Adverse drug effects attributed to phenylpropanolamine: a review of 142 case reports

Imaging of Drug-Related Vasculopathy

Illicit and recreational drugs, such as cocaine, heroin, amphetamines, and marijuana, can result in drug-related vasculitis or vasculopathy. Similarly, the use of certain antithyroid, oncologic, and immunosuppressive medications for therapeutic purposes can lead to vasculopathy. This in turn may result in significant complications in the central nervous system, including intracranial hemorrhage and stroke. Cocaine abuse can also lead to midline destructive lesions of the sinonasal complex. MR imaging, Vessel Wall imaging, and CT/CTA are valuable imaging tools for the evaluation of patients with suspected drug-induced vasculopathy or vasculitis. This article reviews the pathomechanism, clinical presentation, and imaging findings of vasculopathy related to drug abuse and prescribed medications.

Effects of Caffeine on Brown Adipose Tissue Thermogenesis and Metabolic Homeostasis: A Review

The impact of brown adipose tissue (BAT) metabolism on understanding energy balance in humans is a relatively new and exciting field of research. The pathogenesis of obesity can be largely explained by an imbalance between caloric intake and energy expenditure, but the underlying mechanisms are far more complex. Traditional non-selective sympathetic activators have been used to artificially elevate energy utilization, or suppress appetite, however undesirable side effects are apparent with the use of these pharmacological interventions. Understanding the role of BAT, in relation to human energy homeostasis has the potential to dramatically offset the energy imbalance associated with obesity. This review discusses paradoxical effects of caffeine on peripheral adenosine receptors and the possible role of adenosine in increasing metabolism is highlighted, with consideration to the potential of central rather than peripheral mechanisms for caffeine mediated BAT thermogenesis and energy expenditure. Research on the complex physiology of adipose tissue, the embryonic lineage and function of the different types of adipocytes is summarized. In addition, the effect of BAT on overall human metabolism and the extent of the associated increase in energy expenditure are discussed. The controversy surrounding the primary β-adrenoceptor involved in human BAT activation is examined, and suggestions as to the lack of translational findings from animal to human physiology and human in vitro to in vivo models are provided. This review compares and distinguishes human and rodent BAT effects, thus developing an understanding of human BAT thermogenesis to aid lifestyle interventions targeting obesity and metabolic syndrome. The focus of this review is on the effect of BAT thermogenesis on overall metabolism, and the potential therapeutic effects of caffeine in increasing metabolism via its effects on BAT.

The recent advancement of low-dimensional nanostructured materials for drug delivery and drug sensing application: A brief review

In this review article, we have presented a detailed analysis of the recent advancement of quantum mechanical calculations in the applications of the low-dimensional nanomaterials (LDNs) into biomedical fields like biosensors and drug delivery systems development. Biosensors play an essential role for many communities, e.g. law enforcing agencies to sense illicit drugs, medical communities to remove overdosed medications from the human and animal body etc. Besides, drug delivery systems are theoretically being proposed for many years and experimentally found to deliver the drug to the targeted sites by reducing the harmful side effects significantly. In current COVID-19 pandemic, biosensors can play significant roles, e.g. to remove experimental drugs during the human trials if they show any unwanted adverse effect etc. where the drug delivery systems can be potentially applied to reduce the side effects. But before proceeding to these noble and expensive translational research works, advanced theoretical calculations can provide the possible outcomes with considerable accuracy. Hence in this review article, we have analyzed how theoretical calculations can be used to investigate LDNs as potential biosensor devices or drug delivery systems. We have also made a very brief discussion on the properties of biosensors or drug delivery systems which should be investigated for the biomedical applications and how to calculate them theoretically. Finally, we have made a detailed analysis of a large number of recently published research works where theoretical calculations were used to propose different LDNs for bio-sensing and drug delivery applications.

