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Horseman M, Panahi L, Udeani G, Tenpas AS, Verduzco Jr. R, Patel PH, Bazan DZ, Mora A, Samuel N, Mingle AC, Leon LR, Varon J, Surani S. Drug-Induced Hyperthermia Review. Cureus 2022; 14:e27278. [PMID: 36039261 PMCID: PMC9403255 DOI: 10.7759/cureus.27278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
Humans maintain core body temperature via a complicated system of physiologic mechanisms that counteract heat/cold fluctuations from metabolism, exertion, and the environment. Overextension of these mechanisms or disruption of body temperature homeostasis leads to bodily dysfunction, culminating in a syndrome analogous to exertional heat stroke (EHS). The inability of this thermoregulatory process to maintain the body temperature is caused by either thermal stress or certain drugs. EHS is a syndrome characterized by hyperthermia and the activation of systemic inflammation. Several drug-induced hyperthermic syndromes may resemble EHS and share common mechanisms. The purpose of this article is to review the current literature and compare exertional heat stroke (EHS) to three of the most widely studied drug-induced hyperthermic syndromes: malignant hyperthermia (MH), neuroleptic malignant syndrome (NMS), and serotonin syndrome (SS). Drugs and drug classes that have been implicated in these conditions include amphetamines, diuretics, cocaine, antipsychotics, metoclopramide, selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), and many more. Observations suggest that severe or fulminant cases of drug-induced hyperthermia may evolve into an inflammatory syndrome best described as heat stroke. Their underlying mechanisms, symptoms, and treatment approaches will be reviewed to assist in accurate diagnosis, which will impact the management of potentially life-threatening complications.
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van Amsterdam J, Brunt TM, Pierce M, van den Brink W. Hard Boiled: Alcohol Use as a Risk Factor for MDMA-Induced Hyperthermia: a Systematic Review. Neurotox Res 2021; 39:2120-2133. [PMID: 34554408 PMCID: PMC8639540 DOI: 10.1007/s12640-021-00416-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/07/2021] [Accepted: 09/11/2021] [Indexed: 11/10/2022]
Abstract
Although MDMA (ecstasy) is a relatively safe recreational drug and is currently considered for therapeutic use for the treatment of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD), recreational MDMA use occasionally elicits hyperthermia and hyponatremia, sometimes with a fatal outcome. Specific risk factors for both adverse effects are profuse sweating while vigorously dancing under unfavorable conditions such as high ambient temperatures and insufficient fluid suppletion which result in dehydration. Concomitant use of MDMA and alcohol is highly prevalent, but adds to the existing risk, because alcohol facilitates the emergence of MDMA-induced adverse events, like hyperthermia, dehydration, and hyponatremia. Because of potential health-related consequences of concomitant use of MDMA and alcohol, it is important to identify the mechanisms of the interactions between alcohol and MDMA. This review summarizes the main drivers of MDMA-induced hyperthermia, dehydration, and hyponatremia and the role of concomitant alcohol use. It is shown that alcohol use has a profound negative impact by its interaction with most of these drivers, including poikilothermia, exposure to high ambient temperatures, heavy exercise (vigorous dancing), vasoconstriction, dehydration, and delayed initiation of sweating and diuresis. It is concluded that recreational and clinical MDMA-users should refrain from concomitant drinking of alcoholic beverages to reduce the risk for adverse health incidents when using MDMA.
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Affiliation(s)
- Jan van Amsterdam
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Tibor M Brunt
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Mimi Pierce
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Amsterdam University Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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3
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Breed D, Meyer LCR, Steyl JCA, Goddard A, Burroughs R, Kohn TA. Conserving wildlife in a changing world: Understanding capture myopathy-a malignant outcome of stress during capture and translocation. CONSERVATION PHYSIOLOGY 2019; 7:coz027. [PMID: 31304016 PMCID: PMC6612673 DOI: 10.1093/conphys/coz027] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 04/22/2019] [Accepted: 05/03/2019] [Indexed: 05/18/2023]
Abstract
The number of species that merit conservation interventions is increasing daily with ongoing habitat destruction, increased fragmentation and loss of population connectivity. Desertification and climate change reduce suitable conservation areas. Physiological stress is an inevitable part of the capture and translocation process of wild animals. Globally, capture myopathy-a malignant outcome of stress during capture operations-accounts for the highest number of deaths associated with wildlife translocation. These deaths may not only have considerable impacts on conservation efforts but also have direct and indirect financial implications. Such deaths usually are indicative of how well animal welfare was considered and addressed during a translocation exercise. Importantly, devastating consequences on the continued existence of threatened and endangered species succumbing to this known risk during capture and movement may result. Since first recorded in 1964 in Kenya, many cases of capture myopathy have been described, but the exact causes, pathophysiological mechanisms and treatment for this condition remain to be adequately studied and fully elucidated. Capture myopathy is a condition with marked morbidity and mortality that occur predominantly in wild animals around the globe. It arises from inflicted stress and physical exertion that would typically occur with prolonged or short intense pursuit, capture, restraint or transportation of wild animals. The condition carries a grave prognosis, and despite intensive extended and largely non-specific supportive treatment, the success rate is poor. Although not as common as in wildlife, domestic animals and humans are also affected by conditions with similar pathophysiology. This review aims to highlight the current state of knowledge related to the clinical and pathophysiological presentation, potential treatments, preventative measures and, importantly, the hypothetical causes and proposed pathomechanisms by comparing conditions found in domestic animals and humans. Future comparative strategies and research directions are proposed to help better understand the pathophysiology of capture myopathy.
