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He Y, Wu L, Qi X, Wang X, He B, Zhang W, Zhao W, Deng M, Xiong X, Wang Y, Liang S. Efficiency of Protective Interventions on Irinotecan-Induced Diarrhea: A Systematic Review and Meta-Analysis. Integr Cancer Ther 2024; 23:15347354241242110. [PMID: 38567795 PMCID: PMC10993684 DOI: 10.1177/15347354241242110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 01/24/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Irinotecan is widely used in the treatment of various solid tumors, but the adverse effects from it, especially diarrhea, limit its use. Several clinical trials of prophylactic treatment of irinotecan-induced diarrhea (IID) have been ongoing, and some of the data are controversial. This encouraged us to conduct a meta-analysis of the effects of interventions on preventing IID. METHOD This systematic review was conducted based on the PRISMA statement. We performed literature searches from PubMed, Web of Science, Embase, and Cochrane Library. The number registered in PROSPERO is CRD42022368633. After searching 1034 articles in the database and references, 8 studies were included in this meta-analysis. RESULT The RR of high-grade diarrhea and all-grade diarrhea were 0.31 (I2 = 51%, 95% CI: 0.14-0.69; P = .004) and .76 (I2 = 65%, 95% CI: 0.62-0.93; P < .008) respectively, thus the use of intervention measures for preventing IID is effective, and the risk reduction of high-grade diarrhea was more significant. Subgroup analysis revealed that the monotherapy group (RR: 0.48, 95% CI: 0.21-1.13, I2 = 0%) and combination therapy group (RR: 0.14, 95% CI: 0.06-0.32, I2 = 0%) in the risk of high-grade diarrhea had no significant heterogeneity within the groups, and traditional herbal medicines (Kampo medicine Hangeshashin-to, PHY906 and hot ironing with Moxa Salt Packet on Tianshu and Shangjuxu) were effective preventive measures (RR:0.20, 95% CI: 0.07-0.60, I2 = 0%). The Jadad scores for traditional herbal medicines studies were 3, and the follow-up duration was only 2 to 6 weeks. CONCLUSION This systematic review and meta-analysis suggest that preventive treatments significantly reduced the risk of high-grade and all-grade diarrhea, confirming the efficacy in the incidence and severity of IID, among which traditional herbal medicines (baicalin-containing) provided a protective effect in reducing the severity of IID. However, the traditional herbal medicines studies were of low quality. Combined irinotecan therapy can obtain better preventive effects than monotherapy of IID. These would be helpful for the prevention of IID in clinical practice.
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Affiliation(s)
- Yanxi He
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lili Wu
- Zunyi Medical University, Zunyi, China
| | - Xiaoyi Qi
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xuan Wang
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bing He
- Southwest Medical University, Luzhou, China
| | - Wei Zhang
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Wenjing Zhao
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Human Microecology and Precision Diagnosis and Treatment of Luzhou Key Laboratory, Luzhou, China
| | - Mingming Deng
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xia Xiong
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yu Wang
- Gulin County People’s Hospital, Luzhou, China
| | - Sicheng Liang
- The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Southwest Medical University, Luzhou, China
- Human Microecology and Precision Diagnosis and Treatment of Luzhou Key Laboratory, Luzhou, China
- Cardiovascular and Metabolic Diseases of Sichuan Key Laboratory, Luzhou, China
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Takahashi T, Nagai K, Kotake K. Efficacy of Hangeshashinto in the Prevention of Chemotherapy-Induced Diarrhea: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e50377. [PMID: 38213366 PMCID: PMC10782476 DOI: 10.7759/cureus.50377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2023] [Indexed: 01/13/2024] Open
Abstract
Hangeshashinto has attracted attention owing to its potential to prevent chemotherapy-induced diarrhea. However, studies on the efficacy of Hangeshashinto have had conflicting results. Evaluating the efficacy of Hangeshashinto may contribute to reducing the use and adverse events caused by drug therapy for chemotherapy-induced diarrhea. Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, Ichushi, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched to retrieve all the relevant studies. Randomized controlled trials (RCTs) comparing the administration of Hangeshashinto with that of other treatments in patients with cancer receiving chemotherapy were included. The primary outcome was severe (grade 3-4) diarrhea assessed using the Common Terminology Criteria for Adverse Events. The secondary outcome was mild (grade 0-2) diarrhea. Out of 324 records identified, three studies were selected for the meta-analysis. Irinotecan was used for chemotherapy in all these studies. Hangeshashinto did not reduce the incidence of severe diarrhea compared with other treatments (risk ratio (RR) 0.40, 95% confidence interval (CI) 0.11-1.41, P = 0.15; low-quality evidence). Moreover, Hangeshashinto did not reduce the incidence of mild diarrhea (RR 1.35, 95% CI 0.87-2.09, P = 0.18; low-quality evidence). However, in the subgroup analysis compared with no treatment, the Hangeshashinto group had a significantly lower incidence of severe diarrhea (RR 0.17, 95% CI 0.03-0.88, P = 0.03; low-quality evidence). At present, insufficient evidence exists to support the claim that Hangeshashinto prevents diarrhea caused by irinotecan-based chemotherapy.
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Affiliation(s)
| | - Koshi Nagai
- Pharmacy Department, Tokyo Metropolitan Police Hospital, Tokyo, JPN
| | - Kazumasa Kotake
- Pharmacy Department, Okayama Saiseikai General Hospital, Okayama, JPN
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Huang RL, Huang WK, Xiao XY, Ma LF, Gu HZR, Yang GP. Diagnosis and treatment of post-cholecystectomy diarrhoea. World J Gastrointest Surg 2023; 15:2398-2405. [PMID: 38111762 PMCID: PMC10725554 DOI: 10.4240/wjgs.v15.i11.2398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/22/2023] [Accepted: 09/22/2023] [Indexed: 11/26/2023] Open
Abstract
The incidence of cholecystitis is relatively high in developed countries and may usually be attributed to gallstones, the treatment for which involves complete surgical removal of the gallbladder (cholecystectomy). Bile acids produced following cholecystectomy continue to flow into the duodenum but are poorly absorbed by the colon. Excessive bile acids in the colon stimulate mucosal secretion of water and electrolytes leading, in severe cases, to diarrhoea. Bile acid diarrhoea (BAD) is difficult to diagnose, requiring a comprehensive medical history and physical examination in combination with laboratory evaluation. The current work reviews the diagnosis and treatment of BAD following cholecystectomy.
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Affiliation(s)
- Rang-Lang Huang
- Department of Hepatobiliary and Pancreatic Surgery, The Third Xiangya Hospital of The Central South University, Changsha 410013, Hunan Province, China
| | - Wen-Kai Huang
- Department of General Medicine, The Third Xiangya Hospital of The Central South University, Changsha 410013, Hunan Province, China
| | - Xiang-Yi Xiao
- The Xiangya School of Medicine, The Central South University, Changsha 410013, Hunan Province, China
| | - Lin-Feng Ma
- The Xiangya School of Medicine, The Central South University, Changsha 410013, Hunan Province, China
| | - He-Zi-Rui Gu
- The Xiangya School of Medicine, The Central South University, Changsha 410013, Hunan Province, China
| | - Guo-Ping Yang
- Department of Clinical Pharmacy, The Third Hospital of The Central South University, Changsha 410013, Hunan Province, China
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Patel A, Rine NI, Spiller HA, Hays H, Badeti J, Zhu M, Ding K, Smith GA. Loperamide cases reported to United States poison centers, 2010-2022. Inj Epidemiol 2023; 10:61. [PMID: 38001549 PMCID: PMC10668506 DOI: 10.1186/s40621-023-00473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Intentional use of high doses of loperamide has been linked to serious cardiac toxicity. The objective of this study is to investigate the characteristics and trends of loperamide cases reported to United States (US) poison centers and to evaluate the changes in reported loperamide cases following US Food and Drug Administration (FDA) warnings, labeling requirements, and packaging restrictions for loperamide starting in 2016, with an emphasis on intentional exposures. METHODS Data from the National Poison Data System were analyzed. RESULTS There were 12,987 cases reported to US poison centers from 2010 to 2022, for which, loperamide was the most likely substance responsible for observed clinical effects. Although 46.1% of these cases were associated with minor or no effect, 13.4% resulted in a serious medical outcome, including 59 deaths (0.5%). Eight percent (8.1%) of cases were admitted to a critical care unit and 5.0% were admitted to a non-critical care unit. Among cases with a serious medical outcome, most were associated with loperamide abuse (38.0%), intentional-misuse (15.7%), or suspected suicide (27.5%). The majority (60.0%; n = 33) of fatalities were related to abuse, followed by suspected suicide (20.0%; n = 11) and intentional-misuse (5.5%, n = 3). The rate of loperamide cases per 100,000 US population reported to US PCs decreased from 0.44 in 2010 to 0.36 in 2015 (p = 0.0290), followed by an increase to 0.46 in 2017 (p = 0.0013), and then a trend reversal with a decrease to 0.28 in 2022 (p < 0.0001). The rate of serious medical outcomes related to loperamide increased from 0.03 in 2010 to 0.05 in 2015 (p = 0.0109), which subsequently increased rapidly to 0.11 in 2017 (p < 0.0001), and then demonstrated a trend reversal and decreased to 0.04 in 2022 (p < 0.0001). CONCLUSIONS FDA warnings, labeling requirements, and packaging restrictions may have contributed to the observed trend reversal and decrease in reports to US poison centers of loperamide cases related to intentional misuse, abuse, and suspected suicide. This demonstrates the potential positive effect that regulatory actions may have on public health. These findings contribute to the evidence supporting the application of similar prevention efforts to reduce poisoning from other medications associated with intentional misuse, abuse, and suicide.
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Affiliation(s)
- Aaditya Patel
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Kansas City University College of Osteopathic Medicine, Kansas City, MO, USA
| | - Natalie I Rine
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Hannah Hays
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jaahnavi Badeti
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Motao Zhu
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kele Ding
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Gary A Smith
- Center for Injury Research and Policy, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- Child Injury Prevention Alliance, Columbus, OH, USA.
