal side effect of these drugs. The physiopathology of this complication is multifactorial.

Toxicology and overdose of atypical antipsychotics

BACKGROUND

Second-generation antipsychotic medications, or "atypical antipsychotics," are now first-line therapy in the treatment of schizophrenia and other psychotic disorders, and are additionally being used in a wide array of other psychiatric and non-psychiatric conditions in both adults and children. Overdose is frequently reported to poison control centers.

OBJECTIVES

We review the toxicology and general management of poisonings involving the atypical antipsychotic medications.

DISCUSSION

The most serious toxicity involves the cardiovascular system and the central nervous system. All typical and atypical antipsychotics cause sedation, which is pronounced in overdose. The most common cardiovascular effects that occur after atypical antipsychotic overdose are tachycardia, mild hypotension, and prolongation of the QTc interval. Other clinical syndromes in overdose include neuroleptic malignant syndrome (NMS) and antimuscarinic delirium. Seizures may be observed. No antidotes exist for these poisonings, but they most often do well with supportive care.

CONCLUSION

Antipsychotic overdose produces a gamut of manifestations that affect multiple organ systems. Treatment is primarily supportive. Specific therapies for NMS, hypotension, and seizures are discussed.

[Approaches to the improvement of treatment efficacy in patients with acute severe asaleptin intoxication complicated by acute respiratory insufficiency of mixed genesis]

We studied the development of metabolic disorders related to tissue hypoxia in 54 patients with acute severe asaleptin intoxication complicated by acute respiratory insfficiency of mixed genesis. We also estimated the role of a substrate antihypoxant cytoflavin in the correction of these disorders and clinical features of acute intoxication. Cyroflavin was shown to accelerate normalization of metabolic disorders which in turn improves clinical symptoms of severe forms of acute asaleptin intoxication.

[Simultaneous determination of trihexyphenidyl, chlorpromazine and clozapine in blood by GC-MS]

OBJECTIVE

To develop a method to measure trihexyphenidyl, chlorpromazine and clozapine in human blood with GC-MS.

METHODS

The specimens were alkalized (pH > 10) and extracted with V (benzene):V(ethyl acetate) = 1:1, and qualitatively analyzed using GC-MS-Full Scan with internal standard SKF525A. The specimens were alkalized (pH > 10) and extracted with V(benzene):V(ethyl acetate) = 1:1, and quantitatively analyzed using GC-MS-SIM with internal standard diazepam-d5.

RESULTS

The lowest detection limits of trihexyphenidyl, chlorpromazine and clozapine were 0.3, 0.3 and 0.7 ng/mL (S/N > or = 3) respectively. The calibration curve in 20-10 000 ng/mL showed a good linear distribution. The recovery rate was 79.9% to 85.5%. The RSDs of intraday and interday were less than 5.1%.

CONCLUSION

The established method was simple, sensitive and accurate for simultaneous determination of trihexyphenidyl, chlorpromazine and clozapine in human blood, and can be applied in forensic toxicological cases.

Values of using QTc and N-terminal fragment of B-type natriuretic peptide as markers for early detection of acute antipsychotic drugs-induced cardiotoxicity

We aimed at studying the acute cardiotoxicity of the most commonly used antipsychotics in Egypt using QTc interval and NT-proBNP as markers for the early detection of such cases. Eighty-two admitted patients, at El-Minia PCC (period from 1-7-2005 to 30-6-2010), were classified into 3 groups: I: acute thioridazine overdose (n = 28), II: acute pimozide overdose (n = 23), and III: acute clozapine overdose (n = 31). Patients were investigated for NT-proBNP level and QTc on admission (day 0) and after 24 h (day 1). All the studied drugs had the ability to induce cardiotoxicity in the form of hypotension and dysrhythmias. Thioridazine and pimozide had potentially serious cardiotoxic effects than clozapine. NT-proBNP levels were elevated significantly in all groups on days 0 and 1 when compared with the reference value and a significant decrease in the same parameter on day 1 when compared with that of day 0 within the same group. QTc showed a significant prolongation in all studied groups on days 0 and 1, and there was a significant shortening of QTc on day 1 when compared with that of day 0 within the same group. A significant positive correlation of NT-proBNP level elevation with QTc prolongation was reported in all groups on days 0 and 1. Serious dysrhythmias were associated with QTc prolongation greater than 500 ms. And it was concluded that NT-proBNP, in adjunction with QTc measurement, may be a valuable and sensitive laboratory biomarker to predict cardiotoxicity of antipsychotic overdose. Larger multicenter studies are still needed to verify this possible relationship.