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Affiliation(s)
- Dorothy Breed
- Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
- Biodiversity Management Branch, Environmental Management Department, City of Cape Town, Maitland, South Africa
| | - Leith C R Meyer
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Johan C A Steyl
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Amelia Goddard
- Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
| | - Richard Burroughs
- Department of Production Animal Studies, University of Pretoria, Onderstepoort, South Africa
- Centre for Veterinary Wildlife Studies, University of Pretoria, Onderstepoort, South Africa
- Mammal Research Institute, University of Pretoria, Onderstepoort, South Africa
| | - Tertius A Kohn
- Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Cape Town, South Africa
- Department of Paraclinical Sciences, University of Pretoria, Onderstepoort, South Africa
- Corresponding author: Division of Exercise Science and Sports Medicine, Department of Human Biology, University of Cape Town, Boundary Road, Cape Town 7725, South Africa. Tel.: +27 21 406 6235;
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4
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Development of a mechanism-based pharmacokinetic/pharmacodynamic model to characterize the thermoregulatory effects of serotonergic drugs in mice. Acta Pharm Sin B 2016; 6:492-503. [PMID: 27709018 PMCID: PMC5045556 DOI: 10.1016/j.apsb.2016.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/25/2016] [Accepted: 04/27/2016] [Indexed: 01/01/2023] Open
Abstract
We have shown recently that concurrent harmaline, a monoamine oxidase-A inhibitor (MAOI), potentiates serotonin (5-HT) receptor agonist 5-methoxy-N,N-dimethyltryptamine (5-MeO-DMT)-induced hyperthermia. The objective of this study was to develop an integrated pharmacokinetic/pharmacodynamic (PK/PD) model to characterize and predict the thermoregulatory effects of such serotonergic drugs in mice. Physiological thermoregulation was described by a mechanism-based indirect-response model with adaptive feedback control. Harmaline-induced hypothermia and 5-MeO-DMT–elicited hyperthermia were attributable to the loss of heat through the activation of 5-HT1A receptor and thermogenesis via the stimulation of 5-HT2A receptor, respectively. Thus serotonergic 5-MeO-DMT–induced hyperthermia was readily distinguished from handling/injection stress-provoked hyperthermic effects. This PK/PD model was able to simultaneously describe all experimental data including the impact of drug-metabolizing enzyme status on 5-MeO-DMT and harmaline PK properties, and drug- and stress-induced simple hypo/hyperthermic and complex biphasic effects. Furthermore, the modeling results revealed a 4-fold decrease of apparent SC50 value (1.88–0.496 µmol/L) for 5-MeO-DMT when harmaline was co-administered, providing a quantitative assessment for the impact of concurrent MAOI harmaline on 5-MeO-DMT–induced hyperthermia. In addition, the hyperpyrexia caused by toxic dose combinations of harmaline and 5-MeO-DMT were linked to the increased systemic exposure to harmaline rather than 5-MeO-DMT, although the body temperature profiles were mispredicted by the model. The results indicate that current PK/PD model may be used as a new conceptual framework to define the impact of serotonergic agents and stress factors on thermoregulation.
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5
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Cheshire WP. Thermoregulatory disorders and illness related to heat and cold stress. Auton Neurosci 2016; 196:91-104. [DOI: 10.1016/j.autneu.2016.01.001] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/17/2015] [Accepted: 01/05/2016] [Indexed: 01/22/2023]
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6
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Grecco GG, Sprague JE. Impact of Functional Group Modifications on Designer Phenethylamine Induced Hyperthermia. Chem Res Toxicol 2016; 29:871-8. [DOI: 10.1021/acs.chemrestox.6b00030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Gregory G. Grecco
- The Ohio
Attorney General’s
Center for the Future of Forensic Science, Bowling Green State University, Bowling Green, Ohio 43403, United States
| | - Jon E. Sprague
- The Ohio
Attorney General’s
Center for the Future of Forensic Science, Bowling Green State University, Bowling Green, Ohio 43403, United States
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Coman D, Sanganahalli BG, Jiang L, Hyder F, Behar KL. Distribution of temperature changes and neurovascular coupling in rat brain following 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") exposure. NMR IN BIOMEDICINE 2015; 28:1257-66. [PMID: 26286889 PMCID: PMC4573923 DOI: 10.1002/nbm.3375] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 06/22/2015] [Accepted: 07/19/2015] [Indexed: 05/05/2023]
Abstract