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Fan Y, Zhang T, Song Y, Sang Z, Zeng H, Liu P, Wang P, Ge G. Rationally Engineered hCES2A Near-Infrared Fluorogenic Substrate for Functional Imaging and High-Throughput Inhibitor Screening. Anal Chem 2023; 95:15665-15672. [PMID: 37782032 DOI: 10.1021/acs.analchem.3c02873] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Human carboxylesterase 2A (hCES2A) is an important endoplasmic reticulum (ER)-resident enzyme that is responsible for the hydrolytic metabolism or activation of numerous ester-bearing drugs and environmental toxins. The previously reported hCES2A fluorogenic substrates suffer from limited emission wavelength, low specificity, and poor localization accuracy, thereby greatly limiting the in situ functional imaging of hCES2A and drug discovery. Herein, a rational ligand design strategy was adopted to construct a highly specific near-infrared (NIR) substrate for hCES2A. Following scaffold screening and recognition group optimization, HTCF was identified as a desirable NIR fluorophore with excellent photophysical properties and high ER accumulation ability, while several HTCF esters held a high potential to be good hCES2A substrates. Further investigations revealed that TP-HTCF (the tert-pentyl ester of HTCF) was an ideal substrate with ultrahigh sensitivity, excellent specificity, and a substantial signal-to-noise ratio. Upon the addition of hCES2A, TP-HTCF could be rapidly hydrolyzed to release HTCF, a chemically stable product that emitted bright fluorescent signals at around 670 nm. A TP-HTCF-based biochemical assay was then established for the high-throughput screening of potent and cell-active hCES2A inhibitors from an in-house compound library. Furthermore, TP-HTCF displayed high imaging resolution for imaging hCES2A in living cells as well as mouse liver slices and tumor-xenograft mice. Collectively, this study demonstrates a rational strategy for developing highly specific fluorogenic substrates for an ER-resident target enzyme, while TP-HTCF can act as a practical tool for sensing hCES2A in living systems.
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Affiliation(s)
- Yufan Fan
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Tiantian Zhang
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yunqing Song
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Zhipei Sang
- School of Pharmaceutical Sciences, Hainan University, Haikou, Hainan 570228, China
| | - Hairong Zeng
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Peiqi Liu
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Ping Wang
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Guangbo Ge
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
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He Y, Zheng J, Ye B, Dai Y, Nie K. Chemotherapy-induced gastrointestinal toxicity: Pathogenesis and current management. Biochem Pharmacol 2023; 216:115787. [PMID: 37666434 DOI: 10.1016/j.bcp.2023.115787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
Chemotherapy is the most common treatment for malignant tumors. However, chemotherapy-induced gastrointestinal toxicity (CIGT) has been a major concern for cancer patients, which reduces their quality of life and leads to treatment intolerance and even cessation. Nevertheless, prevention and treatment for CIGT are challenging, due to the prevalence and complexity of the condition. Chemotherapeutic drugs directly damage gastrointestinal mucosa to induce CIGT, including nausea, vomiting, anorexia, gastrointestinal mucositis, and diarrhea, etc. The pathogenesis of CIGT involves multiple factors, such as gut microbiota disorders, inflammatory responses and abnormal neurotransmitter levels, that synergistically contribute to its occurrence and development. In particular, the dysbiosis of gut microbiota is usually linked to abnormal immune responses that increases inflammatory cytokines' expression, which is a common characteristic of many types of CIGT. Chemotherapy-induced intestinal neurotoxicity is also a vital concern in CIGT. Currently, modern medicine is the dominant treatment of CIGT, however, traditional Chinese medicine (TCM) has attracted interest as a complementary and alternative therapy that can greatly alleviate CIGT. Accordingly, this review aimed to comprehensively summarize the pathogenesis and current management of CIGT using PubMed and Google Scholar databases, and proposed that future research for CIGT should focus on the gut microbiota, intestinal neurotoxicity, and promising TCM therapies, which may help to develop more effective interventions and optimize managements of CIGT.
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Affiliation(s)
- Yunjing He
- School of Chinese Materia Medica, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Jingrui Zheng
- School of Chinese Materia Medica, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Binbin Ye
- School of Chinese Materia Medica, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Yongzhao Dai
- School of Chinese Materia Medica, Guangdong Pharmaceutical University, Guangzhou 510006, China
| | - Ke Nie
- School of Chinese Materia Medica, Guangdong Pharmaceutical University, Guangzhou 510006, China.
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Lu HR, Damiano BP, Kreir M, Rohrbacher J, van der Linde H, Saidov T, Teisman A, Gallacher DJ. The Potential Mechanisms behind Loperamide-Induced Cardiac Arrhythmias Associated with Human Abuse and Extreme Overdose. Biomolecules 2023; 13:1355. [PMID: 37759755 PMCID: PMC10527387 DOI: 10.3390/biom13091355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/01/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023] Open
Abstract
Loperamide has been a safe and effective treatment for diarrhea for many years. However, many cases of cardiotoxicity with intentional abuse of loperamide ingestion have recently been reported. We evaluated loperamide in in vitro and in vivo cardiac safety models to understand the mechanisms for this cardiotoxicity. Loperamide slowed conduction (QRS-duration) starting at 0.3 µM [~1200-fold (×) its human Free Therapeutic Plasma Concentration; FTPC] and reduced the QT-interval and caused cardiac arrhythmias starting at 3 µM (~12,000× FTPC) in an isolated rabbit ventricular-wedge model. Loperamide also slowed conduction and elicited Type II/III A-V block in anesthetized guinea pigs at overdose exposures of 879× and 3802× FTPC. In ion-channel studies, loperamide inhibited hERG (IKr), INa, and ICa currents with IC50 values of 0.390 µM, 0.526 µM, and 4.091 µM, respectively (i.e., >1560× FTPC). Additionally, in silico trials in human ventricular action potential models based on these IC50s confirmed that loperamide has large safety margins at therapeutic exposures (≤600× FTPC) and confirmed repolarization abnormalities in the case of extreme doses of loperamide. The studies confirmed the large safety margin for the therapeutic use of loperamide but revealed that at the extreme exposure levels observed in human overdose, loperamide can cause a combination of conduction slowing and alterations in repolarization time, resulting in cardiac proarrhythmia. Loperamide's inhibition of the INa channel and hERG-mediated IKr are the most likely basis for this cardiac electrophysiological toxicity at overdose exposures. The cardiac toxic effects of loperamide at the overdoses could be aggravated by co-medication with other drug(s) causing ion channel inhibition.
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Affiliation(s)
- Hua Rong Lu
- Global Safety Pharmacology, Janssen Research and Development, Turnhoutseweg 30, 2340 Beerse, Belgium; (B.P.D.); (J.R.); (H.v.d.L.); (T.S.); (A.T.); (D.J.G.)
| | | | - Mohamed Kreir
- Global Safety Pharmacology, Janssen Research and Development, Turnhoutseweg 30, 2340 Beerse, Belgium; (B.P.D.); (J.R.); (H.v.d.L.); (T.S.); (A.T.); (D.J.G.)
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Miles WM, George P. Physiologic Variants of Cardiac Conduction (Aberration, Gap, Supernormal Conduction). Cardiol Clin 2023; 41:315-332. [PMID: 37321684 DOI: 10.1016/j.ccl.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Wide QRS complexes during supraventricular rhythms can be caused by fixed bundle branch block, functional (intermittent) bundle branch block, preexcitation, or toxic/metabolic causes. Functional bundle branch block can be caused by long-short aberrancy (usually physiologic), or acceleration/deceleration dependent aberrancy (usually pathologic). Electrocardiogram criteria have been proposed to differentiate aberration from ventricular tachycardia; they are not always accurate. The gap phenomenon "paradox" is that with increasingly premature extrastimuli, progressive proximal conduction delay allows time for distal recovery of excitability. Supernormal conduction may explain unusual conduction phenomena in patients with abnormal His-Purkinje function or poorly conducting accessory pathways.
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Affiliation(s)
- William M Miles
- University of Florida College of Medicine, 1329 S.W. 16th Avenue, PO Box 100288, Gainesville, Florida 32608, USA.
| | - Philip George
- University of Florida College of Medicine, 1329 S.W. 16th Avenue, PO Box 100288, Gainesville, Florida 32608, USA
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Zhou Z, Li K, Shi L, Wang Y, He Y, Hu W, Guo J. Self-Assembled Integrative Nutrient Carrier Platform Containing Green Tea Catechin for Short Bowel Syndrome Treatment. Adv Healthc Mater 2023; 12:e2201933. [PMID: 36337003 DOI: 10.1002/adhm.202201933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/28/2022] [Indexed: 11/09/2022]
Abstract
Extensive resection of the small intestine leads to the development of short bowel syndrome (SBS), which reduces the effective absorptive surface area of the intestine and predisposes patients to emaciation, malnutrition, and other severe symptoms. Herein, green tea catechin (-)-epigallocatechin gallate (EGCG) and ferrous ions (Fe2+ ) are utilized to construct a nutrient carrier platform that self-assembles with nutrients to form phenolic-based nutrient complexes (PNCs). PNCs effectively prolong the residence and absorption time of nutrients in the intestine. Further this platform is applied to integrate full nutrient formula, an enteral nutrition (EN) preparation containing a range of full nutrient components. In an SBS rat model, the prepared phenolic-based integrative nutrient complexes (PINCs) enhance nutritional status, improve anemia and immune function, as well as facilitate the growth of remaining intestinal villi and crypts, and maintain the integrity of the intestinal barrier. In addition, PINCs enable the modulation of gut microbial dysbiosis, enrich the abundance of beneficial bacteria, and have no toxic effects after the long-term ingestion. These results provide a proof of principle for the use of polyphenol-based nanocomplexes as EN preparation, offering a feasible strategy for both nutritional support and therapeutic perspectives for SBS treatment.
