Gastrointestinal Side Effects of Antiarrhythmic Medications: A Review of Current Literature

A review of gut failure as a cause and consequence of critical illness

In critical illness, all elements of gut function are perturbed. Dysbiosis develops as the gut microbial community loses taxonomic diversity and new virulence factors appear. Intestinal permeability increases, allowing for translocation of bacteria and/or bacterial products. Epithelial function is altered at a cellular level and homeostasis of the epithelial monolayer is compromised by increased intestinal epithelial cell death and decreased proliferation. Gut immunity is impaired with simultaneous activation of maladaptive pro- and anti-inflammatory signals leading to both tissue damage and susceptibility to infections. Additionally, splanchnic vasoconstriction leads to decreased blood flow with local ischemic changes. Together, these interrelated elements of gastrointestinal dysfunction drive and then perpetuate multi-organ dysfunction syndrome. Despite the clear importance of maintaining gut homeostasis, there are very few reliable measures of gut function in critical illness. Further, while multiple therapeutic strategies have been proposed, most have not been shown to conclusively demonstrate benefit, and care is still largely supportive. The key role of the gut in critical illness was the subject of the tenth Perioperative Quality Initiative meeting, a conference to summarize the current state of the literature and identify key knowledge gaps for future study. This review is the product of that conference.

Amiodarone treatment in cats: evaluation of indications, adverse effects, and survival outcomes

Introduction

Time-and dose-dependent adverse effects of amiodarone have not been described in cats. The primary aim of this retrospective multicenter cohort study was to report the type and frequency of clinical adverse effects and biochemical changes in cats receiving amiodarone chronically. The secondary aim was to report survival outcomes in this population of cats.

Methods

Medical records were reviewed for signalment, arrhythmia diagnosis, presence of structural heart disease, systemic comorbidities and congestive heart failure at presentation, amiodarone dose, serial bloodwork results, adverse events, and survival outcome.

Results

The study population included 27 client-owned cats (2016-2022). All cats had structural cardiac disease, and many were in congestive heart failure (17/27; 63%) at presentation. Amiodarone was most commonly prescribed for ventricular tachycardia (19/27, 70%), and it was administered once daily with a median [range] dose of 8.8 [4.515.2] mg/kg/day. There was a decrease in serum concentration of alanine transaminase between pretreatment values and values measured during the early amiodarone treatment window, 1-90 days (n = 16; p = 0.034). No statistical difference in serum concentration of alanine transaminase (n = 10; p = 0.799) was noted after 90 days of treatment compared to pretreatment. There was no change in hematocrit, neutrophil count, and serum concentration of alkaline phosphatase and total thyroxine during treatment in assessed cats. Ten cats (37%) had at least one episode of hyporexia or vomiting while receiving amiodarone. The median survival time for all-cause mortality was 441 days (95% confidence interval, 126-929 days); cats in which the primary therapeutic target was both supraventricular and concomitant ventricular tachyarrhythmias had at least a two-fold risk of dying compared to cats with supraventricular tachyarrhythmias alone (hazard ratio 12.9, 95% CI 1.86-89.8; p = 0.010).

Discussion

Amiodarone was primarily used to treat ventricular arrhythmias. Transient gastrointestinal signs were reported in approximately one-third of the cats studied, but no clinically significant laboratory abnormalities were found in cats receiving amiodarone.

Factors associated with serious abdominal conditions in geriatric patients visiting the emergency department

BACKGROUND

Abdominal pain occurs in 20% of geriatric patients who visit the emergency department (ED). Geriatric patients usually have more severe conditions and a higher mortality rate. We aimed to determine the factors associated with serious abdominal conditions in geriatric patients who visit the ED with abdominal pain.

METHODS

This retrospective cohort study was conducted from January 1, 2017 to June 30, 2021. The inclusion criteria were patients aged ≥ 65 years and presented at the ED with acute abdominal pain. Significantly associated factors for serious abdominal conditions were examined using univariate and multivariate logistic regression analyses.