(+/-)3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") is an abused psychostimulant that produces strong monoaminergic stimulation and whole-body hyperthermia. MDMA-induced thermogenesis involves activation of uncoupling proteins (UCPs), primarily a type specific to skeletal muscle (UCP-3) and absent from the brain, although other UCP types are expressed in the brain (e.g. thalamus) and might contribute to thermogenesis. Since neuroimaging of brain temperature could provide insights into MDMA action, we measured spatial distributions of systemically administered MDMA-induced temperature changes and dynamics in rat cortex and subcortex using a novel magnetic resonance method, Biosensor Imaging of Redundant Deviation in Shifts (BIRDS), with an exogenous temperature-sensitive probe (thulium ion and macrocyclic chelate 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetramethyl-1,4,7,10-tetraacetate (DOTMA(4-))). The MDMA-induced temperature rise was greater in the cortex than in the subcortex (1.6 ± 0.4 °C versus 1.3 ± 0.4 °C) and occurred more rapidly (2.0 ± 0.2 °C/h versus 1.5 ± 0.2 °C/h). MDMA-induced temperature changes and dynamics in the cortex and body were correlated, although the body temperature exceeded the cortex temperature before and after MDMA. Temperature, neuronal activity, and blood flow (CBF) were measured simultaneously in the cortex and subcortex (i.e. thalamus) to investigate possible differences of MDMA-induced warming across brain regions. MDMA-induced warming correlated with increases in neuronal activity and blood flow in the cortex, suggesting that the normal neurovascular response to increased neural activity was maintained. In contrast to the cortex, a biphasic relationship was seen in the subcortex (i.e. thalamus), with a decline in CBF as temperature and neural activity rose, transitioning to a rise in CBF for temperature above 37 °C, suggesting that MDMA affected CBF and neurovascular coupling differently in subcortical regions. Considering that MDMA effects on CBF and heat dissipation (as well as potential heat generation) may vary regionally, neuroprotection may require different cooling strategies.
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Affiliation(s)
- Daniel Coman
- Magnetic Resonance Research Center (MRRC), Yale University, New Haven, CT 06520, USA
- Core Center for Quantitative Neuroscience with Magnetic Resonance (QNMR), Yale University, New Haven, CT 06520, USA
- Department of Diagnostic Radiology, Yale University, New Haven, CT 06520, USA
| | - Basavaraju G. Sanganahalli
- Magnetic Resonance Research Center (MRRC), Yale University, New Haven, CT 06520, USA
- Core Center for Quantitative Neuroscience with Magnetic Resonance (QNMR), Yale University, New Haven, CT 06520, USA
- Department of Diagnostic Radiology, Yale University, New Haven, CT 06520, USA
| | - Lihong Jiang
- Magnetic Resonance Research Center (MRRC), Yale University, New Haven, CT 06520, USA
- Department of Diagnostic Radiology, Yale University, New Haven, CT 06520, USA
| | - Fahmeed Hyder
- Magnetic Resonance Research Center (MRRC), Yale University, New Haven, CT 06520, USA
- Core Center for Quantitative Neuroscience with Magnetic Resonance (QNMR), Yale University, New Haven, CT 06520, USA
- Department of Diagnostic Radiology, Yale University, New Haven, CT 06520, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT 06520, USA
| | - Kevin L. Behar
- Magnetic Resonance Research Center (MRRC), Yale University, New Haven, CT 06520, USA
- Department of Psychiatry, Yale University, New Haven, CT 06520, USA
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Ding D, Nickell JR, Dwoskin LP, Crooks PA. Quinolyl analogues of norlobelane: novel potent inhibitors of [(3)H]dihydrotetrabenazine binding and [(3)H]dopamine uptake at the vesicular monoamine transporter-2. Bioorg Med Chem Lett 2015; 25:2613-6. [PMID: 25991431 DOI: 10.1016/j.bmcl.2015.04.105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/22/2015] [Accepted: 04/30/2015] [Indexed: 11/16/2022]
Abstract
We have previously shown that quinolyl moieties are attractive structural replacements for the phenyl groups in lobelane. These quinolyl analogues had improved water-solubility over lobelane and retained the potent vesicular monoamine transporter-2 (VMAT-2) inhibitory properties of the parent compound, with quinlobelane (4) exhibiting potent inhibition of uptake at VMAT-2 (Ki=51nM). However, the VMAT-2 inhibitory properties of quinolyl analogues of norlobelane, which is equipotent with lobeline as an inhibitor of [(3)H]dopamine (DA) uptake at VMAT-2, have not been reported. In the current communication, we describe the synthesis of some novel des-methyl quinolyl analogues of lobelane that exhibit greater affinity (Ki=178-647nM) for the dihydrotetrabenazine binding site located on VMAT-2 compared with lobelane (Ki=970nM), norlobelane (Ki=2310nM) and quinlobelane (Ki=2640nM). The most potent compounds, 14 and 15, also exhibited inhibition of [(3)H]DA uptake at VMAT-2 (Ki=42nM) which was comparable to both lobelane (Ki=45nM) and norlobelane (Ki=43nM). Results reveal that binding affinity at VMAT-2 serves as an accurate predictor of inhibition of the function of VMAT-2 for the majority of these analogues. These novel analogues are under consideration for further development as treatments for methamphetamine abuse.