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Affiliation(s)
- Zhengming Zhou
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Ke Li
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Lei Shi
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yunfeng Wang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Yunxiang He
- BMI Center for Biomass Materials and Nanointerfaces, College of Biomass Science and Engineering, Sichuan University, Chengdu, Sichuan, 610065, China
| | - Wen Hu
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, Sichuan, 610041, China.,Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Junling Guo
- BMI Center for Biomass Materials and Nanointerfaces, College of Biomass Science and Engineering, Sichuan University, Chengdu, Sichuan, 610065, China.,Bioproducts Institute, Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, BC, V6T 1Z4, Canada.,State Key Laboratory of Polymer Materials Engineering, Sichuan University, Chengdu, Sichuan, 610065, China
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10
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Geno KA, Badea A, Lynch KL, Jannetto P, Hubbard JA, Nerenz RD, Cervinski MA. An Opioid Hiding in Plain Sight: Loperamide-Induced False-Positive Fentanyl and Buprenorphine Immunoassay Results. J Appl Lab Med 2022; 7:1318-1328. [PMID: 36036092 DOI: 10.1093/jalm/jfac065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/21/2022] [Indexed: 11/09/2023]
Abstract
BACKGROUND Loperamide (Imodium®), a commonly used anti-diarrheal, is a mu opioid receptor agonist that, like all opioids, reduces gastrointestinal tract peristalsis. Loperamide is considered to have low abuse potential as it does not produce an analgesic or euphoric effect due to low bioavailability and first-pass metabolism. However, reports of individuals misusing loperamide through the use of super-therapeutic doses, alone or in combination with P-glycoprotein and/or CYP450 enzyme inhibitors, is increasing. We hypothesized that loperamide could potentially cross-react with laboratory immunoassay drug screens. METHODS Drug-free urine was spiked with loperamide or its principal metabolite, N-desmethyl loperamide (dLop), and assayed on multiple fentanyl and buprenorphine assays. Fentanyl immunoassay screen-positive results at one institution were examined by high-resolution mass spectrometry (MS) for the presence of loperamide and quantified by liquid chromatography- tandem MS when positive. RESULTS Loperamide produced positive results on the Thermo DRI Fentanyl and Immunalysis Fentanyl assays at concentrations greater than 5.72 mg/L and 23.7 mg/L. dLop generated positive results for the Thermo DRI and Immunalysis fentanyl assays at concentrations exceeding 6.9 mg/L and 35.7 mg/L. dLop also produced positive buprenorphine results on the Thermo CEDIA buprenorphine assay at concentrations exceeding 12.2 mg/L. High-resolution MS analysis of 225 fentanyl immunoassay positives (Thermo DRI) yielded 5 specimens containing loperamide and/or dLop, 4 of which contained measurable quantities of fentanyl in addition to loperamide/dLop. CONCLUSIONS Laboratories using these assays should be aware of the potential for false-positive screening results due to the presence of high concentrations of loperamide and its metabolite dLop.
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Affiliation(s)
- K Aaron Geno
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Adina Badea
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Kara L Lynch
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Paul Jannetto
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jacqueline A Hubbard
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Mark A Cervinski
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Health System, Lebanon, NH, USA
- The Geisel School of Medicine at Dartmouth, Hanover, NH, USA
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Lei Z, Rong H, Yang Y, Yu S, Zhang T, Chen L, Nie Y, Song Q, Hu Q, Guo J. Loperamide Induces Excessive Accumulation of Bile Acids in the Liver of Mice with Different Diets. Toxicology 2022; 477:153278. [DOI: 10.1016/j.tox.2022.153278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 01/03/2023]
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Lai X, Wang A. Clinical Study on Prevention of Irinotecan-Induced Delayed-Onset Diarrhea by Hot Ironing with Moxa Salt Packet on Tianshu and Shangjuxu. Emerg Med Int 2022; 2022:6587884. [PMID: 35912389 PMCID: PMC9334062 DOI: 10.1155/2022/6587884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To study the clinical efficacy of hot ironing of the Tianshu and Shangjuxu with moxa salt packet to prevent irinotecan (CPT-11)-induced delayed-onset diarrhea (IIDD). Methods A randomized controlled study was conducted on a sample of 120 patients with advanced colorectal cancer who were hospitalized in our oncology department and treated with FOLFIRI chemotherapy regimen from February 2018 to July 2021. They were equally divided into study group (n = 60) and control group (n = 60) according to whether they were treated with hot ironing with moxa salt packs or not. The general conditions, occurrence of IIDD, occurrence of delayed chemotherapy due to IIDD, time of occurrence and duration of IIDD, Karnofsky performance score (KPS) score, occurrence of leukopenia, and myelosuppression were compared between the two groups. Result The incidence of grade 1, 2, 3, and 4 diarrhea in the study group was 11.67% (7/60), 5.00% (3/60), 3.33% (2/60), and 0.00% (0/60), respectively, while the incidence of grade 1, 2, 3, and 4 diarrhea in the control group was 21.67% (13/60), 8.33% (5/60), 10.00% (6/60), and 3.33% (2/60). The incidence of severe diarrhea and total diarrhea in the study group was (3.33% and 20.00%) lower than that in the control group (13.33% and 43.33%) (P < 0.05). The incidence of delayed chemotherapy was lower in the study group (8.33%) (1/12) than in the control group (23.08%) (6/26) but the difference between the groups was not statistically significant (P > 0.05). The time to onset of IIDD in the study group (6.45 ± 1.53) days was comparable to that in the control group (6.40 ± 1.77 days) (P > 0.05), but the duration of IIDD in the study group (3.25 ± 1.05 days) was shorter than that in the control group (5.70 ± 1.72 days) (P < 0.05). After treatment, the incidence of KPS improvement, stabilization, and reduction in the study group was 38.33% (23/60), 51.67% (31/60), and 10.00% (6/60), respectively, the incidence of KPS improvement, stabilization, and reduction in the control group was 23.33% (14/60), 50.00% (30/60), and 26.67% (16/60), respectively, and the percentage of KPS reduction in the study group was less than that in the control group (P < 0.05). During the observation period after treatment, the total incidence of leucopenia in the study group was 11.67% (7/60) which is lower than 31.67% (19/60) in the control group (P < 0.05). During the observation period after treatment, the incidence of III°+°IV myelosuppression in the study group was 5.00% (3/60) which is lower than 25.00% (15/60) in the control group (P < 0.05). Conclusion The hot ironing with moxa salt packet on Tianshu and Shangjuxu was more effective in preventing IIDD, which could reduce the incidence and severity of IIDD, shorten the duration of diarrhea and significantly increase the quality of life of patients with no significant adverse effects.
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Affiliation(s)
- Xianghong Lai
- Department of Integrated Chinese and Western Medicine Oncology, Hangzhou Cancer Hospital, Hangzhou, Zhejiang 310002, China
| | - Anmei Wang
- Department of Integrated Chinese and Western Medicine Oncology, Hangzhou Cancer Hospital, Hangzhou, Zhejiang 310002, China
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Giesing W, Koester C, Al-Akchar M, Kulkarni A, Labedi M. Loperamide-Induced Ventricular Tachycardia Storm. Avicenna J Med 2022; 12:93-96. [PMID: 35833161 PMCID: PMC9272451 DOI: 10.1055/s-0042-1749628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
AbstractLoperamide is an over-the-counter antilaxative medication with minor opioid properties. For this reason, it has recently become a drug of concern for the Food and Drug Administration due to its potential for abuse. In addition, further apprehension pertaining to its over-the-counter availability has developed due to the recent increase in reported cases of loperamide overdose or prolonged use leading to arrhythmias. We describe a rare case of loperamide-induced ventricular tachycardia storm.
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Affiliation(s)
- William Giesing
- Internal Medicine, Southern Illinois University School of Medicine At the time of authorship, I was a 4th year medical student at Southern Illinois University School of Medicine. Therefore, my division/department name should be “Student”. Or, “Internal Medicine” could be used since that is the specialty into which I am entering for my training., Illinois, United States
| | - Cameron Koester
- Department of Internal Medicine, Medical College of Wisconsin, Wisconsin, United States
- Department of Cardiology, Medical College of Wisconsin, Wisconsin, United States
| | - M Al-Akchar
- Department of Internal Medicine, Southern Illinois University School of Medicine, Illinois, United States
- Department of Cardiology, Southern Illinois University School of Medicine, Illinois, United States
| | - Abhishek Kulkarni
- Department of Internal Medicine, Southern Illinois University School of Medicine, Illinois, United States
- Department of Cardiology, Southern Illinois University School of Medicine, Illinois, United States
| | - Mohamed Labedi
- Department of Internal Medicine, Southern Illinois University School of Medicine, Illinois, United States
- Department of Cardiology, Southern Illinois University School of Medicine, Illinois, United States
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Rehman NU, Ansari MN, Ahmad W, Ahamad SR. Dual Inhibition of Phosphodiesterase and Ca++ Channels Explains the Medicinal Use of Balanites aegyptiaca (L.) in Hyperactive Gut Disorders. Plants 2022; 11:1183. [PMID: 35567184 PMCID: PMC9105777 DOI: 10.3390/plants11091183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 02/03/2023]
Abstract
The present study attempted to evaluate and rationalize the medicinal use of the methanolic extract of the fruits of Balanites aegyptiaca (B. aegyptiaca) in the treatment of hyperactive gut disorders. The in vivo, castor oil-induced diarrhea model in mice was followed to test its antidiarrheal effect. To test the antispasmodic effect and to explore its pharmacodynamic details, isolated small intestines (ileum) obtained from rats were selected to provide physiological conditions for the ex vivo assays. In the in vivo assays, the orally administered extract of B. aegyptiaca protected mice from diarrheal drops with resultant percent inhibitions of 40% and 80% at the respective doses of 200 mg/kg and 400 mg/kg, while the highest protection (100%) was observed with a positive control drug, loperamide, at 10 mg/kg. In the ileum, B. aegyptiaca produced an antispasmodic effect in a concentration-dependent manner by inhibiting the carbachol (CCh; 1 µM) and high K+ (80 mM)-evoked spasms with resultant EC50 values of 1.44 mg/mL (1.08–1.78) and 1.27 mg/mL (0.98–1.66), respectively. Papaverine, a known phosphodiesterase enzyme (PDE) inhibitor and blocker of Ca++ channels (CCB), also inhibited both CCh and high K+ induced contractions at comparable EC50 values of 8.72 µM (7.92–9.24) and 8.14 µM (7.62–8.84), respectively. Contrary to the extract and papaverine, verapamil showed distinctly higher potency in regard to inhibiting high K+, compared to CCh-evoked spasms that had EC50 values of 0.16 µM (0.13–0.261) and 2.54 µM (2.28–2.92), respectively. The inhibitory effects of B. aegyptiaca on PDE were further confirmed when the pre-incubated extract shifted the isoprenaline-mediated relaxation curves (CRCs) towards the left, similar to papaverine, whereas the CCB-like effect was confirmed when the pre-incubated tissues with B. aegyptiaca caused deflection in the Ca++ CRCs towards the right, constructed in Ca++ free medium with suppression of the maximum response. Thus, this study provides detailed, mechanistic support for the medicinal use of B. aegyptiaca in the treatment of hyperactive gut disorders.