Intranasal Application of the α2-Adrenoceptor Agonist BHT-920 Produces Decongestion in the Cat

The effect of α2-selective adrenoreceptor activation on nasal cavity dimension in an experimental model of congestion has not been defined. Presently, we used acoustic rhinometry to evaluate the decongestant activity of BHT-920, a selective α2-adrenergic agonist against nasal congestion produced by intranasal compound 48/80. Administration of the mast cell liberator compound 48/80 (1%) into a nasal passageway decreased ipsilateral volume and minimum cross-sectional area by 73 ± 4% and 42 ± 6%, respectively. The congestant effect of compound 48/80 was blocked by topical BHT-920 (0.3 and 1%) in a dose related manner. In addition, the decrease in minimum cross-sectional area produced by compound 48/80 was attenuated after topical BHT-920 treatment. As a comparison we also evaluated the topical decongestant activity effects of the α1-adrenergic agonist phenylephrine, and the nonselective α-agonist oxymetazoline. Both phenylephrine (0.1–1.0%) and oxymetazoline (0.01–0.3%) produced decongestion. The blood pressure effects of these three drugs also were evaluated. At doses of 0.3 and 1.0%, BHT-920 did not produce hypertension. In contrast, oxymetazoline (0.01–0.1%) produced a transient hypertension that peaked at 15 minutes and fully recovered 45 minutes after administration. The hypertensive effect of phenylephrine at 0.3 and 1.0% lasted over 60 minutes. The present findings indicate that selective α2-agonists may produce decongestant activity with an improved cardiovascular profile compared with current sympathomimetic drugs such as phenylephrine.

Posterior Reversible Encephalopathy Syndrome: Local Experience From Saudi Arabia

OBJECTIVES

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterized by headache, altered mental status, seizures, or loss of vision. In this study, we report the largest series of PRES coming from Saudi Arabia and explore the etiology, clinical presentation, and outcome. We also report new imaging findings associated with this condition.

METHODS

We performed a retrospective study of all cases of PRES admitted to King Abdulaziz Medical City, Jeddah, Saudi Arabia, between the years 2005 and 2015. A neurologist reviewed all charts and analyzed the clinical presentations, etiological factors, and outcomes, and a neuroradiologist reviewed the imaging studies. Only patients with clinical and imaging features consistent with PRES were included in the study.

RESULTS

We collected 31 patients who had clinical and radiological features consistent with PRES. Females were more affected than males (18 females and 13 males), and patients' age ranged from 6 to 95 years, with a mean of 38.3 years. Patients were treated by removing the precipitating causes and treating the underlying conditions. Resolution of neurologic signs occurred within 2 to 3 weeks in all patients.

CONCLUSION

In our opinion, PRES itself is usually a benign condition with complete recovery if the condition is recognized early and managed appropriately. Although clinical signs are nonspecific, the constellation of symptoms including headache, visual problems, seizures, and altered level of consciousness should suggest the possibility of PRES, especially in high-risk group. Abnormalities on magnetic resonance imaging are often characteristic and may be the first clue to the diagnosis.

Synthetic investigation on chirally pure Mannich derivatives of pseudophenylpropanolamine and their anticancer properties against HepG-2 cells with inhibition of JAK2/STAT3

In vitro and in vivo anticancer activity of compound 3a was proved as a novel blocker of JAK2/STAT3 signaling pathway and exerts both anti-proliferative and apoptotic activities in HepG-2 cells with xenograft mice model.

Synthesis of BF₃ catalyzed Mannich derivatives with excellent ee from phenylpropanolamine, study of their antimicrobial activity and molecular docking

Antimicrobial agents 4a-g and 5a-g with very good potency were synthesized with 100% ee from phenylpropanolamine (norephedrine) by BF3 catalyzed three components one pot Mannich reaction in good yields. Obtained compounds were characterized using spectral techniques. Antimicrobial study of these compounds revealed a good to very high potential activity against tested microbes when compared to standard antimicrobial drugs streptomycin and ketoconazole. These synthesized compounds exhibited significant minimum inhibitory concentration (MIC) values against Gram positive and Gram negative bacteria. Amongst compound 4b, 4c, 4d, 4e, 5a, and 5e exhibited very high potent MIC values against tested twelve bacteria and three fungi when compared to control. When subjected to molecular docking, in silico studies revealed significant binding energies ranging from -7.06 to -8.90 kcal/mol for all obtained compounds towards target receptor DNA topoisomerase IV and amongst compounds 4b and 4d have shown maximum binding energies 8.70 and 8.90 kcal/mol, respectively.