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Affiliation(s)
- Derong Ding
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY 40536, USA
| | - Justin R Nickell
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY 40536, USA
| | - Linda P Dwoskin
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Kentucky, Lexington, KY 40536, USA
| | - Peter A Crooks
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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9
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Moore BD, Wiggins NL, Marsh KJ, Dearing MD, Foley WJ. Translating physiological signals to changes in feeding behaviour in mammals and the future effects of global climate change. ANIMAL PRODUCTION SCIENCE 2015. [DOI: 10.1071/an14487] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mammals cannot avoid ingesting secondary metabolites, often in significant amounts. Thus, their intake must be regulated to avoid intoxication. Three broad mechanisms have been described by which this can be achieved. These are conditioned aversions mediated by nausea, non-conditioned aversions and the recognition of limits to detoxification. Although there is some overlap between these, we know little about the way that mechanisms of toxin avoidance interact with regulation of nutrient intake and whether one has priority over the other. Nonetheless, regulation of meal length and inter-meal length allows the intake of some plant secondary metabolites to be matched with an animal’s capacity for detoxification and its nutritional requirements. Toxicity itself is not a fixed limitation and recent work suggests that ambient temperature can be a major determinant of the toxicity of plant secondary metabolites, largely through effects on liver function. These effects are likely to be of major importance in predicting the impact of global climate change on herbivores.
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10
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Dao CK, Nowinski SM, Mills EM. The heat is on: Molecular mechanisms of drug-induced hyperthermia. Temperature (Austin) 2014; 1:183-91. [PMID: 27626045 PMCID: PMC5008714 DOI: 10.4161/23328940.2014.985953] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 11/05/2014] [Accepted: 11/06/2014] [Indexed: 01/01/2023] Open
Abstract
Thermoregulation is an essential homeostatic process in which critical mechanisms of heat production and dissipation are controlled centrally in large part by the hypothalamus and peripherally by activation of the sympathetic nervous system. Drugs that disrupt the components of this highly orchestrated multi-organ process can lead to life-threatening hyperthermia. In most cases, hyperthermic agents raise body temperature by increasing the central and peripheral release of thermoregulatory neurotransmitters that ultimately lead to heat production in thermogenic effector organs skeletal muscle (SKM) and brown adipose tissue (BAT). In many cases hyperthermic drugs also decrease heat dissipation through peripheral changes in blood flow. Drug-induced heat production is driven by the stimulation of mechanisms that normally regulate the adaptive thermogenic responses including both shivering and non-shivering thermogenesis (NST) mechanisms. Modulation of the mitochondrial electrochemical proton/pH gradient by uncoupling protein 1 (UCP1) in BAT is the most well characterized mechanism of NST in response to cold, and may contribute to thermogenesis induced by sympathomimetic agents, but this is far from established. However, the UCP1 homologue, UCP3, and the ryanodine receptor (RYR1) are established mediators of toxicant-induced hyperthermia in SKM. Defining the molecular mechanisms that orchestrate drug-induced hyperthermia will be essential in developing treatment modalities for thermogenic illnesses. This review will briefly summarize mechanisms of thermoregulation and provide a survey of pharmacologic agents that can lead to hyperthermia. We will also provide an overview of the established and candidate molecular mechanisms that regulate the actual thermogenic processes in heat effector organs BAT and SKM.
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Affiliation(s)
- Christine K Dao
- Division of Pharmacology and Toxicology; College of Pharmacy; The University of Texas at Austin ; Austin, TX USA
| | - Sara M Nowinski
- Department of Biochemistry; University of Utah School of Medicine ; Salt Lake City, UT USA
| | - Edward M Mills
- Division of Pharmacology and Toxicology; College of Pharmacy; The University of Texas at Austin ; Austin, TX USA
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11
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Methamphetamine-induced toxicity: an updated review on issues related to hyperthermia. Pharmacol Ther 2014; 144:28-40. [PMID: 24836729 DOI: 10.1016/j.pharmthera.2014.05.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/07/2014] [Indexed: 01/30/2023]
Abstract
Reports of methamphetamine-related emergency room visits suggest that elevated body temperature is a universal presenting symptom, with lethal overdoses generally associated with extreme hyperthermia. This review summarizes the available information on methamphetamine toxicity as it pertains to elevations in body temperature. First, a brief overview of thermoregulatory mechanisms is presented. Next, central and peripheral targets that have been considered for potential involvement in methamphetamine hyperthermia are discussed. Finally, future areas of investigation are proposed, as further studies are needed to provide greater insight into the mechanisms that mediate the alterations in body temperature elicited by methamphetamine.
