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Cameron-Burr KT, Bola RA, Kiyatkin EA. Dantrolene sodium fails to reverse robust brain hyperthermia induced by MDMA and methamphetamine in rats. Psychopharmacology (Berl) 2023; 240:785-795. [PMID: 36700960 DOI: 10.1007/s00213-023-06321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/19/2023] [Indexed: 01/27/2023]
Abstract
RATIONALE Hyperthermia induced by psychomotor stimulants may cause leakage of the blood-brain barrier, vasogenic edema, and lethality in extreme cases. Current treatments such as whole-body cooling are only symptomatic and a clear need to develop pharmacological interventions exists. Dantrolene sodium, a peripheral muscle relaxant used in the treatment of malignant hyperthermia, has been proposed as potentially effective to treat MDMA-hyperthermia in emergency rooms. However, debate around its efficacy for this indication persists. OBJECTIVES To investigate dantrolene as a treatment for illicit hyperthermia induced by psychomotor stimulant drugs, we examined how Ryanodex®, a concentrated formulation of dantrolene sodium produced by Eagle Pharmaceuticals, influences 3,4-methylenedioxymethamphetamine (MDMA)- and methamphetamine (METH)-induced hyperthermia in awake freely moving rats. We injected rats with moderate doses of MDMA (9 mg/kg) and METH (9 mg/kg) and administered Ryanodex® intravenously (6 mg/kg) after the development of robust hyperthermia (>2.5 °C) mimicking clinical acute intoxication. We conducted simultaneous temperature recordings in the brain, temporal muscle, and skin to determine the basic mechanisms underlying temperature responses. To assess the efficacy of dantrolene in attenuating severe hyperthermia, we administered MDMA to rats maintained in a warm ambient environment (29 °C), conditions which produce robust brain and body hyperthermia (>40 °C) and lethality. RESULTS Dantrolene failed to attenuate MDMA- and METH-induced hyperthermia, though locomotor activity was significantly reduced. All animals maintained at warm ambient temperatures that received dantrolene during severe drug-induced hyperthermia died within or soon after the recording session. CONCLUSIONS Our results suggest that dantrolene sodium formulations are not mechanistically suited to treat MDMA- and METH-induced hyperthermia.
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Affiliation(s)
- Keaton T Cameron-Burr
- Behavioral Neuroscience Branch, National Institute on Drug Abuse - Intramural Research Program, National Institutes of Health, DHHS, 251 Bayview Blvd, Baltimore, MD, 21224, USA
| | - R Aaron Bola
- Behavioral Neuroscience Branch, National Institute on Drug Abuse - Intramural Research Program, National Institutes of Health, DHHS, 251 Bayview Blvd, Baltimore, MD, 21224, USA
| | - Eugene A Kiyatkin
- Behavioral Neuroscience Branch, National Institute on Drug Abuse - Intramural Research Program, National Institutes of Health, DHHS, 251 Bayview Blvd, Baltimore, MD, 21224, USA.
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Dantrolene Administration in the Management of the Prehospital Patient with Methylenedioxymethamphetamine Overdose: A Case Series and Literature Review. Case Rep Crit Care 2022; 2022:5346792. [PMID: 36065452 PMCID: PMC9440799 DOI: 10.1155/2022/5346792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 08/10/2022] [Indexed: 11/20/2022] Open
Abstract
Methylenedioxymethamphetamine (MDMA) is a psychoactive substance that is used commonly as a recreational drug at rave music festivals. MDMA intoxication can cause a myriad of symptoms and side effects including the manifestation of hyperpyrexia in patients. Hyperpyrexia can mimic a heat stroke and ultimately lead to various forms of end-organ damage. The most common methods used in treating MDMA-induced hyperpyrexia focus on the rapid reduction of core body temperature. Various off-label medications have also been used in combating MDMA-induced hyperpyrexia. Dantrolene is one such medication, although its role in the treatment of MDMA intoxication remains uncertain. This case series preliminarily examines the efficacy of dantrolene in mitigating MDMA-induced hyperpyrexia and potentially reducing the risk of end-organ damage in patients suffering from MDMA overdose. This study focuses on nine patients who presented after ingesting various forms of MDMA at “rave” music events. All patients were found to be hyperthermic in the field with a maximum core body temperature of 109 degrees Fahrenheit. All patients were immediately managed by cooling measures, and seven patients additionally received dantrolene in the field before being transferred to Arrowhead Regional Medical Center. Upon arrival to the hospital, nearly every patient was found to have significantly decreased body temperatures when compared to previously measured body temperatures out in the field. However, nearly all patients in the study were also noted to have laboratory abnormalities consistent with various forms of end-organ damage. The degree and severity of end-organ damage observed in MDMA-induced hyperpyrexia seem to be a function of initial core body temperature. Higher core body temperature tends to correlate with more forms of end-organ damage and a higher severity of end-organ damage. Intervention with dantrolene and cooling measures appeared to have no effect on reducing the risk of developing end-organ damage in this patient population.