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Wu PE, Juurlink DN. Loperamide Cardiac Toxicity – Pathophysiology, Presentation and Management. Can J Cardiol 2022; 38:1378-1383. [DOI: 10.1016/j.cjca.2022.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/02/2022] Open
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Ibe T, Sileno S, Harrison MF. 24-Year-Old Man With Syncope. Mayo Clin Proc 2022; 97:620-623. [PMID: 35246291 DOI: 10.1016/j.mayocp.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/07/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Tochukwu Ibe
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Sean Sileno
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Jacksonville, FL
| | - Michael F Harrison
- Advisor to residents and Consultant in Emergency Medicine and Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
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Arrari F, Jabri MA, Hammami I, Sebai H. Extraction of Pectin from Orange Peel and Study of Its Protective Effect Against Loperamide-Induced Impaired Gastrointestinal Motor Functions and Oxidative Stress in Rats. J Med Food 2022; 25:892-901. [PMID: 35143346 DOI: 10.1089/jmf.2021.0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pectin is a polysaccharide attached to carbohydrates. These are substances exclusively of plant origin. The aim of the present study is to evaluate the laxative effects of orange peel pectin extract (OPPE) against constipation induced by loperamide (LOP) in rats. Rats were equally divided into six groups and treated daily 1 week as follows: Control, LOP (3 mg/kg, body weight [b.w.], Per Os [p.o.]), LOP+yohimbine (2 mg/kg, b.w., i.p.), and LOP+OPPE (6.25, 12.5, and 25 mg/kg, b.w., p.o.). At the end of the experiment, the effects of OPPE were assessed by fecal parameters (numbers, weight, and water content), gastrointestinal transit, gastric emptying, serum metabolic parameter changes, intestinal and colon mucosa oxidative stress, and the histological examination. The defecation test showed that administration of LOP (3 mg/kg, b.w., p.o.) leads to the production of remarkable constipation. Indeed, the number and water content of stools decreased (25.50 [n/24 h] and 29.86%) significantly (P < .05). Acute pretreatment with OPPE significantly and dose dependently accelerated the stool moistening and allowed an increase of stool weight (2.85, 3.61, 3.93 [g/24 h/rat]) as well as the frequency of defecation (47.36, 54.54, and 56.26 [n/24 h]). OPPE also significantly (P < .05) and dose dependently increased the intestinal motility (70.78%, 73.33%, and 75.01%) and gastric emptying. LOP-induced reduction (P < .05) of intestinal secretion was accompanied by a colonic and small bowel oxidative stress status and histological changes, which was attenuated by OPPE treatment. The findings of this study indicate that OPPE possesses an important role in the gastrointestinal motility regulation, and thus lend pharmacological credence to the suggested use of the natural pectin for the treatment, management, and/or control of constipation.
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Affiliation(s)
- Fatma Arrari
- Unit of Functional Physiology and Valorization of Bio-Resources-Higher Institute of Biotechnology of Beja, University of Jendouba, Beja, Tunisia
| | - Mohamed-Amine Jabri
- Unit of Functional Physiology and Valorization of Bio-Resources-Higher Institute of Biotechnology of Beja, University of Jendouba, Beja, Tunisia
| | - Imen Hammami
- Research Unit n° 17/ES/13, Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Hichem Sebai
- Unit of Functional Physiology and Valorization of Bio-Resources-Higher Institute of Biotechnology of Beja, University of Jendouba, Beja, Tunisia
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Dodu JC, Moncayo RK, Damaj MI, Schlosburg JE, Akbarali HI, O'Brien LD, Kendall DA, Wu Z, Lu D, Lichtman AH. The Cannabinoid Receptor Type 1 Positive Allosteric Modulator ZCZ011 Attenuates Naloxone-Precipitated Diarrhea and Weight Loss in Oxycodone-Dependent Mice. J Pharmacol Exp Ther 2022; 380:1-14. [PMID: 34625464 PMCID: PMC8969135 DOI: 10.1124/jpet.121.000723] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 10/01/2021] [Indexed: 01/03/2023] Open
Abstract
Opioid use disorder reflects a major public health crisis of morbidity and mortality in which opioid withdrawal often contributes to continued use. However, current medications that treat opioid withdrawal symptoms are limited by their abuse liability or lack of efficacy. Although cannabinoid 1 (CB1) receptor agonists, including Δ9-tetrahydrocannabinol, ameliorate opioid withdrawal in both clinical and preclinical studies of opioid dependence, this strategy elicits cannabimimetic side effects as well as tolerance and dependence after repeated administration. Alternatively, CB1 receptor positive allosteric modulators (PAMs) enhance CB1 receptor signaling and show efficacy in rodent models of pain and cannabinoid dependence but lack cannabimimetic side effects. We hypothesize that the CB1 receptor PAM ZCZ011 attenuates naloxone-precipitated withdrawal signs in opioid-dependent mice. Accordingly, male and female mice given an escalating dosing regimen of oxycodone, a widely prescribed opioid, and challenged with naloxone displayed withdrawal signs that included diarrhea, weight loss, jumping, paw flutters, and head shakes. ZCZ011 fully attenuated naloxone-precipitated withdrawal-induced diarrhea and weight loss and reduced paw flutters by approximately half, but its effects on head shakes were unreliable, and it did not affect jumping behavior. The antidiarrheal and anti-weight loss effects of ZCZ0111 were reversed by a CB1 not a cannabinoid receptor type 2 receptor antagonist and were absent in CB1 (-/-) mice, suggesting a necessary role of CB1 receptors. Collectively, these results indicate that ZCZ011 completely blocked naloxone-precipitated diarrhea and weight loss in oxycodone-dependent mice and suggest that CB1 receptor PAMs may offer a novel strategy to treat opioid dependence. SIGNIFICANCE STATEMENT: Opioid use disorder represents a serious public health crisis in which current medications used to treat withdrawal symptoms are limited by abuse liability and side effects. The CB1 receptor positive allosteric modulator (PAM) ZCZ011, which lacks overt cannabimimetic behavioral effects, ameliorated naloxone-precipitated withdrawal signs through a CB1 receptor mechanism of action in a mouse model of oxycodone dependence. These results suggest that CB1 receptor PAMs may represent a viable strategy to treat opioid withdrawal.
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Affiliation(s)
- Julien C Dodu
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Rebecca K Moncayo
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - M Imad Damaj
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Joel E Schlosburg
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Hamid I Akbarali
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Lesley D O'Brien
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Debra A Kendall
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Zhixing Wu
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Dai Lu
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
| | - Aron H Lichtman
- Department of Pharmacology & Toxicology (J.C.D., R.K.M., M.I.D., J.E.S., H.I.A., L.D.O., A.H.L.), and Department of Medicinal Chemistry (A.H.L.), Virginia Commonwealth University, Richmond, Virginia; Department of Pharmaceutical Sciences, University of Connecticut, Mansfield, Connecticut (D.A.K.); and Department of Pharmaceutical Sciences, Texas A&M, College Station, Texas (Z.W., D.L.)
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Modi V, Krinock M, Desai R, Stevens S, Nanda S. Loperamide-Induced Cardiac Events: Case Reports and Review. Cureus 2021; 13:e20744. [PMID: 35111436 PMCID: PMC8792126 DOI: 10.7759/cureus.20744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2021] [Indexed: 11/05/2022] Open
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Isang E, Shali L, Morris CB, Mahlow J. Loperamide-Induced Torsades de Pointes. Cureus 2021; 13:e20299. [PMID: 35028205 PMCID: PMC8747988 DOI: 10.7759/cureus.20299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 11/18/2022] Open
Abstract
Loperamide, an over-the-counter antidiarrheal, works on the µ opioid receptor with minimal opioid activity if taken as directed. Recently, it has gained popularity as the “poor man's methadone” at supratherapeutic dosing. Opioid antagonism with naloxone is beneficial in reversing respiratory depression but has no effect on cardiotoxicity due to the human ether-a-go-go-related gene (hERG). We present the case of a 34-year-old female who presented for syncope after taking 48 tablets of 2 mg loperamide. On arrival, she was obtunded with variable heart block and a QTc of 560 ms. Subsequently, due to further QT prolongation from loperamide to 656 ms, she developed Torsades de Pointes requiring defibrillation at 120 J twice. Ultimately, she was discharged home with psychiatric and substance abuse outpatient follow-up. Patients and healthcare providers face new challenges with the increase in loperamide misuse due to easy access and delayed identification. It is important for clinicians to recognize and be familiar with loperamide overdose given the potential for multiorgan failure and increased mortality.
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Miles WM, George P. Physiologic Variants of Cardiac Conduction (Aberration, Gap, Supernormal Conduction). Card Electrophysiol Clin 2021; 13:607-624. [PMID: 34689890 DOI: 10.1016/j.ccep.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Wide QRS complexes during supraventricular rhythms can be caused by fixed bundle branch block, functional (intermittent) bundle branch block, preexcitation, or toxic/metabolic causes. Functional bundle branch block can be caused by long-short aberrancy (usually physiologic), or acceleration/deceleration dependent aberrancy (usually pathologic). Electrocardiogram criteria have been proposed to differentiate aberration from ventricular tachycardia; they are not always accurate. The gap phenomenon "paradox" is that with increasingly premature extrastimuli, progressive proximal conduction delay allows time for distal recovery of excitability. Supernormal conduction may explain unusual conduction phenomena in patients with abnormal His-Purkinje function or poorly conducting accessory pathways.