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12
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Musselman ME, Hampton JP. "Not for human consumption": a review of emerging designer drugs. Pharmacotherapy 2014; 34:745-57. [PMID: 24710806 DOI: 10.1002/phar.1424] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Synthetic, or "designer" drugs, are created by manipulating the chemical structures of other psychoactive drugs so that the resulting product is structurally similar but not identical to illegal psychoactive drugs. Originally developed in the 1960s as a way to evade existing drug laws, the use of designer drugs has increased dramatically over the past few years. These drugs are deceptively packaged as "research chemicals," "incense," "bath salts," or "plant food," among other names, with labels that may contain warnings such as "not for human consumption" or "not for sale to minors." The clinical effects of most new designer drugs can be described as either hallucinogenic, stimulant, or opioid-like. They may also have a combination of these effects due to designer side-chain substitutions. The easy accessibility and rapid emergence of new designer drugs have created challenges for health care providers when treating patients presenting with acute toxicity from these substances, many of which can produce significant and/or life-threatening adverse effects. Moreover, the health care provider has no way to verify the contents and/or potency of the agent ingested because it can vary between packages and distributors. Therefore, a thorough knowledge of the available designer drugs, common signs and symptoms of toxicity associated with these agents, and potential effective treatment modalities are essential to appropriately manage these patients.
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Affiliation(s)
- Megan E Musselman
- Emergency Medicine/Critical Care, North Kansas City Hospital, Kansas City, Missouri
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13
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Haberzettl R, Bert B, Fink H, Fox MA. Animal models of the serotonin syndrome: a systematic review. Behav Brain Res 2013; 256:328-45. [PMID: 24004848 DOI: 10.1016/j.bbr.2013.08.045] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/26/2013] [Accepted: 08/28/2013] [Indexed: 11/16/2022]
Abstract
The serotonin syndrome (SS) is a potentially life-threatening disorder in humans which is induced by ingestion of an overdose or by combination of two or more serotonin (5-HT)-enhancing drugs. In animals, acute administration of direct and indirect 5-HT agonists also leads to a set of behavioral and autonomic responses. In the current review, we provide an overview of the existing versions of the animal model of the SS. With a focus on studies in rats and mice, we analyze the frequency of behavioral and autonomic responses following administration of 5-HT-enhancing drugs and direct 5-HT agonists administered alone or in combination, and we briefly discuss the receptor mediation of these responses. Considering species differences, we identify a distinct set of behavioral and autonomic responses that are consistently observed following administration of direct and indirect 5-HT agonists. Finally, we discuss the importance of a standardized assessment of SS responses in rodents and the utility of animal models of the SS in translational studies, and provide suggestions for future research.
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Affiliation(s)
- Robert Haberzettl
- Institute of Pharmacology and Toxicology, School of Veterinary Medicine, Freie Universität Berlin, Koserstrasse 20, 14195 Berlin, Germany
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14
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Abstract
The drug with perhaps the greatest impact on the practice of Psychiatry is Methamphetamine. By increasing the extracellular concentrations of dopamine while slowly damaging the dopaminergic neurotransmission, Meth is a powerfully addictive drug whose chronic use preferentially causes psychiatric complications. Chronic Meth users have deficits in memory and executive functioning as well as higher rates of anxiety, depression, and most notably psychosis. It is because of addiction and chronic psychosis from Meth abuse that the Meth user is most likely to come to the attention of the practicing Psychiatrist/Psychologist. Understanding the chronic neurologic manifestations of Meth abuse will better arm practitioners with the diagnostic and therapeutic tools needed to make the Meth epidemic one of historical interest only.
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15
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Abstract
The critical care physician is often called to care for poisoned patients. This article reviews the general approach to the poisoned patient, specifically focusing on the utility of the toxidrome. A toxidrome is a constellation of findings, either from the physical examination or from ancillary testing, which may result from any poison. There are numerous toxidromes defined in the medical literature. This article focuses on the more common toxidromes described in clinical toxicology. Although these toxidromes can aid the clinician in narrowing the differential diagnosis, care must be exercised to realize the exceptions and limitations associated with each.
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Affiliation(s)
- Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, Blue Ridge Poison Center, University of Virginia Health System, University of Virginia School of Medicine, PO Box 800774, Charlottesville, VA 22908-0774, USA.
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16
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Jafferany M, Lowry J. Case report of olanzapine-associated elevation of serum creatine kinase in a 16-year-old boy with heat stroke. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 10:250-2. [PMID: 18615174 DOI: 10.4088/pcc.v10n0312c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Rusyniak DE, Zaretsky DV, Zaretskaia MV, Durant PJ, DiMicco JA. The orexin-1 receptor antagonist SB-334867 decreases sympathetic responses to a moderate dose of methamphetamine and stress. Physiol Behav 2012; 107:743-50. [PMID: 22361264 DOI: 10.1016/j.physbeh.2012.02.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/01/2012] [Accepted: 02/07/2012] [Indexed: 11/29/2022]
Abstract
We recently discovered that inhibiting neurons in the dorsomedial hypothalamus (DMH) attenuated hyperthermia, tachycardia, hypertension, and hyperactivity evoked by the substituted amphetamine 3, 4-methylenedioxymethamphetamine (MDMA). Neurons that synthesize orexin are also found in the region of the DMH. As orexin and its receptors are involved in the regulation of heart rate and temperature, they would seem to be logical candidates as mediators of the effects evoked by amphetamines. The goal of this study was to determine if blockade of orexin-1 receptors in conscious rats would suppress cardiovascular and thermogenic responses evoked by a range of methamphetamine (METH) doses. Male Sprague-Dawley rats (n=6 per group) were implanted with telemetric transmitters measuring body temperature, heart rate, and mean arterial pressure. Animals were randomized to receive pretreatment with either the orexin-1 receptor antagonist SB-334867 (10mg/kg) or an equal volume of vehicle. Thirty minutes later animals were given intraperitoneal (i.p.) injections of either saline, a low (1mg/kg), moderate (5mg/kg) or high (10mg/kg) dose of METH. Pretreatment with SB-334867 significantly attenuated increases in body temperature and mean arterial pressure evoked by the moderate but not the low or high dose of METH. Furthermore, animals treated with SB-334867, compared to vehicle, had lower temperature and heart rate increases after the stress of an i.p. injection. In conclusion, temperature and cardiovascular responses to a moderate dose of METH and to stress appear to involve orexin-1 receptors. The failure to affect a low and a high dose of METH suggests a complex pharmacology dependent on dose. A better understanding of this may lead to the knowledge of how monoamines influence the orexin system and vice versa.
