Fatal overdose from Bendectin

Post-mortem evidence of doxylamine in toxicological analyses

BACKGROUND

Doxylamine (DA) is widely available in pharmacies without prescription and can be used in suicidal intention because of its sedative and anticholinergic properties. Research of literature shows that only a few publications deal with post-mortem evidence of DA and its interpretation during toxicological examination.

MATERIAL AND METHODS

In this study, all cases with a positive detection of DA during toxicological analyses with high-performance liquid chromatography in the time period 2000 to 2010 at the Institute of Legal Medicine and Forensic Sciences in Berlin, Germany were retrospectively analysed and interpreted, taking into account police investigations, autopsy results and toxicological analyses.

RESULTS

In total, 22 cases with DA intoxications were discovered (♂=16/♀=6, age-at-death range 17 to 90years). Maximum blood concentration was measured at 77.5μg/mL. Cause of death was due to DA intoxication in eight suicide cases; seven of those were combined intoxications (DA and other substances, particularly diphenhydramine). During the evaluated time period no monointoxications with DA were discovered.

CONCLUSION

Benchmarks published in past literature are meant as orientation during evaluation of post-mortem DA evidence. These should not be used as absolute values and need to be interpreted individually in each case. Post-mortem redistribution needs to be considered as a main factor in alteration of DA concentration measurement. Furthermore, proof of DA ingestion found in gastric content should only be interpreted quantitatively due to unreliable calculation of the ingested amount. In conclusion, a variety of factors, such as the time period between time of death and the time of the first toxicological analysis, the condition of the body and the findings at autopsy, must also be critically considered.

Fatal blood and tissue concentrations of more than 200 drugs

Fatal drug concentrations in body fluids and tissue samples are presented for more than 200 drugs and chemicals of toxicologic interest. Additionally, a reference list is added with more than 600 original papers concerning intoxications with a lethal outcome. The data can be helpful for the interpretation and plausibility control in own cases of intoxication. However, they should be used with caution, because use of drug data without sufficient knowledge about the patient or victim, the circumstances of the case, and about toxicokinetics and toxicodynamics might give a wrong interpretation in a special case.

Suicide through doxylamine poisoning

Doxylamine is an antihistamine of the ethanolamine class. It is used primarily as a sleep-inducing agent. Only a few reports can be found in the literature about lethal intoxications with doxylamine, but many with combined intoxications. Doxylamine is, aside from diphenhydramine, the only chemically defined active ingredient in some sleeping medications which is available without a prescription in the Federal Republic of Germany. Two cases of doxylamine poisoning are presented, in which high doxylamine concentrations were found in the blood and organs.

Age-specific N-methyl-D-aspartate-induced seizures: perspectives for the West syndrome model

PURPOSE

With intraperitoneal N-methyl-D-aspartate (NMDA; 15-200 mg/kg) administration, we attempted to develop an animal model of age-specific West syndrome to serve for testing of putative anticonvulsant drugs and to determine the mechanisms of this disorder.

METHODS

Experiments were performed in 12-, 18-, and 60-day-old (adult) rats. The effects of systemic pretreatment with hydrocortisone (5-25 mg/kg), pyridoxine (20-250 mg/kg), and sodium valproate (VPA; 200 and 400 mg/kg) against the NMDA-induced automatisms, emprosthotonic (hyperflexion), and clonic-tonic seizures were determined. NMDA-induced EEG changes and alterations of the performance in horizontal bar, rotorod, open field, and elevated plus-maze tests were recorded.

RESULTS

In young rats, hydrocortisone had proconvulsant effects. High doses of pyridoxine induced epileptiform activity independent of and distinct from that induced by NMDA. Only VPA had moderate effects against the NMDA-induced syndrome. EEG consisted of periods of suppression mixed with ictal activity of serrated waves and high-voltage chaotic EEG activity. In adult rats, EEG alterations involved spike and spike-and-wave activity. NMDA also deteriorated performance of young rats in the open field, rotorod, and elevated plus maze tests.

CONCLUSIONS

NMDA syndrome in rats fulfills some, but not all, criteria of the West syndrome model, such as occurrence of flexion seizures, nonspecific diffuse EEG changes, refractoriness to antiepileptic therapy (but a response to VPA), as well as long-term alteration of behavioral tasks. However, NMDA-induced seizures represent an acute model without the occurrence of spontaneous seizures, whereas in the clinical situation, both the seizures and neurologic deterioration are chronic. Further, in the West syndrome and the NMDA seizure model, there is an incongruent response to therapy with antiepileptic drugs.

Proconvulsant effects induced by pyridoxine in young rats

High doses of pyridoxine (vitamin B6) can be neurotoxic in adults. Effects of intraperitoneally administered B6 (100, 250 and 400 mg/kg) were studied in 7, 12, 18 and 60 day old rats. B6 elicited epileptiform EEG discharges without any motor correlate in all age groups. In contrast, motor seizures were rare, seen only in 18 day old rats (250 mg/kg of B6). Data indicate that in young rats, B6 may have proconvulsant effects in doses relevant to those sometimes used in pediatric neurology.

Poisoning with over-the-counter doxylamine preparations: an evaluation of 109 cases

One hundred and nine cases of monointoxication with doxylamine were evaluated with respect to age distribution, amount ingested, plasma level, and clinical symptomatology. The age of 60% of the patients ranged between 16 and 30 years. In about 60% of the cases 10 to 40 times a single therapeutic dose (25 mg) was ingested. Doxylamine plasma concentrations exceeded the maximum plasma level after a therapeutic dose by a factor of 10 to 40 in two-thirds of cases. The most frequent symptoms included impaired consciousness, seizures, tachycardia, mydriasis and a 'psychosis' similar to that in catatonic stupor. A serious complication may be rhabdomyolysis with subsequent impairment of renal function and acute renal failure. No symptoms were observed in 39% of the patients. No correlation was found between the amount ingested or doxylamine plasma level and the clinical symptomatology. Primary detoxication included gastric lavage, administration of activated charcoal and sodium sulfate. Regarding the high frequency of doxylamine overdose and its possible complications the question arises as to whether doxylamine-containing preparations should be subjected to prescription.

Two cases of death involving dicyclomine in infants. Measurement of therapeutic and toxic concentrations in blood

In two deaths of infants investigated by the Medical Examiner, high levels of dicyclomine were detected in blood. In one of the cases, a level of 0.505 micrograms/ml was found, nearly 10 times reported adult therapeutic blood concentrations, and death was ascribed to an overdose of dicyclomine. Gas chromatography/mass spectrometry was used for the analysis of biological specimens.

Physostigmine treatment of anticholinergic poisoning

Physostigmine salicylate, a centrally acting cholinesterase inhibitor, is effective in rapidly and dramatically reversing the effects produced by anticholinergic drugs. Three case reports of successful use of physostigmine are presented. Since physostigmine is a tertiary amine that allows for passage of the drug into the central nervous system, it can reverse both the peripheral and central nervous system effects of anticholinergic poisoning. The adverse effects and contraindications of physostigmine use are discussed.