Tramadol toxicity-induced rhabdomyolysis

Tramadol suppresses growth of orthotopic liver tumors via promoting M1 macrophage polarization in the tumor microenvironment

Tumor-associated macrophages (TAMs) are major infiltrating immune cells in liver cancer. They are polarized to anti-tumor M1 type or tumor-supporting M2 type in a dynamic changing state. Tramadol, a synthetic opioid, exhibits tumor-suppressing effect in several cancers, but whether it plays a role in TAMs polarization is uncertain. In the present study, the potential influence of tramadol on TAMs polarization was explored in liver cancer. An orthotopic murine Hepa 1-6 liver cancer model was constructed. The potential function of tramadol was evaluated by cell viability assay, EdU incorporation assay, flow cytometry, immunofluorescence, quantitative real-time polymerase chain reaction (qRT-PCR), enzyme-linked immunosorbent assay (ELISA) assay, T cell proliferation and suppression assays and western blot. We found that tramadol suppressed proliferation and tumor formation of murine Hepa 1-6 cells in vitro and in vivo. Tramadol reprogramed the immune microenvironment to favor M1 macrophage polarization in orthotopic Hepa 1-6 tumors. Moreover, tramadol facilitated M1 macrophage polarization and inhibited M2 macrophage polarization of bone marrow-derived macrophages (BMDMs) and human THP-1 macrophages in vitro. Furthermore, tramadol-treated BMDMs promoted proliferation and activation of splenic CD4+ and CD8+ T cells. Tramadol induced cellular ROS production and mitochondrial dysfunction of BMDMs. Finally, tramadol activated NF-κB signaling in BMDMs and THP-1 macrophages, while inhibition of NF-κB signaling by JSH-23 attenuated the influence of tramadol on macrophage polarization. In conclusion, these data elucidated a novel anti-tumor mechanism of tramadol in liver cancer. Tramadol might be a promising treatment strategy for liver cancer patients.

Antitumorigenic Effect of Tramadol and Synergistic Effect With Doxorubicin in Human Breast Cancer Cells

Background

Breast cancer in women is one of the leading causes of cancer mortality worldwide, and curative therapy is the main focus of clinical treatment. Anesthetic-analgesic techniques might alter stress responses and immunity and thereby influence outcomes in cancer patients. This study investigated the effect of tramadol on breast cancer progression and metastasis.

Methods

The effects of tramadol on two different subtypes of human breast adenocarcinoma cell lines, MDA-MB-231 and MCF-7, were studied with regard to cell growth, migration, colony formation and invasion and normoxic or hypoxic microenvironment for the expression of hypoxia-inducible factor-1α, reactive oxygen species, epithelial-mesenchymal transition related and cyclin-related proteins. The co-administration of tramadol and doxorubicin was studied to determine whether the effective doxorubicin dose might be reduced in combination with tramadol.

Results

The results showed that tramadol inhibited cell growth at concentrations more than 0.5 and more than 1.0 mg/mL in MDA-MB-231 and MCF-7 cells, respectively. Additionally, cell migration, colony formation and invasion were inhibited in a dose-dependent manner by tramadol in both cell lines. The combination of tramadol and doxorubicin induced synergistic effects in MDA-MD-231 cells and, with specific dosage combinations in MCF-7 cells.

Conclusions

Tramadol may regulate epithelial-mesenchymal transition and possess cytotoxic effects in breast cancer cells. Tramadol inhibits the progression of breast cancer cells and might be a candidate for combination therapy, especially for triple-negative breast cancer, and is a promising treatment strategy for breast cancer.

Acute Toxic Effects of the New Psychoactive Substance "Voodoo" among Patients presented to the Poison Control Center of Ain Shams University Hospitals (PCC-ASUH), Egypt, during 2017

BACKGROUND

Voodoo is a heterogeneous mixture of psychoactive substances that has recently grown in popularity among youth in Egypt. Patients can present with a variety of manifestations that may lead to death in some cases. This study assessed the acute toxic effects of voodoo among patients presented to the Poison Control Center of Ain Shams University Hospitals (PCC-ASUH) during a one year period.

METHODS

This is a retrospective study of all patients presented with voodoo intoxication at the PCC-ASUH from 1 January 2017 to 31 December 2017. Clinical data, routine laboratory findings, and ECG results as well as duration of hospitalization and outcome were compiled from hospital records.

RESULTS

Seventy-one voodoo intoxication cases meeting the inclusion criteria were analyzed (mean age: 25.19 ± 9.54 years, range: 15-50 years, 97.2 % male). Pulse, blood pressure, and respiratory rate were normal in more than half of all patients. Neurological abnormalities including agitation, hallucinations, disturbance of consciousness were the most frequent manifestations. Respiratory acidosis was the most common laboratory finding (54.9 %), followed by increased serum urea (43.6 %), hypokalemia (33.8 %), hyperglycemia (28.1 %), and leukocytosis (26.7 %). The most common ECG finding was sinus tachycardia (31 %), followed by QT prolongation (15.4 %). More than half of the studied patients (53.5 %) co-administered other illicit substances, most frequently cannabis and tramadol. Most patients recovered fully and were discharged, but death occurred in two cases.

CONCLUSIONS

Voodoo toxicity can manifest with many presentations, hampering timely diagnosis. Clinicians should consider possible voodoo poisoning in patients presenting with a history of drug use with neurological symptoms, and they should conduct follow-up arterial blood gases, electrolytes and ECG as voodoo may contain potentially fatal psychoactive substances.

A review on tramadol toxicity: mechanism of action, clinical presentation, and treatment

Aims

As an analgesic that acts upon the central nervous system (CNS), tramadol has gained popularity in treating moderate to severe pain. Recently, it has been increasingly reported as a drug of misuse with intentional overdoses or intoxications. This review focuses on tramadol intoxication in humans and its effects on different systems.