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Affiliation(s)
- Daniel E Rusyniak
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States.
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Abstract
Methamphetamine abuse has reached epidemic proportions in the United States. The repetitive use of methamphetamine causes massive and sustained elevations in central monoamines. These elevations, particularly in dopamine, can cause changes in the function of the central nervous system that can manifest as a variety of neurologic disorders. This article focuses on these disorders, such as neurocognitive disorders and mental illness, including drug-induced psychosis; motor disorders, including the possible risk of Parkinson's disease, the development of choreoathetoid movements, and punding; and changes in the physical appearance of the methamphetamine users, including dental caries.
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Affiliation(s)
- Daniel E Rusyniak
- Department of Emergency Medicine, Indiana University School of Medicine, 1050 Wishard Boulevard, Room 2200, Indianapolis, IN 46202, USA.
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Schep LJ, Slaughter RJ, Vale JA, Beasley DMG, Gee P. The clinical toxicology of the designer "party pills" benzylpiperazine and trifluoromethylphenylpiperazine. Clin Toxicol (Phila) 2011; 49:131-41. [PMID: 21495881 DOI: 10.3109/15563650.2011.572076] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP) are synthetic phenylpiperazine analogues. BZP was investigated as a potential antidepressant in the early 1970s but was found unsuitable for this purpose. More recently, BZP and TFMPP have been used as substitutes for amfetamine-derived designer drugs. They were legally available in a number of countries, particularly in New Zealand, and were marketed as party pills, but are now more heavily regulated. This article will review the mechanisms of toxicity, toxicokinetics, clinical features, diagnosis, and management of poisoning due to BZP and TFMPP. METHODS OVID MEDLINE and ISI Web of Science were searched systematically for studies on BZP and TFMPP and the bibliographies of identified articles were screened for additional relevant studies including nonindexed reports. Nonpeer-reviewed sources were also accessed. In all, 179 papers excluding duplicates were identified and 74 were considered relevant. MECHANISMS OF ACTION BZP and TFMPP have stimulant and amfetamine-like properties. They enhance the release of catecholamines, particularly of dopamine, from sympathetic nerve terminals, increasing intra-synaptic concentrations. The resulting elevated intra-synaptic monoamine concentrations cause increased activation of both central and peripheral α- and β-adrenergic postsynaptic receptors. BZP has primarily dopaminergic and noradrenergic action while TFMPP has a more direct serotonin agonist activity. TOXICOKINETICS There is limited information on the kinetics of these drugs. Following ingestion, peak plasma concentrations are reached after 60 to 90 min. Both drugs would be expected to cross the blood brain barrier and they are metabolized mainly by hydroxylation and N-dealkylation catalyzed by cytochrome P450 and catechol-o-methyl transferase enzymes. In humans, only small amounts of both BZP and TFMPP are excreted in the urine, suggesting a low bioavailability. The serum half-lives of BZP and TFMPP are relatively short with elimination being essentially complete in 44 h for BZP and 24 h for TFMPP. CLINICAL FEATURES These compounds can cause harmful effects when taken recreationally. Commonly reported features include palpitations, agitation, anxiety, confusion, dizziness, headache, tremor, mydriasis, insomnia, urine retention, and vomiting. Seizures are induced in some patients even at low doses. Severe multiorgan toxicity has been reported, though fatalities have not been recorded conclusively. MANAGEMENT Supportive care including the termination of seizures is paramount, with relief of symptoms usually being provided by benzodiazepines alone. CONCLUSIONS BZP and TFMP can cause sympathomimetic effects in the intoxicated patient. Appropriate, symptom-directed supportive care should ensure a good recovery.
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Affiliation(s)
- Leo J Schep
- Department of Preventive and Social Medicine, National Poisons Centre, University of Otago, Dunedin, New Zealand.