Current trends and future prospects of lipstatin: a lipase inhibitor and pro-drug for obesity

A review of the implications and causes of obesity, the status of antiobesity drugs, the mechanism of inhibition of pancreatic lipases, the biosynthesis of lipstatin and the present status of lipstatin production.

Pseudoephedrine-induced Hemorrhage Associated with a Cerebral Vascular Malformation

Background:

Sympathomimetic-related intracerebral hemorrhage is well-documented. Most cases are associated with phenylpropanolamine use.

Case Report:

We report a case of intracerebral hemorrhage occurring in a middle-aged man who suffered from chronic sinusitis and had been ingesting pseudoephedrine daily for one year. This patient was previously well with no known cardiovascular risk factors. Clinical examination revealed no evidence of vasculitis nor coagulopathy and initial neuroimaging (i.e., computed tomography, angiography, magnetic resonance imaging) demonstrated no features consistent with aneurysm, arteriovenous malformation (AVM), cavernoma, nor cerebral metastases. A follow-up cerebral angiogram demonstrated a small AVM arising off a branch of the pericallosal artery and a small arteriovenous fistula arising off the costal marginal branch. The AVM was embolized without incident, however, the AVF was not accessible.

Conclusions:

Sympathomimetics have long been associated with intracerebral hemorrhage. Since 1979, over 30 published case reports have documented the relationship between phenylpropanolamine and stroke. Only one report links phenylpropanolamine consumption to an intracerebral hemorrhage in a patient with an AVM. There is a paucity of literature etiologically inculpating other ephedra alkaloids in the causation of intracerebral hemorrhage. This is a case of pseudoephedrine-induced intracerebral hemorrhage in a patient with an underlying vascular malformation.

Lysosome vacuolation disrupts the completion of autophagy during norephedrine exposure in SH-SY5Y human neuroblastoma cells

In our current study, we examined the mechanism underlying neuronal cell injuries caused by norephedrine in SH-SY5Y human neuroblastoma cells. Norephedrine was found to induce cytoplasmic vacuolation and a resultant loss of cell viability. In the cells treated with norephedrine also, an autophagic marker LC3 was converted to its LC3-II activated form, suggesting the induction of autophagy. In cells transfected with RFP-LC3 and GFP-LAMP1, a punctate patterning of LC3 expression and colocalization of LAMP1 with the formed vacuoles were observed, highlighting the lysosomal nature of the vacuoles and their association with autophagosomes. An autophagic flux assay using tfLC3 (mRFP-GFP-LC3) indicated the formation of autophagosomes and autolysosomes by norephedrine stimulation at an early timepoint (∼3 h). However, at a later timepoint (∼6 h), both the dilation of autolysosomes/lysosomes and the neutralization of the vacuolar pH were also observed. These results thus indicate that norephedrine induces autophagy at an early timepoint and cell death with lysosomal dysfunction and autophagy disruption at a later timepoint.

Toxicity of weight loss agents

INTRODUCTION

With the rise of the obesity epidemic in the United States over the last several decades and the medical complications seen with it, weight loss and dieting have become a national public health concern.

DISCUSSION

Because of their increased use and availability through internet sales, several different dieting agents were reviewed for potential toxicity. These included: syrup of ipecac, cathartics, human chorionic gonadotropin hormone, 2,4 Dinitrophenol, guar gum, phenylpropanolamine, ma huang/ ephedra, caffeine, clenbuterol, fenfluramine, sibutramine, thyroid hormone, orlistat and cannabinoid antagonists.

CONCLUSIONS

With the internet making even banned products readily accessible, healthcare providers need to be aware of the potential toxicities of a wide range of weight loss agents. Our review covered topics we thought to be most historically significant as well as pertinent to the practice of medical toxicology today.

Metabolic encephalopathies

Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.

[Pharmacologically-induced neurocatastrophes]

Drug-induced adverse reactions represent a significant health problem in developed countries. These events cause 5% of hospital admissions and are one of the main causes of mortality. Neurological manifestations are among the most frequent. This article reviews catastrophic cerebrovascular situations and confusional syndromes, as well as epilepsy, structural encephalopathy, neuromuscular disorders, catastrophic movement disorders and infections, all of which can be drug-induced.