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Affiliation(s)
- William M Miles
- University of Florida College of Medicine, 1329 S.W. 16th Avenue, PO Box 100288, Gainesville, Florida 32608, USA.
| | - Philip George
- University of Florida College of Medicine, 1329 S.W. 16th Avenue, PO Box 100288, Gainesville, Florida 32608, USA
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Etaee F, Tobin M, Vuppala S, Komaki A, Delisle BP, Di Biase L, Catanzaro JN, Natale A, Elayi CS. Effects of opioid receptor agonist and antagonist medications on electrocardiogram changes and presentation of cardiac arrhythmia: review article. J Interv Card Electrophysiol 2021. [PMID: 34674120 DOI: 10.1007/s10840-021-01072-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE Mortality associated with prescription opioids has significantly increased over the past few decades and is considered a global pandemic. Prescribed opioids can cause cardiac arrhythmias, leading to fatal outcomes and unexpected death, even in the absence of structural cardiac disease. Despite the extent of cardiac toxicity and death associated with these medications, there is limited data to suggest their influences on cardiac electrophysiology and arrhythmias, with the exception of methadone. The goal of our review is to describe the possible mechanisms and to review the different ECG changes and arrhythmias that have been reported. METHODS A literature search was performed using Google Scholar, PubMed, Springer, Ovid, and Science Direct to identify studies that demonstrated the use of prescription opioids leading to electrocardiogram (ECG) changes and cardiac arrhythmias. RESULTS Many of the commonly prescribed opioid medications can uniquely effect the ECG, and can lead to the development of various cardiac arrhythmias. One of the most significant side effects of these drugs is QTc interval prolongation, especially when administered to patients with a baseline risk for QTc prolongation. A prolonged QTc interval can cause lethal torsades de pointes and ventricular fibrillation. Obtaining an ECG at baseline, following a dosage increase, or after switching an opioid medication, is appropriate in patients taking certain prescribed opioids. Opioids are often used first line for the treatment of acute and chronic pain, procedural sedation, medication opioid use disorders, and maintenance therapy. CONCLUSIONS To reduce the risk of cardiac arrhythmias and to improve patient outcomes, consideration of accurate patient selection, concomitant medications, electrolyte monitoring, and vigilant ECG monitoring should be considered.
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Betting DJ, Chenoweth JA, Jarman AF. A Case Report of Cardiogenic Syncope Due to Loperamide Abuse: Acute Presentation and Novel Use of Buprenorphine. Clin Pract Cases Emerg Med 2021; 5:214-217. [PMID: 34437008 PMCID: PMC8143836 DOI: 10.5811/cpcem.2021.3.51152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/12/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Loperamide is a non-prescription anti-diarrheal agent targeting μ-opioid receptors in the intestinal tract. At high doses it crosses the blood-brain barrier, where μ-opioid agonism can cause euphoric effects. Misuse has been increasing for both the euphoric effects and as an alternative treatment for opioid dependence and withdrawal. Case Report Here we report the case of a 30-year-old woman presenting with syncope, who was found to have severe myocardial conduction delays in the setting of chronic loperamide abuse. Conclusion Treatment with sodium bicarbonate and hypertonic sodium resulted in improvement of her conduction abnormalities. Prior to discharge she was initiated on buprenorphine for her opioid use disorder.
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Affiliation(s)
- David J Betting
- UC Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - James A Chenoweth
- UC Davis Medical Center, Department of Emergency Medicine, Sacramento, California
| | - Angela F Jarman
- UC Davis Medical Center, Department of Emergency Medicine, Sacramento, California
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Abstract
Loperamide, a popular and inexpensive over-the-counter antidiarrheal medicine, is a potent μ-opioid receptor agonist approved by the U.S. Food and Drug Administration (FDA). It has been on the market since 1976 and is relatively safe with no central nervous system-related side effects when used for a short period of time at the recommended therapeutic dose (2-8 mg/day). In recent years, loperamide has become notoriously known as the "poor man's methadone" for people with substance dependence due to the increase in loperamide overdoses from self-administered medication to treat opioid withdrawal symptoms. As a result, in 2018, the FDA decided to limit the available packaged dose of loperamide to stop prominent abuse. This review provides the synthesis and chemical properties of loperamide as well as the pharmacology and adverse effects of its use and the social effects of such abuse.
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Affiliation(s)
- Cori A. Malinky
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Craig W. Lindsley
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
- Department of Chemistry, Vanderbilt Institute of Chemical Biology, Vanderbilt University, Nashville, Tennessee 37232, United States
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
| | - Changho Han
- Warren Center for Neuroscience Drug Discovery, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, United States
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Vearrier D, Grundmann O. Clinical Pharmacology, Toxicity, and Abuse Potential of Opioids. J Clin Pharmacol 2021; 61 Suppl 2:S70-S88. [PMID: 34396552 DOI: 10.1002/jcph.1923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/03/2021] [Indexed: 12/15/2022]
Abstract
Opioids were the most common drug class resulting in overdose deaths in the United States in 2019. Widespread clinical use of prescription opioids for moderate to severe pain contributed to the ongoing opioid epidemic with the subsequent emergence of fentanyl-laced heroin. More potent analogues of fentanyl and structurally diverse opioid receptor agonists such as AH-7921 and MT-45 are fueling an increasingly diverse illicit opioid supply. Overdose from synthetic opioids with high binding affinities may not respond to a typical naloxone dose, thereby rendering autoinjectors less effective, requiring higher antagonist doses or resulting in a confusing clinical picture for health care providers. Nonscheduled opioid drugs such as loperamide and dextromethorphan are associated with dependence and risk of overdose as easier access makes them attractive to opioid users. Despite a common opioid-mediated pathway, several opioids present with unique pharmacodynamic properties leading to acute toxicity and dependence development. Pharmacokinetic considerations involve half-life of the parent opioid and its metabolites as well as resulting toxicity, as is established for tramadol, codeine, and oxycodone. Pharmacokinetic considerations, toxicities, and treatment approaches for notable opioids are reviewed.
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Affiliation(s)
- David Vearrier
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Oliver Grundmann
- Department of Medicinal Chemistry, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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Abstract
In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.
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Acquisto NM, Slocum GW, Bilhimer MH, Awad NI, Justice SB, Kelly GF, Makhoul T, Patanwala AE, Peksa GD, Porter B, Truoccolo DMS, Treu CN, Weant KA, Thomas MC. Key articles and guidelines for the emergency medicine clinical pharmacist: 2011-2018 update. Am J Health Syst Pharm 2021; 77:1284-1335. [PMID: 32766731 DOI: 10.1093/ajhp/zxaa178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To summarize recently published research reports and practice guidelines on emergency medicine (EM)-related pharmacotherapy. SUMMARY Our author group was composed of 14 EM pharmacists, who used a systematic process to determine main sections and topics for the update as well as pertinent literature for inclusion. Main sections and topics were determined using a modified Delphi method, author and peer reviewer groups were formed, and articles were selected based on a comprehensive literature review and several criteria for each author-reviewer pair. These criteria included the document "Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009)" but also clinical implications, interest to reader, and belief that a publication was a "key article" for the practicing EM pharmacist. A total of 105 articles published from January 2011 through July 2018 were objectively selected for inclusion in this review. This was not intended as a complete representation of all available pertinent literature. The reviewed publications address the management of a wide variety of disease states and topic areas that are commonly found in the emergency department: analgesia and sedation, anticoagulation, cardiovascular emergencies, emergency preparedness, endocrine emergencies, infectious diseases, neurology, pharmacy services and patient safety, respiratory care, shock, substance abuse, toxicology, and trauma. CONCLUSION There are many important recent additions to the EM-related pharmacotherapy literature. As is evident with the surge of new studies, guidelines, and reviews in recent years, it is vital for the EM pharmacist to continue to stay current with advancing practice changes.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Giles W Slocum
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | | | - Nadia I Awad
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ
| | | | - Gregory F Kelly
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Therese Makhoul
- Department of Pharmacy, Santa Rosa Memorial Hospital, Santa Rosa, CA
| | - Asad E Patanwala
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Gary D Peksa
- Department of Pharmacy, Rush University Medical Center, Chicago, IL
| | - Blake Porter
- Department of Pharmacy, University of Vermont Medical Center, Burlington, VT
| | | | - Cierra N Treu
- Department of Pharmacy, NewYork Presbyterian-Brooklyn Methodist Hospital, Brooklyn, NY
| | - Kyle A Weant
- Medical University of South Carolina College of Pharmacy, Medical University of South Carolina, Charleston, SC
| | - Michael C Thomas
- McWhorter School of Pharmacy, Samford University, Birmingham, AL
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Abstract
PURPOSE A case of loperamide-induced recurrent torsades de pointes is reported to raise awareness of an increasingly common phenomenon that could be encountered by medical providers during the current opioid epidemic. SUMMARY A 40 year-old-man with a prior history of opioid abuse who presented to the emergency department after taking up to 100 tablets of loperamide 2 mg daily for 5 years to blunt opioid withdrawal symptoms and was subsequently admitted to the intensive care unit for altered mental status and hyperthermia. The patient had prolonged QTc and 2 episodes of torsades de pointes (TdP) that resulted in cardiac arrest with return of spontaneous circulation. He was managed with isoproterenol, overdrive pacing, and methylnatrexone with no other events of TdP or cardiac arrest. CONCLUSION A 40-year-old male who developed torsades de pointes from loperamide overdose effectively treated with overdrive pacing, isoproterenol, and methylnatrexone.
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Affiliation(s)
- Gregory G Jackson
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christine R Lopez
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Elizabeth S Bermudez
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nina E Hill
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dan M Roden
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.,Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness Brain Dysfunction Survivorship Center, Nashville, Vanderbilt University Medical Center, Nashville, TN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA.,Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, Nashville, TN, USA
| | - Joanna L Stollings
- Division of Clinical Pharmacology, Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA.,Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
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Affiliation(s)
- Catherine E Lowe
- Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Michael D Winniford
- Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson
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Pessoa MLDS, Silva LMO, Araruna MEC, Serafim CADL, Júnior EBA, Silva AO, Pessoa MMB, Neto HD, Lima EDO, Batista LM. Antifungal activity and antidiarrheal activity via antimotility mechanisms of (-)-fenchone in experimental models. World J Gastroenterol 2020; 26:6795-6809. [PMID: 33268962 PMCID: PMC7684460 DOI: 10.3748/wjg.v26.i43.6795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/12/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND (-)-Fenchone is a bicyclic monoterpene present in essential oils of plant species, such as Foeniculum vulgare and Peumus boldus, used to treatment of gastrointestinal diseases. Pharmacological studies report its anti-inflammatory, antioxidant, and antinociceptive activity.