[Electrocardiographic abnormalities in acute olanzapine poisonings]

BACKGROUND

Olanzapine is an atypical antipsychotic used for many years in the treatment of schizophrenia and bipolar disorder. Poisonings with this medicine can results with cardiotoxic effects in the form of ECG abnormalities.

AIM OF THE STUDY

To evaluate the nature and incidence of electrocardiographic abnormalities in patients with acute olanzapine poisoning.

MATERIAL

23 adult (mean age 38.4 +/- 15.5 years) patients with acute olanzapine poisoning, including 10 men (30.4 +/- 8.1 years) and 11 women (45.7 +/- 17.2 years), where 1 man and 1 woman were poisoned twice. The toxic serum level of olanzapine (above 100 ng/mL) was confirmed in each patient.

METHODS

Evaluation of electrocardiograms performed in patients in the first day of hospitalization with automatic measurement of durations of PQ, QRS and QTc and the identification of arrhythmias and conduction disorders on the basis of visual analysis of the ECG waveforms. Statistical analysis of the results using the methods of descriptive statistics.

RESULTS

The mean durations of PQ, QRS and QTc in the study group were as follows: 135 +/- 23 ms, 91 +/- 12 ms, and 453 +/- 48 ms, respectively. The most common ECG abnormalities were prolonged QTc and supraventricular tachycardia (including sinus tachycardia) - each 22%; less common were ST-T changes (17%) and supraventricular premature complexes (9%), and only in individual cases (4%) ventricular premature complexes, bundle branch block, sinus bradycardia and atrial fibrillation were present.

CONCLUSIONS

In the course of acute olanzapine poisonings: (1) prolonged QTc interval is quite common, but rarely leads to torsade de pointes tachycardia; (2) fast supraventricular rhythms are also common, but rarely cause irregular tachyarrhythmias, eg. atrial fibrillation; (3) conduction disorders (atrioventricular blocks, bundle branch blocks) are not typical abnormalities; (4) the observed ECG abnormalities emphasize the need of continuous ECG monitoring in these patients.

[Acute clozapine poisonings in years 2007 - 2010 in material of Clinic of Toxicology in Kraków]

18 patients with acute clozapine poisoning, 6 female and 12 male, were analyzed. The mean age was 42.8 years. Six patients were intoxicated only clozapine. Mixed poisoning (clozapine and other factor) was diagnosed in nine cases. Among the additional factors dominated psychotropic drugs. According to the Poisoning Severity Score (PSS) criteria in the study group was only a one mild intoxication. Acute pneumonia developed in 3 patients, acute bronchitis and rabdomyolysis were reported in one case. The most common symptoms included: agitation, confusion (83.3%), tachycardia (77.8%), CNS depression (66.7%), excessive mucus production in bronchi, hypersalivation (44.4%), miosis (50%). Disordered breathing requiring intubation or mechanical ventilation occurred in 27.7% of poisoned. The average duration of hospitalization was less than 7 days.

[Laboratory investigations in acute olanzapine poisonings]

BACKGROUND

Olanzapine is an atypical antipsychotic with multireceptor affinity and different pharmacological effects, which can result with abnormalities in laboratory investigations.

AIM OF THE STUDY

To assess the nature and frequency of laboratory tests abnormalities in patients with an acute olanzapine poisoning.

MATERIAL

26 adult cases (mean age 37.7 +/- 15.3 years) of an acute olanzapine poisoning (serum level above 100 ng/mL). Group consisted of 11 men and 13 women, but 1 man and 1 woman were poisoned twice.

METHODS

Prospective analysis of the following laboratory parameters: complete blood count (CBC), coagulation tests (APTT, INR), serum concentration of sodium, potassium, chlorides, glucose, BUN, creatinine and bilirubin, serum activity of AST, ALT, GGTP and CPK, urinalysis.