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Cusack L, de Crespigny C, Athanasos P. Heatwaves and their impact on people with alcohol, drug and mental health conditions: a discussion paper on clinical practice considerations. J Adv Nurs 2011; 67:915-22. [PMID: 21214621 DOI: 10.1111/j.1365-2648.2010.05551.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM This article discusses the clinical implications of adverse health outcomes derived during heatwaves for people with mental health disorders, substance misuse and those taking prescribed medications such as lithium, various neuroleptic and anticholinergic drugs. BACKGROUND With climate change it is predicted that the incidence of prolonged periods of extreme heat will increase. Specific adverse health outcomes associated with high environmental temperatures include heat stroke and heat exhaustion. Those at increased risk for heat-related mortality are those with chronic health conditions, including those with mental health disorders and substance misuse. DATA SOURCES Sources of evidence included and 'grey' literature published between 1985 and 2010, such as key texts, empirical research, public policies, training manuals and community information sheets on heat waves. DISCUSSION Current clinical practice and clinical impact of heatwaves on those people with comorbidity is explored. This includes the physiological components of heat stress, heat regulation, and the impact of alcohol and other drugs; and, ramifications and professional practice issues for those with mental health conditions and those requiring mental health medications. IMPLICATIONS FOR NURSING Client education covering modification of the environment and the use of client heat safety action plans. Secure, accessible stores of prescribed medication are recommended and emergency substance withdrawal kits could be made available. CONCLUSION All nurses have a responsibility to increase the capability and resilience of their clients to manage their chronic health needs during a heatwave. At these times nurses need to give extra monitoring and assistance when clients lack the capacity or resources to protect themselves.
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Affiliation(s)
- Lynette Cusack
- School of Nursing and Midwifery, Faculty of Health Science, Flinders University, Adelaide, South Australia, Australia.
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Abstract
Heatstroke is the most severe form of heat-related disorders that include mild heat intolerance, heat exhaustion and heat stress. The incidence of heat-related disorders is increasing due to several factors that include climate change, co-morbidities and drug usage. Patients with heatstroke present with a core body temperature above 40°C, multiorgan dysfunction and central nervous system disorder. The pathogenesis of heatstroke is not fully understood; however, heat-shock proteins, inflammatory cytokines and their modulators have been implicated. The clinical biochemistry laboratory plays an important role in the management of patients with heatstroke. Biochemical findings in patients with heatstroke include elevated urea, creatinine, cardiac and skeletal muscle enzymes, myoglobin and troponin. There is also biochemical evidence of metabolic acidosis, respiratory alkalosis, hepatic injury with elevated enzyme levels as well as abnormal hematological and coagulation indices. This review article aims at increasing awareness of the biochemical changes seen in patients with heatstroke and their possible role in prognosis and in elucidating the pathogenesis of heatstroke.
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Affiliation(s)
- Ibrahim A Hashim
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9073, USA
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Choi JT, Kang GH, Jang YS, Ahn HC, Seo JY, Sohn YD. Fatality from acute chlorfenapyr poisoning. Clin Toxicol (Phila) 2010; 48:458-9. [DOI: 10.3109/15563651003750074] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Boyle JS, Bechtel LK, Holstege CP. Management of the critically poisoned patient. Scand J Trauma Resusc Emerg Med 2009; 17:29. [PMID: 19563673 PMCID: PMC2720377 DOI: 10.1186/1757-7241-17-29] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Accepted: 06/29/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinicians are often challenged to manage critically ill poison patients. The clinical effects encountered in poisoned patients are dependent on numerous variables, such as the dose, the length of exposure time, and the pre-existing health of the patient. The goal of this article is to introduce the basic concepts for evaluation of poisoned patients and review the appropriate management of such patients based on the currently available literature. METHODS An unsystematic review of the medical literature was performed and articles pertaining to human poisoning were obtained. The literature selected was based on the preference and clinical expertise of authors. DISCUSSION If a poisoning is recognized early and appropriate testing and supportive care is initiated rapidly, the majority of patient outcomes will be good. Judicious use of antidotes should be practiced and clinicians should clearly understand the indications and contraindications of antidotes prior to administration.
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Affiliation(s)
- Jennifer S Boyle
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia, USA.
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A rare case of neuroleptic malignant syndrome presenting with serious hyperthermia treated with a non-invasive cooling device: a case report. J Med Case Rep 2009; 3:6170. [PMID: 19830098 PMCID: PMC2726532 DOI: 10.4076/1752-1947-3-6170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Accepted: 11/18/2008] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION A rare side effect of antipsychotic medication is neuroleptic malignant syndrome, mainly characterized by hyperthermia, altered mental state, haemodynamic dysregulation, elevated serum creatine kinase and rigor. There may be multi-organ dysfunction including renal and hepatic failure as well as serious rhabdomyolysis, acute respiratory distress syndrome and disseminated intravascular coagulation. The prevalence of neuroleptic malignant syndrome is between 0.02% and 2.44% for patients taking neuroleptics and it is not necessary to fulfil all cardinal features characterizing the syndrome to be diagnosed with neuroleptic malignant syndrome. Because of other different life-threatening diseases matching the various clinical findings, the correct diagnosis can sometimes be hard to make. A special problem of intensive care treatment is the management of severe hyperthermia. Lowering of body temperature, however, may be a major clinical problem because hyperthermia in neuroleptic malignant syndrome is typically unresponsive to antipyretic agents while manual cooling proves difficult due to peripheral vasoconstriction. CASE PRESENTATION A 22-year-old Caucasian man was admitted unconscious with a body temperature of 42 degrees C, elevated serum creatine phosphokinase, tachycardia and hypotonic blood pressure. In addition to intensive care standard therapy for coma and shock, a non-invasive cooling device (Arctic Sun 2000((R)), Medivance Inc., USA), originally designed to induce mild therapeutic hypothermia in patients after cardiopulmonary resuscitation, was used to lower body temperature. After successful treatment it became possible to obtain information from the patient about his recent ambulant treatment with Olanzapin (Zyprexa(R)) for schizophrenia. CONCLUSION Numerous case reports have been published about patients who developed neuroleptic malignant syndrome due to Olanzapin (Zyprexa(R)) medication. Frequently hyperthermia has been observed in these cases with varying outcomes. In our case the only residual impairment for the patient is dysarthria with corresponding symmetric cerebellar pyramidal cell destruction demonstrated by increased signal intensity in T2-weighted magnetic resonance imaging, most likely caused by the excessive hyperthermia.