AIM To investigate antidiarrheal activity related to gastrointestinal motility, intestinal secretion and antimicrobial activity.
METHODS A castor oil-induced diarrhea model was used to evaluate antidiarrheal activity. Intestinal transit and gastric emptying protocols were used to assess a possible antimotility effect. Muscarinic receptors, presynaptic α2-adrenergic and tissue adrenergic receptors, KATP channels, nitric oxide were investigated to uncover antimotility mechanisms of action and castor oil-induced enteropooling to elucidate antisecretory mechanisms. The antimicrobial activity was evaluated in the minimum inhibitory concentration model, the fractional inhibitory concentration index using the (-)-fenchone association method with standard antifungal agents.
RESULTS (-)-Fenchone (75, 150 and 300 mg/kg) showed antidiarrheal activity, with a significant decrease in the evacuation index. This activity is possibly related to a percentage of reduced intestinal transit (75, 150 and 300 mg/kg). The antimotility effect of (-)-fenchone decreased in the presence of pilocarpine, yohimbine, propranolol, L-NG-nitroarginine methyl ester or glibenclamide. In the enteropooling model, no reduction in intestinal fluid weight was observed. (-)- Fenchone did not show antibacterial activity; on the other hand, inhibits the growth of strains of fungi with a minimum fungicide concentration of 32 μg/mL. However, when it was associated with amphotericin B, no synergism was observed.
CONCLUSION The antidiarrheal effect of (-)-fenchone in this study involves antimotility effect and not involve antisecretory mechanisms. (-)-Fenchone presents antifungal activity; however, it did not show antibacterial activity.
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Affiliation(s)
- Michelle Liz de Souza Pessoa
- Department of Pharmaceutical Sciences, IPeFarM, Federal University of Paraíba, João Pessoa 58051-970, Paraíba, Brazil
| | | | - Maria Elaine Cristina Araruna
- Department of Pharmaceutical Sciences, IPeFarM, Federal University of Paraíba, João Pessoa 58051-970, Paraíba, Brazil
| | | | - Edvaldo Balbino Alves Júnior
- Department of Pharmaceutical Sciences, IPeFarM, Federal University of Paraíba, João Pessoa 58051-970, Paraíba, Brazil
| | - Alessa Oliveira Silva
- Department of Pharmaceutical Sciences, IPeFarM, Federal University of Paraíba, João Pessoa 58051-970, Paraíba, Brazil
| | | | - Hermes Diniz Neto
- Department of Pharmaceutical Sciences, IPeFarM, Federal University of Paraíba, João Pessoa 58051-970, Paraíba, Brazil
| | - Edeltrudes de Oliveira Lima
- Department of Pharmaceutical Sciences, IPeFarM, Federal University of Paraíba, João Pessoa 58051-970, Paraíba, Brazil
| | - Leônia Maria Batista
- Postgraduate Program in Natural and Synthetic Bioactive Products, Universidade Federal da Paraiba, João Pessoa 58051-900, Brazil
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31
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Sobczak Ł, Goryński K. Pharmacological Aspects of Over-the-Counter Opioid Drugs Misuse. Molecules 2020; 25:E3905. [PMID: 32867117 DOI: 10.3390/molecules25173905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
Several over-the-counter (OTC) drugs are known to be misused. Among them are opioids such as codeine, dihydrocodeine, and loperamide. This work elucidates their pharmacology, interactions, safety profiles, and how pharmacology is being manipulated to misuse these common medications, with the aim to expand on the subject outlined by the authors focusing on abuse prevention and prevalence rates. The reviewed literature was identified in several online databases through searches conducted with phrases created by combining the international non-proprietary names of the drugs with terms related to drug misuse. The results show that OTC opioids are misused as an alternative for illicit narcotics, or prescription-only opioids. The potency of codeine and loperamide is strongly dependent on the individual enzymatic activity of CYP2D6 and CYP3A4, as well as P-glycoprotein function. Codeine can also be utilized as a substrate for clandestine syntheses of more potent drugs of abuse, namely desomorphine (“Krokodil”), and morphine. The dangerous methods used to prepare these substances can result in poisoning from toxic chemicals and impurities originating from the synthesis procedure. OTC opioids are generally safe when consumed in accordance with medical guidelines. However, the intake of supratherapeutic amounts of these substances may reveal surprising traits of common medications.
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Cruz LF, Figueiredo GFD, Pedro LP, Amorin YM, Andrade JT, Passos TF, Rodrigues FF, Souza ILA, Gonçalves TPR, Dos Santos Lima LAR, Ferreira JMS, Araújo MGDF. Umbelliferone (7-hydroxycoumarin): A non-toxic antidiarrheal and antiulcerogenic coumarin. Biomed Pharmacother 2020; 129:110432. [PMID: 32768935 DOI: 10.1016/j.biopha.2020.110432] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/09/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023] Open
Abstract
Gastrointestinal diseases are very common problems; available treatments are very limited and come with a range of side effects. Coumarins are an extensive class of phenolic compounds that can be found in plants, fungi and bacteria. The 7-hydroxycoumarin, also known as umbelliferone (UMB), is a compound that comes from coumarin and has been showing biological activities in other studies. As of this scenario, the present study was designed to evaluate the acute oral toxicity, mutagenic, antidiarrheal, anti-bacterial, and antiulcerogenic effects, and antioxidant capacity of UMB. An investigation was conducted through the hippocratic screening method and through histopathological analysis in animals to evaluate the effects of acute oral administration of a dose of 50, 100 and 200 mg/kg of UMB. A micronucleus test on peripheral blood of Swiss mice, which were orally treated with three doses (50, 100 and 200 mg/kg), was conducted to evaluate mutagenic activities. The antiulcerogenic activity was accomplished through the ethanol-induced damage method. Antidiarrheal activities were tested for inducing diarrhea with castor oil and evaluating intestinal transit duration; additionally, the antimicrobial effect against some enteropathogenic bacteria was analyzed. Finally, the antioxidant capability was determined by the capacity of the UMB sample to kidnap the stable radical 2,2-diphenyl-1-picrylhydrazyl. Of the evaluated doses, signs of toxicity after acute administration of the compound were not observed. UMB presented antiulcerogenic activity (100 and 200 mg/kg), which was explained because of its antioxidant capacity. A gastro protective effect was similar to the positive control, and the UMB was able to significantly reduce intestinal transit, and also diarrheal symptoms. Furthermore, UMB had an anti-bacterial effect with minimum inhibitory concentration fluctuating between 62.5 and 1000 μg/mL. Based on these findings, we can suggest that UMB has important biological activities in vivo and in vitro and is not toxic under the evaluated circumstances, which demonstrates its large potential for pharmacological use.
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Affiliation(s)
- Luisa Ferreira Cruz
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil.
| | - Geisa Fantini de Figueiredo
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Lidiane Paula Pedro
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Yuri Martins Amorin
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Jessica Tauany Andrade
- Laboratory of Medical Microbiology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Tiago Faustino Passos
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Felipe Fernandes Rodrigues
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Israel Lucas Antunes Souza
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Thaís Paula Rodrigues Gonçalves
- Laboratory of Phytochemistry, Federal University of São João Del-Rei, Campus Centro Oeste Dona Lindu, Divinópolis, MG, Brazil
| | | | - Jaqueline Maria Siqueira Ferreira
- Laboratory of Medical Microbiology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
| | - Marcelo Gonzaga de Freitas Araújo
- Laboratory of Pharmacology, Federal University of São João Del-Rei, Sebastião Gonçalves Coelho, 400, Chanadour, 35501-296, Divinópolis, MG, Brazil
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33
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Abstract
Loperamide is a widely available, over-the-counter medication. The advent of the opioid epidemic has seen cases of loperamide overdose being reported. The common side effects of the medication can be relatively benign, but at high doses, loperamide can precipitate life-threatening arrhythmias. Our case highlights rare side effects of loperamide overdose inducing ventricular tachycardia, with unfavorable consequences. This case emphasizes that the distribution and availability of this medication should be restricted, to be a prescription drug, to prevent overdose and adverse outcomes.
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Affiliation(s)
- Zain Ali
- Physician, Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Umer Shoukat
- Physician, Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Mariya Khan
- Civil Hospital, Karachi, Dow University of Health Sciences, Karachi, Pakistan
| | - Sohaib Roomi
- Resident Physician, Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
| | - Waqas Ullah
- Physician, Internal Medicine, Abington Memorial Hospital, Abington, PA, USA.,Civil Hospital, Karachi, Dow University of Health Sciences, Karachi, Pakistan.,Resident Physician, Internal Medicine, Abington Memorial Hospital, Abington, PA, USA
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34
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Abstract
Loperamide is a synthetic, over-the-counter, antidiarrheal medication that is widely available and used for the treatment of diarrhea. It is a peripherally acting opioid agonist acting mostly on the μ-opioid receptors in the gut. It was thought to be a very safe medication up until very recently, as the bioavailability of the drug is very low. At significantly higher doses, it is able to cross the blood-brain barrier and mimic the effects of centrally acting opioids. However, at these significantly high doses it also leads to significant cardiotoxic consequences. Here we present a case of a 31-year-old male with significant cardiotoxicity secondary to misuse and abuse of loperamide.