RESULTS

The most common laboratory abnormalities in the study group were: hyperglycaemia (96%), hyper-prolactinaemia (83%), elevated CPK (80%), hypokalaemia (75%), hyperbilirubinaemia (60%), leukocytosis (55%). Less frequent parameters were: elevated AST (20%), hyponatraemia (15%), elevated ALT(10%) and thrombocytopenia (5%). The onset of some parameters was as follows: 1st day of hospitalization hyperglycaemia, leukocytosis and hypokalaemia, 2nd - hyperbilirubinaemia and elevated CPK, and 3rd - hyperprolactinaemia.

CONCLUSIONS

In acute olanzapine poisonings: (1) muscle and liver injury, serum glucose and electrolytes abnormalities, and changes in CBC can be present; (2) the valuable parameters for the monitoring of the course of poisonings are: serum activity of CPK and transaminases (AST, ALT), serum level of bilirubin, glucose, potassium and sodium, and CBC; (3) hyperprolactinaemia probably lacks of practical importance, but the further investigations are needed in this area.

[The clinical picture of acute olanzapine poisonings]

BACKGROUND

Olanzapine is a second generation antipsychotic of thienobenzodiazepin group, which is used in the treatment of schizophrenia, bipolar disorder, and others, mainly psychiatric. Its multireceptor action (antagonism to dopaminergic D1, D2, D4, serotoninergic 5-HT2A, 5-HT2C, histaminergic H1, cholinergic M1-5, and a1--adrenergic receptors) results in multiple clinical symptoms in the course of acute poisoning.

AIM OF THE STUDY

Evaluation of incidence and intensity of clinical symptoms in patients with of acute olanzapine intoxication. The pathophysiological mechanisms of particular symptoms are also described.

MATERIAL

26 patients (mean age 37.7 +/- 15.3 years) hospitalized in 2005-2008 in toxicological centers in Krakow and Gdansk because of acute olanzapine poisoning (all patients had the toxic serum level of olanzapine above 100 ng/mL). The study group consisted of 11 men (29.3 +/- 8.5 years) and 13 women (44.9 +/- 16.4 years); 1 man and 1 woman were poisoned twice.

METHODS

Prospective analysis (using descriptive statistics) of data taken from medical anamnesis and results of physical examination, considering the following ones: consciousness disturbances (Glasgow Coma Scale, Matthew's scale, qualitative disturbances), vital signs (arterial blood pressure, heart rate, breathing rate, temperature), neurological findings (muscular tension, tendon reflexes, extrapyramidal symptoms, pupils) and others (oral and bronchial secretion, Poisoning Severity Score).

RESULTS

The mean dose of ingested olanzapine in the study group was 352.5 +/- 220.0 mg, while the mean time since ingestion to hospital admission was 4.4 +/- 3.5 h. The half of the patients took other medicines together with olanzapine, and 23% consumed alcohol, as well. The following intensity of quantitative consciousness disturbances according to Matthew's scale were observed: grade 0 - 8%, I - 15%, II - 23%, III - 50%, and IV - 4%. The minimal and maximal values of blood pressure were: 102/63 +/- 16/14 and 163/ 97 +/- 27/18 mmHg, respectively; heart rate: 77 +/- 15 and 138 +/- 22 beats/min; temperature: 36.3 +/- 0.5 and 37.9 +/- 0.8 degrees C; breathing rate in non-intubated patients: 14 +/- 2 and 22 +/- 7 breaths/min. The mean duration of consciousness disturbances, endotracheal intubation and mechanical ventilation were: 44.9 +/- 31.3; 22.0 +/- 33.3 and 7.0 +/- 25.9 h, respectively. The study revealed tachycardia (85%), psychomotor agitation (81%), hypertension (73%), miosis (65%), and coma (54%) as the most common symptoms of poisoning. The hospitalization of poisoned patients lasted on average 5.7 +/- 3.6 days and the half of them were poisoned severely (PSS 3).

CONCLUSIONS

In the course of acute olanzapine poisoning: (1) the prevailing symptoms come from circulatory and central nervous systems; (2) some symptoms are mutually opposed, eg.: coma - psychomotor agitation, hypertension - hypotension, tachycardia - bradycardia, hyperthermia - hypothermia, miosis - mydriasis; (3) rarely consciousness disturbances may persist for up to 6 days after olanzapine overdose; (4) the course of poisoning can be severe, sometimes complicated, but fatal outcomes are rare.