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Eyer F, Zilker T. Bench-to-bedside review: mechanisms and management of hyperthermia due to toxicity. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:236. [PMID: 18096088 PMCID: PMC2246210 DOI: 10.1186/cc6177] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Body temperature can be severely disturbed by drugs capable of altering the balance between heat production and dissipation. If not treated aggressively, these events may become rapidly fatal. Several toxins can induce such non-infection-based temperature disturbances through different underlying mechanisms. The drugs involved in the eruption of these syndromes include sympathomimetics and monoamine oxidase inhibitors, antidopaminergic agents, anticholinergic compounds, serotonergic agents, medicaments with the capability of uncoupling oxidative phosphorylation, inhalation anesthetics, and unspecific agents causing drug fever. Besides centrally disturbed regulation disorders, hyperthermia often results as a consequence of intense skeletal muscle hypermetabolic reaction. This leads mostly to rapidly evolving muscle rigidity, extensive rhabdomyolysis, electrolyte disorders, and renal failure and may be fatal. The goal of treatment is to reduce body core temperature with both symptomatic supportive care, including active cooling, and specific treatment options.
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Affiliation(s)
- Florian Eyer
- Department of Clinical Toxicology, II Medizinische Klinik, Klinikum rechts der Isar, Technical University, D-81675 Munich, Germany.
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Perspectives on genetic animal models of serotonin toxicity. Neurochem Int 2008; 52:649-58. [DOI: 10.1016/j.neuint.2007.08.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 08/23/2007] [Accepted: 08/29/2007] [Indexed: 12/28/2022]
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Blessing WW, Zilm A, Ootsuka Y. Clozapine reverses increased brown adipose tissue thermogenesis induced by 3,4-methylenedioxymethamphetamine and by cold exposure in conscious rats. Neuroscience 2006; 141:2067-73. [PMID: 16814930 DOI: 10.1016/j.neuroscience.2006.05.050] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2006] [Revised: 05/19/2006] [Accepted: 05/22/2006] [Indexed: 11/16/2022]
Abstract
Clozapine, an atypical antipsychotic agent important for the treatment of schizophrenia, has marked inhibitory effects on sympathetic outflow to the thermoregulatory cutaneous circulation. In rabbits clozapine reverses ear pinna vasoconstriction induced either by administration of MDMA (3,4-methylenedioxymethamphetamine, ecstasy) or by exposing the animal to a cold environment. In rats, both these procedures are known to increase sympathetic activation of interscapular brown adipose tissue (iBAT) thermogenesis, important for heat production in the rat. In the present study in conscious rats we determined whether clozapine reduces iBAT thermogenesis induced by MDMA and by exposure to cold. We designed our study so that we could also determine effects of clozapine on the acute (stress-induced) increases in iBAT thermogenesis initiated by the process of s.c. injection. MDMA increased iBAT temperature (+1.7+/-0.2 degrees C after 90 min, P<0.01, n=14 measurements from seven rats each studied on two occasions). Clozapine acutely reversed the MDMA-elicited increase in iBAT temperature (-1.3+/-0.2 degrees C 60 min after clozapine treatment following MDMA versus +0.3+/-0.2 degrees C for 60 min after vehicle treatment following MDMA, P<0.01, n=7). Clozapine also reduced stress-induced increases in iBAT temperature, as well as increases elicited by exposing rats to a cold (5 degrees C) environment. Results, taken together with our previous findings, suggest that MDMA activates the sympathetic thermoregulatory outputs (including the output to iBAT) that defend body temperature against cold exposure and that increase body temperature in response to environmental stress. Clozapine's marked inhibition of iBAT thermogenesis may provide a clue to its marked tendency to cause obesity when used to treat humans with mental disorders including schizophrenia. Our demonstration in rats that clozapine decreases sympathetically-mediated increases in iBAT temperature elicited by MDMA adds to the likelihood that clozapine and clozapine-like agents might be therapeutically effective in life threatening hyperthermia induced by MDMA in humans.
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Affiliation(s)
- W W Blessing
- Departments of Human Physiology and Medicine, Centre for Neuroscience, School of Medicine, Flinders University, Flinders Medical Centre, Bedford Park, South Australia 5042, Australia.
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