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Affiliation(s)
- Mohammed Ali
- Pulmonary and Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, USA
| | - Aisha Mujahid
- Medicine, Shadan Institute of Medical Sciences, NTR University of Health Sciences, Hyderabad, IND
| | | | - Salim Surani
- Internal Medicine, Texas A&M Health Science Center, Bryan, USA
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35
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Watson CJ, Whitledge JD, Barbuto AF, Boyle KL, Ganetsky M. Toxicity of agents used for opioid withdrawal: a case-based approach. Int Anesthesiol Clin 2020; 58:19-27. [PMID: 31904630 DOI: 10.1097/AIA.0000000000000265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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36
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Eggleston W, Palmer R, Dubé PA, Thornton S, Stolbach A, Calello DP, Marraffa JM. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila) 2019; 58:355-359. [DOI: 10.1080/15563650.2019.1681443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, NY, USA
- Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA
| | | | - Pierre-André Dubé
- Department of Environmental Health and Toxicology, Institut National de Santé Publique du Québec, Quebec, Canada
| | - Stephen Thornton
- Emergency Medicine, University of Kansas Medical Center, Kansas City, KS, USA
- Poison Control Center, University of Kansas Health System, Kansas City, KS, USA
| | - Andrew Stolbach
- Emergency Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Diane P Calello
- Rutgers New Jersey Medical School, Department of Emergency Medicine, New Jersey Poison Information and Education System, Newark, NJ, USA
| | - Jeanna M Marraffa
- Department of Emergency Medicine, Upstate Medical University, Upstate New York Poison Center, Syracuse, NY, USA
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37
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Ishii K, Morii N, Yamashiro H. Pertuzumab in the treatment of HER2-positive breast cancer: an evidence-based review of its safety, efficacy, and place in therapy. Core Evid 2019; 14:51-70. [PMID: 31802990 PMCID: PMC6827570 DOI: 10.2147/ce.s217848] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/01/2019] [Indexed: 12/23/2022]
Abstract
Human epidermal growth factor receptor 2 (HER2)-positive breast cancer is a distinct subset of breast cancer that results from overexpression of HER2 protein. Pertuzumab-a recombinant humanized monoclonal antibody that binds to the extracellular dimerization domain II of HER2-was recently approved for adjuvant therapy and neoadjuvant therapy of HER2-positive early breast cancer. As pertuzumab and trastuzumab bind to different domains of the extracellular dimerization domain of HER2, a combination therapy of pertuzumab and trastuzumab is beneficial for the treatment of metastatic cancer, advanced local cancer, or early cancer by dual HER2 blockage. Many clinical trials have been performed using pertuzumab for breast cancer patients; these include the CLEOPATRA trial for palliative therapy, the APHINITY trial for adjuvant therapy, and the NeoSphere and the TRYPHAENA trials for neoadjuvant therapy. These trials revealed pertuzumab to be a safe and effective drug regardless of the patient age and hormone receptor status. Notably, pertuzumab use was associated with severe cardiac toxicity in some cases; however, the risk of pertuzumab-induced cardiac dysfunction was low. The most common adverse effect associated with pertuzumab-use was diarrhea, but most cases were not severe. Several different chemotherapeutic agents have been investigated to determine optimal chemotherapeutic combinations for dual HER2 blockage. Some exploratory analyses indicate that pertuzumab treatment offered little benefit to patients with node-negative and small primary tumors; pertuzumab treatment was also found not be cost-effective. Further research will reveal the appropriate usage of pertuzumab for treating a subset of eligible patients.
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Affiliation(s)
- Kei Ishii
- Department of Breast Surgery, Tenri Hospital, Tenri, Japan
| | - Nao Morii
- Department of Breast Surgery, Tenri Hospital, Tenri, Japan
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38
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Lin QM, Li YH, Liu Q, Pang NH, Xu RA, Cai JP, Hu GX. Functional characteristics of CYP3A4 allelic variants on the metabolism of loperamide in vitro. Infect Drug Resist 2019; 12:2809-2817. [PMID: 31571937 PMCID: PMC6750855 DOI: 10.2147/idr.s215129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/08/2019] [Indexed: 11/23/2022] Open
Abstract
Background Cytochrome P450 3A4 (CYP3A4) appears to be genetically polymorphic, which in turn contributes to interindividual variability in response to therapeutic drugs. Loperamide, identified as a CYP3A4 substrate, is prone to misuse and abuse and has high risks of life-threatening cardiotoxicity. Methods Thus, this study is designed to evaluate the enzymatic characteristics of 29 CYP3A4 alleles toward loperamide in vitro, including the 7 novel CYP3A4 variants (*28-*34). The incubation system (containing CYP3A4 enzyme, cytochrome b5, 0.5-20 μM loperamide, potassium phosphate buffer and nicotinamide adenine dinucleotide phosphate) was subject to 40-mins incubation at 37°C and the concentrations of N-demethylated loperamide were quantified by UPLC-MS/MS. Results As a result, CYP3A4.6, .17, .20 and .30 showed extremely low activity or no activity and the rest of CYP3A4 variants presented varying degrees of decrements in catalytical activities when compared with CYP3A4.1. Conclusion As the first study to identify the properties of these CYP3A4 variants toward loperamide metabolism, our investigation may establish the genotype-phenotype relationship for loperamide, predict an individual's capability in response to loperamide, and provide some guidance of clinical medication and treatment for loperamide.
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Affiliation(s)
- Qian-Meng Lin
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Ying-Hui Li
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Qian Liu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Ni-Hong Pang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Ren-Ai Xu
- Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325035, People's Republic of China
| | - Jian-Ping Cai
- The Ministry of Health (MOH) Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing 100730, People's Republic of China
| | - Guo-Xin Hu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou 325035, People's Republic of China
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39
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Affiliation(s)
- Justin P. Reinert
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
| | - Rebecca L. Dunn
- Fisch College of Pharmacy, The University of Texas at Tyler, Tyler, TX, USA
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40
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Teigeler T, Stahura H, Alimohammad R, Kalahasty G, Koneru JN, Ellenbogen M, Ellenbogen KA, Padala SK. Electrocardiographic changes in loperamide toxicity: Case report and review of literature. J Cardiovasc Electrophysiol 2019; 30:2618-2626. [DOI: 10.1111/jce.14129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 06/16/2019] [Accepted: 08/08/2019] [Indexed: 01/18/2023]
Affiliation(s)
- Todd Teigeler
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Heather Stahura
- Capital Cardiology Associates Albany Medical Center Albany New York
| | | | - Gautham Kalahasty
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Jayanthi N. Koneru
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Michael Ellenbogen
- Division of General Internal Medicine Johns Hopkins University School of Medicine Baltimore Maryland
| | - Kenneth A. Ellenbogen
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
| | - Santosh K. Padala
- Division of Cardiac Electrophysiology Virginia Commonwealth University Richmond Virginia
- Capital Cardiology Associates Albany Medical Center Albany New York
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41
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Nukala PK, Palekar S, Patki M, Fu Y, Patel K. Multi-dose oral abuse deterrent formulation of loperamide using hot melt extrusion. Int J Pharm 2019; 569:118629. [PMID: 31425818 DOI: 10.1016/j.ijpharm.2019.118629] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/02/2019] [Accepted: 08/13/2019] [Indexed: 01/01/2023]
Abstract
Loperamide, an over the counter anti-diarrheal drug, also infamously referred to as "poor man's methadone". Due to the ease of availability and low price, people/patients abuse it by consuming more than 30 tablets to achieve euphoric effect and to combat opioid withdrawal. But supratherapeutic doses of loperamide result in severe respiratory depression, cardiac dysrhythmia and mortality. To address this issue, we developed a unique and innovative technology to deter multi-dose oral abuse. The concept is to design a tablet which can immediate release loperamide in diarrheic patients (single tablet) while stops loperamide release in case of intentional multi-dose ingestion. Loperamide was molecularly dispersed into gastric soluble cationic polymers - Eudragit® EPO and Kollicoat® Smartseal 100P using hot melt extrusion to obtain filament. Filaments were milled and compressed into tablets ((Eudragit® EPO (SJU1) and Kollicoat® Smartseal (SJU2)) with optimized amount of L-Arginine. Dissolution in 250 mL of Fasted state simulated gastric fluid (FaSSGF) revealed that single tablet of Imodium® (marketed formulation) and SJU1 showed >85% of release within 15 min. Most importantly, in multi-unit dissolution (15 tablets), Imodium® exhibited >90% release but SJU tablets showed <2% of drug release thus demonstrating its ability to deter multi-dose oral abuse.
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Affiliation(s)
- Pavan Kumar Nukala
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, United States
| | - Siddhant Palekar
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, United States
| | - Manali Patki
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, United States
| | - Yige Fu
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, United States
| | - Ketan Patel
- College of Pharmacy and Health Sciences, St. John's University, Queens, NY 11439, United States.
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42
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Lin QM, Pang NH, Li YH, Huang HL, Zhang XD, Hu GX, Wang ZS. Investigation of the effects of axitinib on the pharmacokinetics of loperamide and its main metabolite N-demethylated loperamide in rats by UPLC-MS/MS. Chem Biol Interact 2019; 310:108744. [PMID: 31299239 DOI: 10.1016/j.cbi.2019.108744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 01/10/2023]
Abstract
The epidemic of loperamide abuse and misuse in the patients for the alternative to opioids has become an increasing worldwide concern and has led to considerations about the potential for drug-drug interactions between loperamide and other combined drugs, especially inhibitors of cytochrome P450 (CYP450) enzymes, such as axitinib. This study assessed the effects of axitinib on the metabolism of loperamide and its main metabolite N-demethylated loperamide in rats and in rat liver microsomes (RLM), human liver microsomes (HLM) and recombinant human CYP3A4*1. The concentrations of both compounds were determined by ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). The exposures (AUC(0-t), AUC(0-∞) and Cmax) of loperamide and N-demethylated loperamide showed a conspicuous increase when loperamide was co-administered with axitinib. The Tmax of loperamide increased while CLz/F decreased under the influence of axitinib. In vitro, axitinib inhibited loperamide metabolism with the IC50 of 18.34 μM for RLM, 1.705 μM for HLM and 1.604 μM for CYP3A4*1, and it was confirmed as a non-competitive inhibitor in all enzymes. Taken together, the results indicated that axitinib had an obvious inhibitory impact on loperamide metabolism both in vivo and in vitro. Thus, more attention should be paid to the concurrent use of loperamide and axitinib to reduce the risk of unexpected clinical outcomes.
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Affiliation(s)
- Qian-Meng Lin
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Ni-Hong Pang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Ying-Hui Li
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Huan-le Huang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Xiao-Dan Zhang
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - Guo-Xin Hu
- School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China.
| | - Zeng-Shou Wang
- Department of Pharmacy, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325027, Zhejiang Province, China.