Exploratory study of factors influencing practice of pharmacists in Australia and Thailand with respect to dietary supplements and complementary medicines

Objective

To explore opinions and practices of pharmacists in Australia and Thailand in relation to dietary supplements and complementary medicines (DS/CM)

Method

Data were collected from individual in-depth interviews of 10 pharmacists from the Sydney metropolitan area, Australia, and 10 pharmacists from the north-eastern region of Thailand, using semi-structured interview protocol to guide the interview.

Key findings

Australian respondents evaluated the necessity and safety of use of DS/CM in the same way as for conventional medicines. Thai respondents performed a quick assessment to ensure that customers were in a normal-health condition before selling them DS/CM products. The provision of information about DS/CM products and their efficacy, and advice on the maintenance of healthy lifestyles were still inadequate in both studied groups. When assisting customers in selecting products, Australian respondents would select a product about which they had knowledge, while Thai respondents would suggest brands that were relatively cheap but yielded a higher profit margin. Criteria used by Australian respondents to select DS/CM products to sell in pharmacies were clinical evidence and the credibility of companies and distributors, while Thai respondents appeared to be influenced by companies' credibility, customers' income, products' appearance and companies' policies about unsold products.

Conclusion

It was found that neither Australian nor Thai respondents were proactive in providing professional services to support the appropriate use of DS/CM. Among Australian respondents, the decision to sell or recommend DS/CM was often motivated by customers' desire and customers' health conditions. Among Thai respondents the action taken was often motivated by customers' request and the profit to be made from the sale.

Therapeutic management of allergic diseases

Allergic diseases are characterized by the activation of inflammatory cells and by a massive release of mediators. The aim of this chapter was to describe succinctly the modes of action, indications, and side effects of the major antiallergic and antiasthmatic drugs. When considering the ideal pharmacokinetic characteristics of a drug, a poorly metabolized drug may confer a lower variability in plasma concentrations and metabolism-based drug interactions, although poorly metabolized drugs may be prone to transporter-based disposition and interactions. The ideal pharmacological properties of a drug include high binding affinity, high selectivity, and appropriate association and dissociation rates. Finally, from a patient perspective, the frequency and route of administration are important considerations for ease of use.

Diretrizes para o manejo de pacientes com hemorragia intraparenquimatosa cerebral espontânea

A hemorragia intraparenquimatosa cerebral (HIC) é o subtipo de AVC de pior prognóstico e com tratamento ainda controverso em diversos aspectos. O comitê executivo da Sociedade Brasileira de Doenças Cerebrovasculares, através de uma revisão ampla dos artigos publicados em revistas indexadas, elaborou sugestões e recomendações que são aqui descritas com suas respectivas classificações de níveis de evidência. Estas diretrizes foram elaboradas com o objetivo de prover o leitor de um racional para o manejo apropriado dos pacientes com HIC, baseado em evidências clínicas.

Drug-induced liver injury: Is it somehow foreseeable?

The classic view on the pathogenesis of drug-induced liver injury is that the so-called parent compounds are made hepatotoxic by metabolism (formation of neo-substances that react abnormally), mainly by cytochromes P-450 (CYP), with further pathways, such as mitochondrial dysfunction and apoptosis, also playing a role. Risk factors for drug-induced liver injury include concomitant hepatic diseases, age and genetic polymorphisms of CYP. However, some susceptibility can today be predicted before drug administration, working on the common substrate, by phenotyping and genotyping studies and by taking in consideration patients’ health status. Physicians should always think of this adverse effect in the absence of other clear hepatic disease. Ethical and legal problems towards operators in the health care system are always matters to consider.