Subject and method

This narrative review provides a comprehensive view of the pharmacokinetics, mechanism of action, and incidence of tramadol toxicity with an in-depth look at its side effects. In addition, the main approaches to the management of tramadol poisoning are described.

Results

Tramadol poisoning can affect multiple organ systems: gastrointestinal, central nervous system (seizure, CNS depression, low-grade coma, anxiety, and over time anoxic brain damage), cardiovascular system (palpitation, mild hypertension to life-threatening complications such as cardiopulmonary arrest), respiratory system, renal system (renal failure with higher doses of tramadol intoxication), musculoskeletal system (rhabdomyolysis), endocrine system (hypoglycemia), as well as, cause serotonin syndrome. Seizure, a serious nervous disturbance, is more common in tramadol intoxication than with other opioids. Fatal tramadol intoxications are uncommon, except in ingestion cases concurrent with other medications, particularly CNS depressants, most commonly benzodiazepines, and ethanol.

Conclusion

With the increasing popularity of tramadol, physicians must be aware of its adverse effects, substantial abuse potential, and drug interactions, to weigh its risk–benefit ratio for pain management. Alternative therapies might be considered in patients with a previous overdose history to reduce risks for adverse outcomes.

Tramadol sensing in non-invasive biological fluids using a voltammetric electronic tongue and an electrochemical sensor based on biomimetic recognition

Tramadol (TRA) is a weak opioid analgesic, prescribed to relieve mild to moderately severe pain. However, side effects of TRA overdoses, including vomiting, depression, tachycardia, convulsions, morbidity and mortality are often reported. In this study, an electrochemical sensor based on molecularly imprinted conductive polymer was firstly developed for the quantitative and non-invasive detection of TRA. Secondly, a voltammetric electronic tongue (VE-Tongue) combined with chemometric methods was used for the qualitative analysis. The MIP sensor was constructed by self-assembling a poly-aniline layer coated with silver nanoparticles (PANI-AgNPs) on a screen-printed gold electrode (Au-SPE). Then, 2-amino-thiophenol was polymerised in the presence of TRA. The electronic device exhibits, under optimal conditions, responses proportional to TRA concentrations (0.01-100 µg/mL) with detection and quantification limits of 9.42 µg/mL and 28.55 µg/mL, respectively. Moreover, its selectivity was proven by insignificant interferences of substances (paracetamol and citric acid). Spiked saliva and urine samples were used for the sensor practical application with a significant recovery above 90% and standard deviations below 4.5%. Besides, urine samples' analyses using VE-Tongue and pattern recognition methods show good discrimination, classification, and prediction results with scores above 95%. Correspondingly, both electro-analytical devices could be viable for monitoring drugs in biological matrices.

Acute tramadol poisoning and its clinical and laboratory findings

BACKGROUND

Tramadol is a centrally acting analgesic with opioid and nonopioid properties, which extensively used in the relief of mild to moderate pain. Tramadol poisoning is a common cause of acute pharmaceutical poisoning in Iran. There are a few studies about clinical and laboratory findings related to acute tramadol poisoning. Therefore, the aim of this study was to demonstrate the clinical and laboratory findings in tramadol acute poisoning cases.

MATERIALS AND METHODS

This was a retrospective descriptive study of patients with acute tramadol poisoning who referred to Loghman Hakim Hospital Poison Center during January to April 2012. Data such as patient's age, sex, time of ingestion, ingested dose, cause of poisoning, mean duration of hospitalization, patient's clinical presentations, laboratory findings, therapeutic measures, and patient's outcome have collected in a predesigned checklist.

RESULTS

A total of 144 patients including 111 men (77%) and 33 women (23%) with acute tramadol poisoning was included in this study. The mean ingested dose was 1971.2 mg (100-20000 mg). Seizure (47.91%) was the most frequent clinical symptom. Blood gas on admission showed pH (7.3 ± 0.1), PCO2 (49.7 ± 8.6 mmHg) and HCO3 (-) (24.1 ± 3.8 mEq/L), indicating pure acute respiratory acidosis may be occurred in tramadol-intoxicated patients. There were significant differences between tramadol-intoxicated cases with and without a seizure with regard to the time interval between ingestion and admission on hospital, ingested dose and PCO2.

CONCLUSION

Seizure and rise of PCO2 were the most findings in this study.

Facilitating adverse drug event detection in pharmacovigilance databases using molecular structure similarity: application to rhabdomyolysis

BACKGROUND

Adverse drug events (ADE) cause considerable harm to patients, and consequently their detection is critical for patient safety. The US Food and Drug Administration maintains an adverse event reporting system (AERS) to facilitate the detection of ADE in drugs. Various data mining approaches have been developed that use AERS to detect signals identifying associations between drugs and ADE. The signals must then be monitored further by domain experts, which is a time-consuming task.

OBJECTIVE

To develop a new methodology that combines existing data mining algorithms with chemical information by analysis of molecular fingerprints to enhance initial ADE signals generated from AERS, and to provide a decision support mechanism to facilitate the identification of novel adverse events.

RESULTS

The method achieved a significant improvement in precision in identifying known ADE, and a more than twofold signal enhancement when applied to the ADE rhabdomyolysis. The simplicity of the method assists in highlighting the etiology of the ADE by identifying structurally similar drugs. A set of drugs with strong evidence from both AERS and molecular fingerprint-based modeling is constructed for further analysis.

CONCLUSION

The results demonstrate that the proposed methodology could be used as a pharmacovigilance decision support tool to facilitate ADE detection.