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Capela JP, Carmo H, Remião F, Bastos ML, Meisel A, Carvalho F. Molecular and Cellular Mechanisms of Ecstasy-Induced Neurotoxicity: An Overview. Mol Neurobiol 2009; 39:210-71. [DOI: 10.1007/s12035-009-8064-1] [Citation(s) in RCA: 210] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 02/27/2009] [Indexed: 11/29/2022]
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Nisijima K, Shioda K, Iwamura T. Neuroleptic malignant syndrome and serotonin syndrome. PROGRESS IN BRAIN RESEARCH 2007; 162:81-104. [PMID: 17645916 DOI: 10.1016/s0079-6123(06)62006-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This chapter is focused on drug-induced hyperthermia with special regard to use of antipsychotics and antidepressants for the treatment of schizophrenia and major depression, respectively. Neuroleptic malignant syndrome (NMS) develops during the use of neuroleptics, whereas serotonin syndrome is caused mainly by serotoninergic antidepressants. Although both syndromes show various symptoms, hyperthermia is the main clinical manifestation. In this review we describe the historical background, clinical manifestations, diagnosis, and differential diagnosis of these two syndromes based on our observations on the experimental and clinical data.
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Affiliation(s)
- Koichi Nisijima
- Department of Psychiatry, Jichi Medical University, Minamikawachi-Machi, Kawachi-Gun, Tochigi-Ken 329-0498, Japan.
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Hall AP, Henry JA. Acute toxic effects of ‘Ecstasy’ (MDMA) and related compounds: overview of pathophysiology and clinical management. Br J Anaesth 2006; 96:678-85. [PMID: 16595612 DOI: 10.1093/bja/ael078] [Citation(s) in RCA: 199] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Since the late 1980s 'Ecstasy' (3,4-methylenedioxymethamphetamine, MDMA) has become established as a popular recreational drug in western Europe. The UK National Criminal Intelligence Service estimates that 0.5-2 million tablets are consumed weekly in Britain. It has been reported that 4.5% of young adults (15-34 yr) in the UK have used MDMA in the previous 12 months. Clinically important toxic effects have been reported, including fatalities. While the phenomenon of hyperpyrexia and multi-organ failure is now relatively well known, other serious effects have become apparent more recently. Patients with acute MDMA toxicity may present to doctors working in Anaesthesia, Intensive Care and Emergency Medicine. A broad knowledge of these pathologies and their treatment is necessary for anyone working in an acute medical speciality. An overview of MDMA pharmacology and acute toxicity will be given followed by a plan for clinical management.
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Affiliation(s)
- A P Hall
- Department of Anaesthesia and Intensive Care Medicine, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
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Sprague JE, Brutcher RE, Mills EM, Caden D, Rusyniak DE. Attenuation of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy)-induced rhabdomyolysis with alpha1- plus beta3-adrenoreceptor antagonists. Br J Pharmacol 2004; 142:667-70. [PMID: 15159279 PMCID: PMC1575043 DOI: 10.1038/sj.bjp.0705823] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
1. Studies were designed to examine the effects of alpha(1) (alpha(1)AR)- plus beta(3)-adrenoreceptor (beta(3)AR) antagonists on 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy)-induced hyperthermia and measures of rhabdomyolysis (creatine kinase (CK)) and renal function (blood urea nitrogen (BUN) and serum creatinine (sCr)) in male Sprague-Dawley rats. 2. MDMA (40 mg x kg(-1), s.c.) induced a rapid and robust increase in rectal temperature, which was significantly attenuated by pretreatment with the alpha(1)AR antagonist prazosin (100 microg x kg(-1), i.p.) plus the beta(3)AR antagonist SR59230A (5 mg x kg(-1), i.p.). 3. CK levels significantly increased (peaking at 4 h) after MDMA treatment and were blocked by the combination of prazosin plus SR59230A. 4. At 4 h after MDMA treatment, BUN and sCr levels were also significantly increased and could be prevented by this combination of alpha(1)AR- plus beta(3)AR-antagonists. 5. The results from this study suggest that alpha(1)AR and beta(3)AR play a critical role in the etiology of MDMA-mediated hyperthermia and subsequent rhabdomyolysis.