Drug-induced liver injury due to “natural products” used for weight loss: A case report

Taking herbal-extracts to lose weight is an underestimated health hazard. Often, these products contain active agents that can cause acute liver damage. In this case report, a 22-year-old female patient, who presented with a feature of cholestatic syndrome, was so sure that the “natural products” were not dangerous that she did not inform her physicians that she had taken them, making their task that much more challenging. Clinical presentation mimicked acute cholecystitis and the patient underwent a cholecystectomy. Surgery was without any consequences and complications, although it did not completely cure the illness. She later admitted to having taken herbal remedies and this led to the correct diagnosis of phytotherapy-related hepatotoxicity and a successful therapeutic approach. The true incidence of phytotherapy-related hepatotoxicity and its pathogenic mechanisms are largely unknown. It is important to increase the awareness of both clinicians and patients about the potential dangers of herbal remedies.

Cutaneous Pseudovasculitis

Cutaneous pseudovasculitis represents a heterogeneous collection of disorders that are capable of simulating cutaneous vasculitis and can be broadly classified into diseases that produce hemorrhage (petechiae, purpura, and ecchymoses) or vessel occlusion with resultant livedo, cyanosis, ulcers, digital necrosis, and/or gangrene. Overlap is not uncommon, but if present, one mechanism dominates. Hemorrhagic pseudovasculitis is due to vessel wall dysfunction (incompetence), which can be related to diverse factors that include vessel wall deposition of metabolic substances (amyloid, calcium), nutritional deficiencies (scurvy), nonvasculitic inflammatory purpura (pigmented purpuric dermatitis, arthropod, viral and drug reactions), degeneration of the vessel wall and supporting stroma (senile/solar purpura), direct vessel wall invasion of infective organisms, coagulation-fibrinolytic disorders (eg, thrombocytopenia), and vessel wall trauma. Cyanotic-infarctive pseudovasculitis is due vaso-occlusion by emboli, thrombi, or fibrointimal hyperplasia (endarteritis obliterans) and includes varied conditions such as purpura fulminans, Coumadin necrosis, antiphospholipid antibody syndrome, cardiac myxoma, cholesterol embolization, calciphylaxis, and radiation arteritis. Delayed and inappropriate diagnosis of pseudovasculitis leads to incorrect management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. The diagnosis of a pseudovasculitic disorder requires a high index of suspicion and should always be part of the differential diagnosis of vasculitis. Skin biopsy is a crucial step in differentiating pseudovasculitis from authentic vasculitis; absence of histologic evidence of vasculitis, particularly after multiple biopsies, should direct evaluation and diagnosis towards pseudovasculitis.

Safety of drug therapies used for weight loss and treatment of obesity

Some of the medications used for weight loss in the management of obesity have been associated with unacceptable morbidity and mortality. Safety concerns have led to the withdrawal of aminorex, followed by the fenfluramines in 1997, and phenylpropanolamine (norephedrine) in 2000. Aminorex was associated with an increased prevalence of primary pulmonary hypertension (PPH), fenfluramines with an increased prevalence of PPH and valvulopathy, and phenylpropanolamine with an increased risk of haemorrhagic stroke. Several studies have investigated the safety of the fenfluramines, yet the benefit-risk profile has not been conclusively quantified. This is due to several deficiencies in the published studies, including a lack of data on the baseline prevalences of comorbid conditions in obese subjects, and potential confounders and biases in the study designs. Although several studies and systematic reviews support an increased risk of PPH and valvulopathy in patients who have taken fenfluramines, without knowledge of the background prevalence it is not possible to determine if the exposure preceded the outcome. The population at higher risk of these adverse effects includes those taking higher doses or with a longer duration of exposure to fenfluramines and those with pre-existing cardiac disease or a genetic predisposition. Patients exposed to fenfluramines continue to be monitored, with some follow-up studies indicating no overall worsening in valvulopathy over time. There are limited efficacy and safety data for amfepramone (diethylpropion) and phentermine and their approval for the management of obesity is limited to short-term use. Orlistat and sibutramine are the only currently approved medications for long-term management of obesity. Although the benefit-risk profiles of sibutramine and orlistat appear positive, sibutramine continues to be monitored because of long-term safety concerns. The safety and efficacy of currently approved drug therapies have not been evaluated in children and elderly patient populations and there is limited information in adolescents, whilst the long-term safety of current and potential new drug therapies in adults will require several years of postmarketing surveillance to fully elucidate their adverse effect profiles.