RESULTS

A total of 1221 patients were included in this study. Multivariate logistic regression analysis showed that the significant factors associated with serious abdominal conditions were male (adjusted odds ratio [AOR] 2.29, 95% CI:1.3-4.04; p = 0.004), anorexia (AOR 2.16, 95% CI:1.08-4.32; p = 0.03), NEWS 5-6 (AOR 2.96, 95% CI:1.35-6.49; p = 0.007), SBP 100-125 mmHg (AOR 1.5, 95% CI:0.75-2.99; p ≤ 0.001), guarding (AOR 6.92, 95% CI:3.39-14.12; p ≤ 0.001), WBC ≥ 14,000 cells/mm3 (AOR 2.08, 95% CI:1.06-4.09; p = 0.034), ED length of stay (EDLOS) 4-8 h (AOR 2.17, 95% CI:1.08-4.36; p = 0.03), and EDLOS ≥ 8 h (AOR 3.22, 95% CI:1.15-9; p = 0.025).

CONCLUSIONS

The statistically significant factors associated with serious abdominal conditions in geriatric patients were male, anorexia, NEWS 5-6, SBP 100-125 mmHg, guarding, WBC ≥ 14,000 cells/mm3, EDLOS 4-8 h, and EDLOS ≥ 8 h.

Efficacy and safety of berberine for premature ventricular contractions: a meta-analysis and systematic review of randomized controlled trials

CONTEXT

Berberine is a potential drug that can effectively treat cardiovascular diseases, including premature ventricular contractions (PVCs).

OBJECTIVE

This study was conducted to assess the efficacy and safety of berberine for PVCs.

METHODS

The literature was searched using PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang, and Chinese Biomedical Literature Database (CBM) for randomized controlled trials (RCTs) from inception to October 1, 2022. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to assess the quality of evidence.

RESULTS

Ten RCTs with 896 participants were included in the meta-analysis. The results showed that compared to antiarrhythmic drugs (AD), berberine (BE) combined with AD had a higher effective rate (RR = 1.26; 95% CI:1.12, 1.42; p = 0.0001) with no significant incidence of adverse reactions (RR = 0.93; 95% CI:0.33, 2.57; p = 0.88), and BE alone had no significant difference in effective rate (RR = 0.91; 95% CI:0.77, 1.07; p = 0.23), and a lower incidence of adverse reactions (RR = 0.38; 95% CI:0.15, 0.97; p = 0.04) and recurrence rate (RR = 0.40; 95% CI:0.18, 0.88; p = 0.02).

CONCLUSIONS

The results suggest that BE is an effective and safe adjunctive method for PVCs. In addition, BE is recommended for patients with PVCs who had severe adverse reactions after administrating AD as an alternative therapy.

Pharmacokinetic and pharmacodynamic herb-drug interactions-part I. Herbal medicines of the central nervous system

Unlike conventional drug substances, herbal medicines are composed of a complex of biologically active compounds. Therefore, the potential occurrence of herb-drug interactions is even more probable than for drug-drug interactions. Interactions can occur on both the pharmacokinetic and pharmacodynamic level. Herbal medicines may affect the resulting efficacy of the concomitantly used (synthetic) drugs, mainly on the pharmacokinetic level, by changing their absorption, distribution, metabolism, and excretion. Studies on the pharmacodynamic interactions of herbal medicines and conventional drugs are still very limited. This interaction level is related to the mechanism of action of different plant constituents. Herb-drug interactions can cause changes in drug levels and activities and lead to therapeutic failure and/or side effects (sometimes toxicities, even fatal). This review aims to provide a summary of recent information on the potential drug interactions involving commonly used herbal medicines that affect the central nervous system (Camellia, Valeriana, Ginkgo, Hypericum, Humulus, Cannabis) and conventional drugs. The survey databases were used to identify primary scientific publications, case reports, and secondary databases on interactions were used later on as well. Search keywords were based on plant names (botanical genera), officinal herbal drugs, herbal drug preparations, herbal drug extracts.