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43
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Powell JW, Presnell SE. Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina. J Forensic Sci 2019; 64:1726-1730. [DOI: 10.1111/1556-4029.14115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 01/10/2023]
Affiliation(s)
- John W. Powell
- The Medical University of South Carolina Charleston SC29415
| | - Susan Erin Presnell
- Department of Pathology and Laboratory Medicine The Medical University of South Carolina Charleston SC29425-9080
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44
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White CM. Loperamide: A Readily Available but Dangerous Opioid Substitute. J Clin Pharmacol 2019; 59:1165-1169. [DOI: 10.1002/jcph.1449] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 05/09/2019] [Indexed: 11/10/2022]
Affiliation(s)
- C. Michael White
- University of Connecticut School of Pharmacy and Hartford Hospital Hartford CT USA
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45
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Díaz-Ruano S, López-Pérez AE, Girón R, Pérez-García I, Martín-Fontelles MI, Abalo R. Fluoroscopic Characterization of Colonic Dysmotility Associated to Opioid and Cannabinoid Agonists in Conscious Rats. J Neurogastroenterol Motil 2019; 25:300-315. [PMID: 30870877 PMCID: PMC6474695 DOI: 10.5056/jnm18202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 12/25/2022] Open
Abstract
Background/Aims Gastrointestinal adverse effects have a major impact on health and quality of life in analgesics users. Non-invasive methods to study gastrointestinal motility are of high interest. Fluoroscopy has been previously used to study gastrointestinal motility in small experimental animals, but they were generally anesthetized and anesthesia itself may alter motility. In this study, our aim is to determine, in conscious rats, the effect of increasing doses of 2 opioid (morphine and loperamide) and 1 cannabinoid (WIN 55,212-2) agonists on colonic motility using fluoroscopic recordings and spatio-temporal maps. Methods Male Wistar rats received barium sulfate intragastrically, 20–22 hours before fluoroscopy, so that stained fecal pellets could be seen at the time of recording. Animals received an intraperitoneal administration of morphine, loperamide, or WIN 55,212-2 (at 0.1, 1, 5, or 10 mg/kg) or their corresponding vehicles (saline, Cremophor, and Tocrisolve, respectively), 30 minutes before fluoroscopy. Rats were conscious and placed within movement-restrainers for the length of fluoroscopic recordings (120 seconds). Spatio-temporal maps were built, and different parameters were analyzed from the fluoroscopic recordings in a blinded fashion to evaluate colonic propulsion of endogenous fecal pellets. Results The analgesic drugs inhibited propulsion of endogenous fecal pellets in a dose-dependent manner. Conclusions Fluoroscopy allows studying colonic propulsion of endogenous fecal pellets in conscious rats. Our method may be applied to the noninvasive study of the effect of different drug treatments and pathologies.
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Affiliation(s)
- Susana Díaz-Ruano
- Unidad de Dolor, Servicio de Anestesiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Ana E López-Pérez
- Unidad de Dolor, Servicio de Anestesiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Madrid, Spain
| | - Rocío Girón
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.,Unidad Asociada I+D+i al Instituto de Investigación en Ciencias de la Alimentación, CIAL (CSIC), Madrid, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica, IQM (CSIC), Madrid, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Madrid, Spain
| | - Irene Pérez-García
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain
| | - María I Martín-Fontelles
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.,Unidad Asociada I+D+i al Instituto de Investigación en Ciencias de la Alimentación, CIAL (CSIC), Madrid, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica, IQM (CSIC), Madrid, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Madrid, Spain
| | - Raquel Abalo
- Departamento de Ciencias Básicas de la Salud, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.,Unidad Asociada I+D+i al Instituto de Investigación en Ciencias de la Alimentación, CIAL (CSIC), Madrid, Spain.,Unidad Asociada I+D+i al Instituto de Química Médica, IQM (CSIC), Madrid, Spain.,Grupo de Excelencia Investigadora URJC-Banco de Santander-Grupo Multidisciplinar de Investigación y Tratamiento del Dolor (i+DOL), Madrid, Spain
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Kohli U, Altujjar M, Sharma R, Hassan S. Wide interindividual variability in cardiovascular toxicity of loperamide: A case report and review of literature. HeartRhythm Case Rep 2019; 5:221-224. [PMID: 30997339 PMCID: PMC6453448 DOI: 10.1016/j.hrcr.2019.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Parker BM, Rao T, Matta A, Quitanna M, Reynolds HN, Stein DM, Haase D. Loperamide induced cardiac arrhythmia successfully supported with veno-arterial ECMO (VA-ECMO), molecular adsorbent recirculating system (MARS) and continuous renal replacement therapy (CRRT). Clin Toxicol (Phila) 2019; 57:1118-1122. [PMID: 30806091 DOI: 10.1080/15563650.2019.1580370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: This case of Loperamide misuse had refractory ventricular arrhythmias and was successfully supported by VA ECMO. Loperamide is currently available without prescription and can be obtained in large quantities over the internet despite Food and Drug Administration (FDA) 2016 black box warning noting cardiac toxicity. This case illustrates the life-threatening toxicity of loperamide and suggests a supportive modality to provide clinical time while the drug is cleared endogenously or exogenously. Case report: A 36-year-old female was found minimally responsive. Vital signs and monitoring revealed wide complex bradycardia, undetectable blood pressure, hypothermia, bradypnea, and hypoglycemia. The rhythm degenerated to polymorphic ventricular tachycardia cardia refractory to multiple ACLS protocols. VA-ECMO was initiated with immediate stabilization. Subsequent history revealed massive consumption of loperamide taking 400-600 mg daily. Highest known loperamide and N-desmethyl-loperamide levels were 32 and 500 ng/ml respectively. Since loperamide and metabolites are known to be protein bound, molecular adsorbent recirculating system (MARS) was initiated for toxin clearance. Additionally, she developed acute renal failure supported by CRRT. She was ultimately weaned from ECMO, MARS, and CRRT and discharged neurologically intact on hospital day 12. Discussion: VA ECMO for hemodynamic support provided the needed time for natural resolution of the cardiac toxicity while providing adequate perfusion. MARS was used in the setting of highly protein bound toxins, but drug clearance could not be demonstrated through serial levels. VA ECMO (or referral to a center with VA ECMO) should be considered with lethal loperamide-induced cardiotoxicity and perhaps other cardio-toxins.
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Affiliation(s)
- Brandon Masi Parker
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
| | - Tejaus Rao
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
| | - Ann Matta
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
| | - Megan Quitanna
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
| | - H Neal Reynolds
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
| | - Deborah M Stein
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
| | - Daniel Haase
- Division of Critical Care Medicine, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center , Baltimore , MD , USA
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Abstract
Novel drugs of abuse are synthetic illicit drugs, or analogues of known illicit drugs, that can be more potent. Novel drugs of abuse are often labeled as designer drugs, research chemicals, legal highs, or psychoactive substances. They are often sold as designated legal or nondrug products, such as incense, plant food, or bath salts, with labeling such as "Not for Human Consumption" or "For Use in Research Only." The prevalence of use of novel drugs of abuse is difficult to determine because specific drugs, compounds, and availability of these drugs are constantly evolving. Changes in chemical structures lead to heterogeneity in physiologic response and clinical symptoms, even within the same category of drug. Pediatricians and emergency medicine physicians should be knowledgeable about novel drugs of abuse and their resulting symptoms for prevention and identification of their use.
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Affiliation(s)
- George Sam Wang
- Section of Emergency Medicine and Medical Toxicology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.,Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO
| | - Christopher Hoyte
- Rocky Mountain Poison and Drug Center, Denver Health Hospital, Denver, CO.,Department of Emergency Medicine and Medical Toxicology, University of Colorado Anschutz Medical Campus, University Hospital, Aurora, CO
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49
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Lee VR, Vera A, Alexander A, Ruck B, Nelson LS, Wax P, Campleman S, Brent J, Calello DP. Loperamide misuse to avoid opioid withdrawal and to achieve a euphoric effect: high doses and high risk. Clin Toxicol (Phila) 2018; 57:175-180. [DOI: 10.1080/15563650.2018.1510128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Vincent R. Lee
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Ariel Vera
- Department of Emergency Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Andreia Alexander
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bruce Ruck
- Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Lewis S. Nelson
- Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Paul Wax
- UT Southwestern Medical School, Dallas, TX, USA
- American College of Medical Toxicology, Phoenix, AZ, USA
| | | | - Jeffrey Brent
- American College of Medical Toxicology, Phoenix, AZ, USA
- School of Medicine, University of Colorado, Aurora, CO, USA
| | - Diane P. Calello
- Department of Emergency Medicine, New Jersey Poison Information and Education System, Rutgers New Jersey Medical School, Newark, NJ, USA
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50
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Toce MS, Chai PR, Burns MM, Boyer EW. Pharmacologic Treatment of Opioid Use Disorder: a Review of Pharmacotherapy, Adjuncts, and Toxicity. J Med Toxicol 2018; 14:306-322. [PMID: 30377951 PMCID: PMC6242798 DOI: 10.1007/s13181-018-0685-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/09/2018] [Accepted: 10/12/2018] [Indexed: 12/27/2022] Open
Abstract
Opioid use disorder continues to be a significant source of morbidity and mortality in the USA and the world. Pharmacologic treatment with methadone and buprenorphine has been shown to be effective at retaining people in treatment programs, decreasing illicit opioid use, decreasing rates of hepatitis B, and reducing all cause and overdose mortality. Unfortunately, barriers exist in accessing these lifesaving medications: users wishing to start buprenorphine therapy require a waivered provider to prescribe the medication, while some states have no methadone clinics. As such, users looking to wean themselves from opioids or treat their opioid dependence will turn to alternative agents. These agents include using prescription medications, like clonidine or gabapentin, off-label, or over the counter drugs, like loperamide, in supratherapeutic doses. This review provides information on the pharmacology and the toxic effects of pharmacologic agents that are used to treat opioid use disorder. The xenobiotics reviewed in depth include buprenorphine, clonidine, kratom, loperamide, and methadone, with additional information provided on lofexidine, akuamma seeds, kava, and gabapentin.
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Affiliation(s)
- Michael S Toce
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA.
| | - Peter R Chai
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Edward W Boyer
- Harvard Medical Toxicology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Division of Medical Toxicology, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA
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