Respiratory failure following isolated ziprasidone ingestion in a toddler

Ziprasidone is an atypical antipsychotic approved for the treatment of schizophrenia and bipolar mania in adults and is used off label in children and adolescents. Despite increasing use of ziprasidone in both adult and pediatric populations, there remains a paucity of reports describing unintentional pediatric exposures. The following report describes a patient with isolated ziprasidone ingestion who required intubation secondary to respiratory failure. A 15-month-old previously healthy boy presented to the emergency department shortly after his father found him with approximately five partially dissolved 80-mg ziprasidone tablets in his mouth. The child was flaccid and lethargic with no eye opening, withdrawing from pain only. Two hours after arrival, he developed worsening CNS depression with inability to protect his airway and underwent endotracheal intubation. A serum ziprasidone level was 330 ng/mL by LC/MS. The patient was extubated approximately 14 h later and was discharged from the hospital shortly thereafter in good health without neurological sequelae. Isolated pediatric ingestion of ziprasidone resulting in the need for significant medical intervention has not been previously reported. We report a case of respiratory failure requiring intubation following accidental ziprasidone ingestion with confirmatory serum levels.

[The review of acute risperidone poisoning]

Risperidone (RIS) is a benzisoxazole derivative, an atypical neuroleptic used in the treatment of schizophrenia and other psychoses. The therapeutic action of RIS depends not only on the parent compound but also its major active metabolite, 9-hydroxyrisperidone (9-OH-RIS), and the pharmacokinetics is modified by the genetic polymorphism of CYP2D6, the main site o RIS metabolism. Diverse symptoms of an acute RIS poisoning result from its interaction with multiple receptors, i.e. serotoninergic 5-HT2A and 5-HT7, dopaminergic D2, adrenergic alpha1 and alpha2, as well as histamine H1. The clinical picture of acute RIS poisoning consists predominantly of central nervous system and cardiovascular effects and the most severe symptoms are: hypotension, dysrrhythmias, consciousness disturbances, seizures and respiratory failure. No specific antidote for RIS poisoning is known and the treatment is only symptomatic and supportive. Quantitative determination of RIS blood concentration seems to be helpful in confirmation and monitoring of acute poisoning, nevertheless further investigations are needed to evaluate the relation between drug concentration and clinical symptoms.

[Toxicity of sulpiride]

Sulpiride is a benzamide neuroleptic used in the treatment of some psychiatric and gastroenterological disorders. Its antipsychotic, antiautistic, activizing and antidepressive properties result from antagonistic action to dopaminergic D2, D3 and D4 receptors in the central nervous system (CNS). The oral bioavailability of sulpiride is poor and it does not appear to have an extensive first-pass metabolism, nor is it extensively protein-bound. Elimination of sulpiride appears to depend primarily on the kidneys. The acute sulpiride poisoning includes mainly neuropsychiatric (i.e., agitation, hallucinations, and CNS depression) as well as cardiac effects (i.e., hypotension, dysrhythmias, and sinus tachycardia). The life-threatening conditions with sometimes fatal outcome after sulpiride poisoning are prolongation of QTc interval with consequent torsade de pointes (TdP) and neuroleptic malignant syndrome (NMS). The quantitative methods for the measurement of sulpiride blood concentration are not routinely available and the toxic blood concentration is probably higher than 2 mg/L. Treatment of acute sulpiride poisoning includes standard protocols of gastrointestinal decontamination and further symptomatic and supportive measures, among them TdP (magnesium sulphate, isoproterenol, electrotherapy) and NMS treatment (benzodiazepines, bromocriptine, dantrolene, physical cooling).

Iatrogenic intravenous medication errors reported to the GIZ-Nord Poisons Center Göttingen

BACKGROUND

We analyzed the iatrogenic intravenous medication errors (IIME) reported to the GIZ-Nord Poisons Center Göttingen.

METHODS

IIME over a ten year period were analyzed retrospectively and categorized into error types, age groups, drugs involved, and severity of IIME at registration and after known outcome.