Capillary gas chromatographic determination of phenylpropanolamine in pharmaceutical preparation

Analytical procedure has been developed for the gas chromatographic determination of phenylpropanolamine (PPA) using trifluoroacetylacetone (FAA) as derivatizing reagent. Elution is carried out from the column HP-5 (30 mx0.32 mm i.d.) with film thickness 0.25 microm at initial column temperature 70 degrees C for 5 min, followed by heating rate 10 degrees C/min up to 120 degrees C. Injection port temperature was maintained at 270 degrees C. Nitrogen flow rate was 2 ml/min and detection was by FID. The linear calibration curve was obtained with 30-150 microg/ml PPA with detection limit of 6.0 microg/ml. The method was used for the determination of PPA from Sinutab and Tavegyl-D tablets. The relative standard deviation (R.S.D.) for the analysis of pharmaceutical preparation was obtained within 0.4-0.9%.

Cardiac Toxicity From Phenylpropanolamine Overdose in a Dog

A 5-year-old, 29-kg, female Labrador retriever developed tachypnea, tachycardia, and ataxia following ingestion of approximately 48 mg/kg of phenylpropanolamine. Initial diagnostic tests showed multiform ventricular tachycardia, left ventricular dilatation with a focal dyskinetic region in the dorsal interventricular septum, and elevations in creatinine kinase and cardiac troponin I. All abnormalities resolved within 6 months. The transient electrocardiographic, echocardiographic, and biochemical abnormalities were consistent with myocardial necrosis from infarction or direct catecholamine-induced myocardial toxicity.

The impact of oral phenylpropanolamine on blood pressure: a meta-analysis and review of the literature

Oral phenylpropanolamine is commonly used to treat congestion and obesity. Clinicians often wonder what effect it has on blood pressure and whether they are safe in hypertensive patients. The purpose of our systematic review was to assess whether these drugs cause clinically meaningful elevations in pulse or blood pressure. English-language, randomized, placebo-controlled trials of oral phenylpropanolamine in adults with extractable data on pulse or blood pressure were studied. MEDLINE (1966-2003), Embase, the Cochrane library and reviewed article references were used as sources. Systolic (SBP) and diastolic blood pressure (DBP) and heart rate data were extracted. Additional extracted data included demographics, year, study design, study duration, drug dose and frequency, duration of washout and country. Study quality was assessed using the methods of Jadad and data were synthesized using a random effects model using weighted mean differences. In all, 33 trials reporting 48 treatment arms with 2165 patients were included. Phenylpropanolamine increased SBP 5.5 mmHg (95% CI: 3.1-8.0) and DBP 4.1 mmHg (95% CI: 2.2-6.0) with no effect on pulse. Patients with controlled hypertension were not at greater risk of blood pressure elevation. Immediate release preparations had greater effects on blood pressure than sustained release ones. Higher doses and shorter duration use also caused greater increases. Eighteen studies contained at least one treated subjects having blood pressure elevations > or =140/90 mmHg, an increase in SBP > or =15 mmHg or an increase in DBP > or =10 mmHg. In conclusion, phenylpropanolamine caused a small, but significant increase in systolic blood pressure. The effect was more pronounced with shorter-term administration, higher doses of medication and immediate release formulations.

Use of alternative medicine among Hispanics

OBJECTIVES

To determine the prevalence and patterns of use of alternative medicine among urban Hispanics.

DESIGN

A cross-sectional survey.

SETTINGS/LOCATION

Churches located in the northern part of Los Angeles and outpatients and inpatients in a county hospital in southern California.

SUBJECTS

179 Hispanic subjects.

OUTCOME MEASURES

The following issues related to alternative medicine were evaluated: frequency and reasons for its use; perceived efficacy; safety; costs; sources of information; overall satisfaction; and subject-physician interaction with respect to alternative medicine.