Novel CuO/Mn3O4/ZnO nanocomposite with superior photocatalytic activity for removal of Rabeprazole from water

In this work, a nanohybrid of CuO/Mn3O4/ZnO was generated through a simple hydrothermal based procedure. The CuO/Mn3O4/ZnO nanohybrid has been characterized using X-ray diffraction, transmission electron microscopy high resolution transmission electron microscopy, X-ray photoelectron spectroscopy, scanning electron microscopy and energy dispersive X-ray analysis. UV-visible spectrophotometry and photoluminescence techniques allowed evaluation of optical properties that additionally suggested the prevalence of strong interfacial interaction between the three moieties of the nanohybrid and suppressed electron-hole recombination. The hybrid photocatalyst brought on ~ 97.02 ± 1.15% disintegration of rabeprazole when illuminated with visible light. The progress of the photodegradation was in conformity with pseudo-first order kinetic model and had a velocity constant of 0.07773 min-1. Additionally, ~ 84.45% of total organic carbon removal was achieved while chemical oxygen demand was reduced by ~ 73.01%. Using high resolution liquid chromatograph mass spectrometry technique, identification of the degraded products was made and accordingly the mechanistic route of the aforesaid degradation was proposed.

Drug Repurposing on G Protein-Coupled Receptors Using a Computational Profiling Approach

G protein-coupled receptors (GPCRs) are the largest human membrane receptor family regulating a wide range of cell signaling. For this reason, GPCRs are highly desirable drug targets, with approximately 40% of prescribed medicines targeting a member of this receptor family. The structural homology of GPCRs and the broad spectrum of applications of GPCR-acting drugs suggest an investigation of the cross-activity of a drug toward different GPCR receptors with the aim of rationalizing drug side effects, designing more selective and less toxic compounds, and possibly proposing off-label therapeutic applications. Herein, we present an original in silico approach named “Computational Profiling for GPCRs” (CPG), which is able to represent, in a one-dimensional (1D) string, the physico-chemical properties of a ligand–GPCR binding interaction and, through a tailored alignment algorithm, repurpose the ligand for a different GPCR. We show three case studies where docking calculations and pharmacological data confirm the drug repurposing findings obtained through CPG on 5-hydroxytryptamine receptor 2B, beta-2 adrenergic receptor, and M2 muscarinic acetylcholine receptor. The CPG code is released as a user-friendly graphical user interface with numerous options that make CPG a powerful tool to assist the drug design of GPCR ligands.

Digoxin in Atrial Fibrillation: An Old Topic Revisited

Digoxin has been used for more than 50 years in patients with Atrial Fibrillation (AF), with the goal of Controlling Heart Rate (HR) and restoring sinus rhythm. In the last two decades, several studies have correlated therapeutic use of digoxin with increased mortality. However, such studies have potential biases that cannot be disregarded, mainly because they are cross-sectional experiments or post-hoc analyses of Randomized Controlled Trials (RCTs). Despite uncertainties regarding the safety of digoxin in this setting, it remains one of the most prescribed drugs for AF worldwide. On the other hand, the absence of any RCTs designed to evaluate mortality makes a definitive conclusion more difficult to reach; therefore, this medication must be used with care. In this review, we explored the therapeutic use of digoxin in the context of AF, discussed mortality data by means of critical analysis in the light of the best available evidence, and position ourselves in relation to more rigorous control of serum levels of this drug in daily practice.

Clindamycin-Induced Esophageal Injury: Is It an Underdiagnosed Entity?

There are increased reports of pill-induced esophagitis in the past 2 decades, with almost 100 different substances identified as the cause for more than 700 cases, and the overall incidence is estimated to be 0.004% per year. Antibiotics are one of the major contributors for these cases, especially tetracycline and doxycycline; other major contributors are bisphosphonates, nonsteroidal anti-inflammatory drugs, and iron pills. Clindamycin is commonly prescribed by physicians, yet side effect in the form of esophagitis is uncommon and mostly documented in case report. It is possible that these cases are mostly unnoticed due to initial consideration of common and more serious problems. Thus, patients may be assumed to be having a severe episode of acid reflux, and it is not routinely reported or recognized. In this case series, we presented 8 patients with clindamycin-induced esophagitis. The initial presentation of all patients was odynophagia, which appeared within the first day of taking the antibiotic. All patients were subjected to endoscopic examination and ulcer was found in all cases, in the form of localized solitary or multiple ulcers with sharply defined borders. Patients were treated with proton pump inhibitor and sucralfate, and the symptoms subside within 1 week. Patient education regarding the proper way of ingesting drug seems to be the key factor in the prevention of pill-induced esophagitis. The prevention of esophagitis is even more important with antibiotics as adverse effect would decrease the patient compliance in completing the regimen and would ultimately increase antibiotic resistance.