RESULTS

265 IIME were registered from 1997 to 2006. They rose from 12 in 1997 to 45 in 2006 corresponding to an increase from 0.058 to 0.148% of all calls of the respective year. Children were affected in (21.1%) and adults in 78.9% of all cases. The drug classes (ATC classification) involved most frequently were antipsychotics (7.9%) and antithrombotic agents (6.0%). The main types of IIME were dosing error (37.7%) and wrong route of administration (28.7%). The severity of IIME at registration was none (33.6%), minor (32.5%), moderate (13.6%), severe (13.6%), fatal (1.5%), and unratable (5.2%). In the 46 cases followed to a known outcome, 15 were asymptomatic and 27 were symptomatic with minor (11 cases), moderate (5 cases) and severe features (11 cases). Four cases of IIME were already fatal at registration and one severe case died in the further course. Dosing error of theophylline was often observed in severe outcomes.

CONCLUSION

IIME increased from 1997 to 2006. Intravenous use of antipsychotics and theophylline should be restricted to a minimum.

Self-poisoning in older adults: patterns of drug ingestion and clinical outcomes

BACKGROUND AND AIMS

self-poisoning accounts for a substantial proportion of acute medical hospital presentations, but has been poorly characterised in older adults. This study sought to determine the agents ingested by older adults presenting to hospital after drug overdose, and to compare clinical outcomes to younger patients.

METHODS

a retrospective observational study of patients admitted via the emergency department due to drug overdose between 2004 and 2007.

RESULTS

during the study period, there were 8,059 admissions, including 4,632 women (57.5%). This included a subgroup of 361 patients (4.5%) who were >60 years of age. This subgroup was more likely to require hospital stay >1 night, odds ratio (95% confidence interval) = 4.3 (3.6-5.5, P < 0.0001), transfer to a critical care area = 3.8 (1.1-13.0, P = 0.0340) and had higher mortality = 4.8 (1.1-22.1, P = 0.0463). A higher proportion of older patients required transfer to a psychiatric unit (P < 0.0001) or to a general medical ward (P < 0.0001) than younger adults.

CONCLUSIONS

older adults that presented to hospital after drug overdose had ingested different drugs than younger patients, possibly due to different prescribing patterns, and had a poorer outcome. The use of drugs associated with significant toxicity should be avoided in older patients at risk of self-harm.

A systematic review of cardiovascular effects after atypical antipsychotic medication overdose

As the use of atypical antipsychotic medications (AAPMs) increases, the number of overdoses continues to grow. Cardiovascular toxicity was common with older psychiatric medications but seems uncommon with AAPM. We conducted a systematic literature review to describe the cardiovascular effects reported after overdose of 5 common AAPM: aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone. We included case reports and case series describing overdose of these 5 medications identified in a search of MEDLINE, EMBASE, and abstracts from major toxicology meetings. We found 13 pediatric cases (age, <7 years), 22 adolescent cases (age, 7-16 years), and 185 adult cases. No pediatric case described a ventricular dysrhythmia or a cardiovascular death. In the adolescent and adult cases, we found numerous reports of prolonged corrected QT interval and hypotension, but there were only 3 cases of ventricular dysrhythmia and 3 deaths that may have been due to direct cardiovascular toxicity. The results from case series reports were similar to the single case report data. Our review suggests that overdose of AAPM is unlikely to cause significant cardiovascular toxicity.

Acute intoxication by triazolam and promazine: a case report

A fatality due to ingestion of triazolam and promazine is reported. Triazolam is a benzodiazepine widely prescribed as a hypnotic drug for the treatment of sleep disorders. Promazine is a neuroleptic drug. There is no previous evidence in the literature of death due to an overdose related to the contemporaneous intake of these two drugs. In this report the authors present the case of a 76-year-old woman who was found deceased at home with no evidence of trauma or asphyxia; near the body several empty pharmaceutical boxes containing triazolam and promazine were noticed. Toxicological analyses were performed and drug levels measured by means of gas chromatography coupled with mass spectrometry. The triazolam concentration in each specimen was as follows: blood 1100ng/ml; gastric content 1300ng/ml; the promazine concentration in blood and in gastric content was 3450ng/ml and 5800ng/ ml respectively. Based on the autopsy findings, patient history and toxicological results, the cause of death was determined to be acute intoxication due to the effect of triazolam and promazine and the manner of suicide.