RESULTS

Sixty-three percent (63%) of respondents reported using or had used one or more types of alternative medicine. The majority of users were women (75%, 95% confidence interval [CI], 66%-83%). The most commonly reported alternative therapies were herbs (57%, 95% CI 47%-66%), prayer (43%, 95% CI 34%-53%), and dietary supplements (21%, 95% CI 14-30%). Compared to nonusers, users of alternative medicine had significantly lower yearly income, less proficiency in English language, and lower educational level. The main indications for using alternative medicine were pain (61.4%, 95% CI 51%-71%), lack of energy (38.6%, 95% CI 29%-49%), and overweight (22.8%, 95% CI 16%-33%). Only 5.2% of subjects (95% CI 2%-12%) believed that herbs are more effective than medications prescribed by physician. A majority of users (61%, 95% CI 50%-68%) had more confidence in their physicians than in their alternative medicine provider. Forty-five percent (45%) of users (95% CI 34%-56%) believed prescribed medication was safer than alternative medicine, whereas only 7% (95% CI 3%-15%) believed the reverse. Adverse effects related to herbs and dietary supplements were reported by 11 users. The majority of participants (78.9%, 95% CI 69-87%) did not speak to their physicians about alternative therapy. The mean score of overall satisfaction with conventional medicine was significantly higher than with alternative medicine.

CONCLUSIONS

Despite the common use of alternative medicine among Hispanics, the majority of users believe that conventional medicine is superior to alternative medicine. There is a significant gap in communication between physicians and patients with respect to alternative medicine.

Hemorrhagic stroke after naphazoline exposition: case report

Ten percent of all strokes are due to spontaneous cerebral hemorrhages. They are associated to drugs (licit and illicit) in 9.5% of all cases in young adults. This is a case report of a 44-year-old man, without previous morbidities, who presented a sudden onset headache and arterial hypertension 24 hours after use of naphazoline as nasal decongestant. Cranial tomography showed right thalamus hemorrhage. Cerebral angiography showed no aneurisms, vascular malformations or vasculitis. No other risk factors were found during investigation in this patient and the stroke was attributed to naphazoline exposition.

Cerebral infarcts in a pediatric patient secondary to phenylpropanolamine, a recalled medication

Phenylpropanolamine (PPA) recently has been publicly implicated as a cause of stroke and other neurologic events. In November of 2000, the Food and Drug Administration (FDA) requested a voluntary recall of the product from all manufacturers. However, medications containing PPA still can be found in many homes of those unaware of the voluntary recall. We present a case of stroke after PPA ingestion that occurred 4 months after the recall in an 8-year-old boy on chronic peritoneal dialysis. The patient developed occipital infarcts and was found to have extremely elevated levels of PPA in his blood and dialysis fluid. Though the voluntary recall was in effect, the family already had a bottle of the medication at home. Physicians must be aware that the public is still ingesting the drug and remain rigorous in including its toxicity in the differential diagnosis of acute neurologic events.

Fatal pulmonary arterial hypertension associated with phenylpropanolamine exposure

Exogenous substances such as the appetite suppressant fenfluramine are known to be causally related to the development of pulmonary arterial hypertension (PAH). In these cases, the clinical course as well as the pulmonary vascular disease pathologically is indistinguishable from idiopathic PAH. Other exogenous substances, such as amphetamines, cocaine, and meta-amphetamines, have been considered to be potential risk factors for inducing PAH. SOPHIA (the study of pulmonary hypertension in America), in addition to confirming previous reports of a causal association between the appetite suppressant fenfluramine and PAH, unexpectedly found a significantly increased risk for the development of PAH with exposure to over-the-counter antiobesity agents containing phenylpropanolamine. The first case is reported of fatal PAH in a child heavily treated with cold remedies containing phenylpropanolamine, which, in addition to the results of SOPHIA, strengthens the hypothesis that phenylpropanolamine is a risk factor for the development of PAH.