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MESH Headings
- Adrenergic alpha-1 Receptor Antagonists
- Adrenergic beta-3 Receptor Antagonists
- Animals
- Blood Urea Nitrogen
- Body Temperature/drug effects
- Body Temperature/physiology
- Creatine Kinase/antagonists & inhibitors
- Creatine Kinase/blood
- Drug Administration Schedule
- Drug Therapy, Combination
- Fever/chemically induced
- Fever/physiopathology
- Injections, Intraperitoneal
- Injections, Subcutaneous
- Male
- N-Methyl-3,4-methylenedioxyamphetamine/administration & dosage
- N-Methyl-3,4-methylenedioxyamphetamine/adverse effects
- N-Methyl-3,4-methylenedioxyamphetamine/antagonists & inhibitors
- Prazosin/administration & dosage
- Prazosin/blood
- Prazosin/pharmacokinetics
- Propanolamines/administration & dosage
- Propanolamines/blood
- Propanolamines/pharmacokinetics
- Rats
- Rats, Sprague-Dawley
- Receptors, Adrenergic, alpha-1/administration & dosage
- Receptors, Adrenergic, alpha-1/therapeutic use
- Receptors, Adrenergic, beta-3/administration & dosage
- Receptors, Adrenergic, beta-3/therapeutic use
- Rhabdomyolysis/chemically induced
- Rhabdomyolysis/prevention & control
- Time Factors
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Affiliation(s)
- Jon E Sprague
- The Department of Pharmaceutical and Biomedical Sciences, The Raabe College of Pharmacy, Ohio Northern University, Ada, OH 45810, USA.
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Ben-Abraham R, Szold O, Rudick V, Weinbroum AA. ???Ecstasy??? intoxication: life-threatening manifestations and resuscitative measures in the intensive care setting. Eur J Emerg Med 2003; 10:309-13. [PMID: 14676510 DOI: 10.1097/00063110-200312000-00013] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The ingestion of 3,4-methylenedioxymethamphetamine ('ecstasy') can cause severe neurological impairment and multi-system damage. We describe the potentially life-threatening clinical features and the management of intoxication by this psychedelic drug in patients transferred from emergency services to the intensive care area. METHODS We conducted a retrospective analysis of 'ecstasy'-intoxicated patients admitted to a municipal hospital during a three-month period. RESULTS Of the 32 patients brought to the emergency services, three (9.3%; mean age 21+/-2 years) were transferred to the intensive care area in a comatose state associated with seizures after ingesting one to three tablets of 150 mg 3,4-methylenedioxymethamphetamine. All required artificial ventilation and none responded to painful stimuli. The brain computed tomography scan and lumbar puncture results were normal. The main clinical manifestations were hyponatremia, high fever, rhabdomyolysis, dehydration and metabolic acidosis accompanied by impaired liver and renal functions. All three patients regained consciousness after 2.1+/-0.8 days of system-oriented supportive care and were discharged for further surveillance in medical wards after 4.3+/-2.1 days. CONCLUSION The increase in life-threatening episodes of 3,4-methylenedioxymethamphetamine intoxication that mandate admission, treatment and close surveillance in an intensive care milieu make it incumbent to establish appropriate management protocols for minimizing immediate mortality and late morbidity.
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Affiliation(s)
- Ron Ben-Abraham
- Department of Anesthesiology and Critical Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Caldicott DGE, Edwards NA, Kruys A, Kirkbride KP, Sims DN, Byard RW, Prior M, Irvine RJ. Dancing with "death": p-methoxyamphetamine overdose and its acute management. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2003; 41:143-54. [PMID: 12733852 DOI: 10.1081/clt-120019130] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Para-methoxyamphetamine (PMA) is a substituted synthetic amphetamine used in the recreational drug scene. It is unusual because of the high incidence of significant morbidity and mortality in overdose. We report a case of PMA overdose in South Australia, and review our experience with the drug. We review the literature on PMA overdose and offer suggestions on the management of overdose with this dangerous drug.
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Affiliation(s)
- David G E Caldicott
- Emergency Department, Royal Adelaide Hospital, North Terrace, Adelaide, Australia.