Paradoxical and severe hypotension in response to adrenaline infusions in massive quetiapine overdose

Atypical antipsychotics (quetiapine, olanzapine, risperidone and clozapine) are increasingly prescribed in Australia, and emergency departments report growing rates of overdose of these agents. As these drugs are comparatively new, the spectrum of toxicity may be unfamiliar to critical care physicians. Severe hypotension is a recognised consequence of quetiapine poisoning. We describe three patients with massive quetiapine overdose who developed significant hypotension resistant to fluid resuscitation. In each case, blood pressure fell dramatically after commencement of adrenaline infusions. Haemodynamic stability was restored when noradrenaline was substituted for adrenaline. The pharmacodynamics of quetiapine and the literature on overdose are reviewed. We present these cases to broaden the knowledge of physicians treating quetiapine overdose and to publicise the potential deleterious interaction with adrenaline. We recommend use of noradrenaline in preference to adrenaline in pharmacological management of shock in these patients.

A severe case of olanzapine overdose with analytical data

INTRODUCTION

Olanzapine is a second-generation atypical antipsychotic agent approved for the treatment of psychotic disorders and mania. While olanzapine overdoses are common, cases with whole blood concentrations are less so. We describe here a well-documented case of a pure olanzapine overdose in which whole blood concentrations were determined, and compared with other concentrations in the literature.

CASE REPORT

A 58-year-old woman with a 10-year history of paranoid schizophrenia and poor therapeutic compliance was found unconscious with two empty 28-tablet vials of Zyprexa (olanzapine) 10 mg tablets. Her initial vital signs were blood pressure 110/70 mmHg, pulse rate 82 beats/minute (sinus rhythm), respirations 20 breaths/minute, and the Glasgow Coma Scale score was 7. In the Intensive Care Unit, her pulse rate was 160 beats/minute, in sinus rhythm, and QTc 0.423 seconds (normal <0.4 seconds). Relevant analytical findings were metabolic acidosis, leukocytosis, creatine phosphokinase 1992 mg/dL, and glucose 207 mg/dL. Ten hours after being found, her blood sugar was 350 mg/dL and became normal at 25 hours. The patient needed intubation and insulin.

RESULTS

Olanzapine was detected and quantitated by gas chromatography with nitrogen-phosphorus detector and confirmed by gas chromatography-mass spectrometry using a validated analytical method. At approximately 4, 8, and 12 hours post-ingestion, whole blood concentrations of olanzapine were 0.41, 0.34, and 0.38 mg/L, respectively.

CONCLUSIONS

This study reports an acute olanzapine monointoxication with severe toxicity and high whole blood olanzapine concentrations. Clinical and analytical data of similar samples obtained in non-fatal life-threatening cases can be very useful when interpreting postmortem cases.

[Morphological aspects of acute intoxication with azaleptin]

Clinico-anatomical analysis, chemico-toxicological and histological examination of material from 54 deceased from intoxication with azaleptin both in urgent toxicology department and pre-admission stage, were performed. Morphology of intoxication with azaleptin was studied, structural base of genopathy at these intoxications was developed.

Fatality due to amisulpride toxicity: a case report

Amisulpride is an atypical antipsychotic agent effective in the treatment of schizophrenia. There are few cases in the literature relating to the toxicity of this agent and reported fatalities are rare. Drug induced prolongation of the QT interval of the electrocardiograph (ECG) is increasingly recognised with various classes of drugs and in particular with antipsychotics. Cardiotoxicity can manifest as ventricular tachyarrhythmia, including torsades de pointes (TdP), complicating QT prolongation. We report a case of fatal amisulpride toxicity where the post-mortem blood concentration was 48 mg/L. Hitherto under-recognised toxic effects of novel chemotherapeutic agents can pose challenges for the forensic pathologist charged with performing medico-legal autopsies in cases of sudden unexpected death in young adults and particularly in those with schizophrenia. A knowledge of the ability of antipsychotic agents to induce fatal cardiac arrhythmias should inform the approach to the autopsy (including determination of the cause and mechanism of death) in such cases, as should an appreciation of the dangers inherent in the interpretation of post-mortem toxicology.

Endovascular cooling in a patient with neuroleptic malignant syndrome

We report a case of severe neuroleptic malignant syndrome with hyperthermia, rhabdomyolysis and hepatic failure where we applied endovascular cooling in order to reverse hyperthermia. After rapid normalization of core temperature at 37.5 degrees C, the patient's condition improved and CK levels dropped. However, upon withdrawl of endovascular temperature control there was a relapse. This is the first case where endovascular cooling was applied successfully in neuroleptic malignant syndrome.