Pharmacokinetic interactions between phenylpropanolamine, caffeine and chlorpheniramine in rats

As the mechanism involved in the serious adverse effects associated with phenylpropanolamine (PPA) has not yet been clarified, and as PPA in usual cases is not being ingested without other drugs combination, the aim of this study was to characterize the possibility of pharmacokinetic interactions between PPA and most often combined drugs existing in the same dosage. The pharmacokinetics of PPA in rat brain and blood were evaluated when administered alone (group I), combined with caffeine (group II), combined with chlorpheniramine (group III), combined with both caffeine and chlorpheniramine (group IV) and finally when existed in one of the available OTC products (group V). This product contains multiple ingredients of PPA, caffeine and chlorpheniramine. In brain the pharmacokinetic parameters of PPA were significantly affected with the combined administration of caffeine and/or chlorpheniramine. The single intraperitoneal administration of caffeine (5 mg/kg) with PPA (2.5 mg/kg) to rats caused 1.6-fold increase in the AUC of PPA in brain compared to the single administration of PPA, and was comparable to the 1.5-fold increase caused by chlorpheniramine (0.4 mg/kg). The multiple combinations caused an increase in the AUC by 1.9-fold, which is comparable to the increase in the AUC of PPA obtained from the OTC product (2.2-fold). On the other hand, there was no significant difference in the pharmacokinetics of PPA in blood between the groups except for the C(max) of PPA in groups I and IV. The observed adverse effects associated with PPA use could be related to the significant increase in its levels in the brain.

High performance liquid chromatography with fluorescence detection for the determination of phenylpropanolamine in human plasma and rat’s blood and brain microdialysates using DIB-Cl as a label

A high performance liquid chromatographic method for the determination of phenylpropanolamine (PPA) in human plasma and rat's brain and blood microdialysates using fluorescence (FL) detection after precolumn derivatization with 4-(4,5-diphenyl-1H-imidazole-2-yl)benzoyl chloride (DIB-Cl) is described. PPA was extracted from plasma samples by a liquid-liquid extraction method with ethyl acetate followed by derivatization with DIB-Cl, while the blood and brain microdialysates were directly subjected for derivatization. The DIB-derivatives of PPA and the internal standard, ephedrine (EP), were then separated using an isocratic HPLC-FL set at excitation and emission wavelengths of 325 and 430 nm, respectively, on an ODS column. Calibration curves of PPA in spiked human plasma were linear over the concentration range of 5-5000 nM (0.755-755 ng/ml) and those in spiked blood and brain microdialysates were linear over the range of 25-5000 nM (3.775-755 ng/ml) with limits of detection of 17, 48 and 40 fmol on column in plasma and blood and brain microdialysates, respectively. As well, the intra- and the inter-assay precisions were lower than 12% for human plasma and the microdialysates. The method was successfully applied for the monitoring of PPA levels in rat's brain and blood microdialysates administered with a single oral dose of PPA (2.5 mg/kg).

Stroke associated with sympathomimetics contained in over-the-counter cough and cold drugs

BACKGROUND AND PURPOSE

Phenylpropanolamine (PPA) and pseudoephedrine are sympathomimetics contained in over-the-counter cold preparations. A case-control study linked PPA use with hemorrhagic stroke in women. Twenty-two patients with stroke associated with use of these drugs are described.

METHODS

In a consecutive stroke registry since 1988, 22 patients had stroke associated with over-the-counter sympathomimetics. Sympathomimetic dosage and type, time interval until stroke onset, and neuroimaging findings are described.

RESULTS

Ten male and 12 female patients were included. Intracerebral hemorrhage occurred in 17 patients, subarachnoid hemorrhage in 4, and ischemic stroke in 1. Stroke was associated with PPA use in 16 patients (dose 75 to 675 mg), with pseudoephedrine in 4 (dose 60 to 300 mg), and with others administered by the nasal route in 2 (oxymetazoline and phenylephrine). Stroke occurred after a single dose in 17 patients and after daily use during several days in 5. The interval between drug exposure and clinical onset varied from 30 minutes to 24 hours. Stroke occurred after recommended doses of PPA (50 to 75 mg) in 32% and pseudoephedrine (60 mg) in 50% of patients. Eight patients had acute hypertension at stroke onset. Cerebral angiography was normal in 8 cases and showed diffuse vasospasm or beading in 10 patients.

CONCLUSIONS

Stroke related to over-the-counter sympathomimetics was associated with acute hypertension and/or vasospasm or angiitis mechanisms, most related to the use of PPA; however, stroke also occurred with the use of other sympathomimetics, particularly pseudoephedrine. Although stroke complications occurred when doses were used that were higher than recommended doses, apparently there is also a stroke risk when these agents are taken properly.