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Abstract
Ecstasy is the second most widely abused illegal drug in Europe. Ecstasy is the colloquial name for 3,4-methylenedioxymethamphetamine (MDMA), but not all Ecstasy tablets contain MDMA. When taken in hot, crowded environments, Ecstasy/MDMA users have developed acute complications that have had fatal consequences. Epidemiological evidence indicates that adverse reactions to Ecstasy/MDMA intoxication are rare and idiosyncratic. Potential mechanisms of action are reviewed. In animal studies, MDMA damages serotonergic fibres and reduces the number of serotonin transporter sites within the CNS. Demonstration of neurotoxicity in human users of Ecstasy is hampered by a number of confounds that the majority of published studies have failed to address. These confounds are reviewed and their impact is discussed.
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Affiliation(s)
- J C Cole
- Psychology Department, Liverpool University, Liverpool L69 7ZA, UK.
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Abstract
"Club drugs" have become alarmingly popular. The use of 3,4-methylenedioxymethamphetamine (MDMA, Ecstasy) and gamma-hydroxybutyrate (GHB), in particular, has increased dramatically from 1997-1999. The pharmacokinetics of MDMA and GHB appear to be nonlinear, making it difficult to estimate a dose-response relationship. The drug MDMA is an amphetamine analog with sympathomimetic properties, whereas GHB is a gamma-aminobutyric acid analog with sedative properties. Symptoms of an MDMA toxic reaction include tachycardia, sweating, and hyperthermia. Occasional severe sequelae include disseminated intravascular coagulation, rhabdomyolysis, and acute renal failure. Treatment includes lowering the body temperature and maintaining adequate hydration. Symptoms of GHB intoxication include coma, respiratory depression, unusual movements, confusion, amnesia, and vomiting. Treatment includes cardiac and respiratory support. Because of the popularity of these agents and their potentially dangerous effects, health care professionals must be familiar with these substances and the treatment options for patients who present with symptoms of a toxic reaction.
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Affiliation(s)
- C J Teter
- College of Pharmacy, University of Michigan, Ann Arbor 48109-1065, USA.
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Affiliation(s)
- R J Hadfield
- Intensive Care Unit, Liverpool Hospital, University of New South Wales, Locked bag 7103, Liverpool BC, NSW 1871, Sydney, Australia
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Abstract
Serotonin syndrome is characterized by varied degrees of cognitive, autonomic, and neuromuscular dysfunction and can only be produced by drug therapy that increases central nervous system serotonin neurotransmission. Information gained from a retrospective review of 127 cases of serotonin syndrome is presented. It is not uncommon for severe cases of serotonin syndrome to be confused with neuroleptic malignant syndrome. Treatment is mainly supportive, but specific pharmacologic therapy with serotonin antagonists may be potentially beneficial.
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Affiliation(s)
- K C Mills
- Department of Emergency Medicine and Medical Toxicology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Dar KJ, McBrien ME. MDMA induced hyperthermia: report of a fatality and review of current therapy. Intensive Care Med 1996; 22:995-6. [PMID: 8905441 DOI: 10.1007/bf02044131] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Ingestion of 3,4-methylene dioxymethamphetamine (MDMA), commonly known as "Ecstasy", can produce toxicity that is characterised by hyperthermia, coagulopathy, rhabdomyolysis and renal failure. We report a fatality associated with MDMA ingestion and briefly review the current literature on MDMA-induced hyperthermia.
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Affiliation(s)
- K J Dar
- New York Hospital-Cornell Medical Center, 1520 East 70th Street, Starr 505, New York, NY 10021, USA
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Robert P, Senard JM, Fabre M, Cabot C, Cathala B. [Serotonin syndrome in acute poisoning with antidepressive agents]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1996; 15:663-5. [PMID: 9033760 DOI: 10.1016/0750-7658(96)82131-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report a case of severe serotonin syndrome after self-poisoning with two antidepressant drugs, paroxetine (a selective inhibitor of serotonin reuptake) and moclobemide (a reversible inhibitor of MAO-A). The serotonin syndrome is characterized by neuromuscular, behavioural, and autonomic changes. It occurs with the use of drugs able to increase serotonergic transmission in brain by acting on biosynthesis, reuptake, catabolism or release of serotonin. Treatment is symptomatic. The incidence of severe cases seems to have increased, probably due to the use of new antidepressant "specific" inhibitors of the serotonin reuptake.
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Affiliation(s)
- P Robert
- Département d'anesthésie-réanimation, hôpital Purpan, Toulouse, France
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