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Ebo DG, Mertens C, Sabato V, Elst J. Suspected pholcodine allergy: the conundrum of clinically irrelevant immunoglobulin E and basophil responsiveness to morphine and codeine. Br J Anaesth 2024; 132:808-810. [PMID: 38245453 DOI: 10.1016/j.bja.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024] Open
Affiliation(s)
- Didier G Ebo
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp-University Hospital of Antwerp, Antwerp University, Antwerp, Belgium; Department of Immunology and Allergology, AZ Jan Palfijn Ghent, Ghent, Belgium.
| | - Christel Mertens
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp-University Hospital of Antwerp, Antwerp University, Antwerp, Belgium
| | - Vito Sabato
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp-University Hospital of Antwerp, Antwerp University, Antwerp, Belgium
| | - Jessy Elst
- Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp-University Hospital of Antwerp, Antwerp University, Antwerp, Belgium
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Savic L, Hopkins PM. Pholcodine and allergy to neuromuscular blocking agents: where are we and how did we get here? Br J Anaesth 2024; 132:457-460. [PMID: 38071149 DOI: 10.1016/j.bja.2023.11.029] [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: 05/04/2023] [Revised: 10/20/2023] [Accepted: 11/19/2023] [Indexed: 02/15/2024] Open
Abstract
Despite the purported link between pholcodine and neuromuscular blocking agent allergy, screening for prior pholcodine use offers no practical benefit to patients, and anaesthetists should continue to use a neuromuscular blocking agent where this is clinically indicated.
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Affiliation(s)
- Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Philip M Hopkins
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Institute of Medical Research at St James's, University of Leeds, Leeds, UK
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Roshdy A, Salam RA, Hadad G, Belal F, Elmansi H. Fast concurrent determination of guaifenesin and pholcodine in formulations and spiked plasma using first derivative synchronous spectrofluorimetric approach. LUMINESCENCE 2024; 39:e4660. [PMID: 38286595 DOI: 10.1002/bio.4660] [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: 09/19/2023] [Revised: 10/25/2023] [Accepted: 12/05/2023] [Indexed: 01/31/2024]
Abstract
Guaifenesin and pholcodine are frequently co-formulated in certain dosage forms. A new fast first derivative synchronous spectrofluorometric method has been used for their simultaneous analysis in mixtures. Here, first derivative synchronous spectrofluorometry enabled the successful simultaneous estimation of guaifenesin at 283 nm and pholcodine at 275 nm using a wavelength difference (Δλ) of 40 nm. The method was fully validated following International Council of Harmonization guidelines. For guaifenesin and pholcodine, linearity was determined within the corresponding ranges of 0.05-0.30 and 0.10-6.0 μg/ml. The two drugs were effectively analyzed using the developed approach in their respective formulations, and the results showed good agreement with those attained using reference methods. The method demonstrated excellent sensitivity, with detection limits down to 0.007 and 0.030 μg/ml and quantitation limits of 0.020 and 0.010 μg/ml for guaifenesin and pholcodine, respectively. Therefore, the procedure was successful in determining these drugs simultaneously in vitro in spiked plasma samples and syrup dosage form. The developed methodology also offered an environmentally friendly advantage by utilizing water as the optimal diluting solvent throughout the whole work. Different greenness approaches were investigated to ensure the method's ecofriendly properties.
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Affiliation(s)
- Aya Roshdy
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Horus University-Egypt, New Damietta, Egypt
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Randa Abdel Salam
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Ghada Hadad
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Suez Canal University, Ismailia, Egypt
| | - Fathalla Belal
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
| | - Heba Elmansi
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
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Bulat V, Likic R, Pondeljak N, Azdajic MD. Pholcodine-induced Stevens-Johnson syndrome in a patient with COVID-19. Postgrad Med J 2022; 98:499-500. [PMID: 33879549 PMCID: PMC8061564 DOI: 10.1136/postgradmedj-2021-139892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Vedrana Bulat
- Department of Dermatology and Venereology, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Robert Likic
- Department of Internal Medicine, Division of Clinical Pharmacology and Therapeutics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Nives Pondeljak
- Department of Dermatology and Venereology, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
| | - Marija Delas Azdajic
- Department of Dermatology and Venereology, University Hospital Centre Sestre Milosrdnice, Zagreb, Croatia
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Elmansi H, Belal F, Magdy G. Determination of pholcodine alone or in combination with ephedrine in human plasma using fluorescence spectroscopy. Sci Rep 2022; 12:9372. [PMID: 35672340 PMCID: PMC9174196 DOI: 10.1038/s41598-022-13194-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/23/2022] [Indexed: 11/18/2022] Open
Abstract
In this study, sensitive, facile, and cost-effective spectrofluorimetric approaches were developed for the determination of pholcodine and ephedrine. Method I is a novel spectrofluorimetric method depending on measuring the native fluorescence of pholcodine at 337 nm after excitation at 284 nm over a concentration range of 0.01-2.4 μg/mL. The method sensitivity reached quantitation and detection limits down to 10.0 and 5.0 ng/mL, respectively. Method II relied on the simultaneous estimation of pholcodine and ephedrine using synchronous fluorimetry for the first time. The cited drugs were measured concurrently at 286 and 304 nm for pholcodine and ephedrine, respectively at Δλ of 40 nm without interference. Excellent linear relationship between concentration and response was obtained over the ranges of 0.05-6.0 μg/mL and 0.02-1.0 μg/mL for pholcodine and ephedrine, respectively. The method showed distinct sensitivity and exhibited quantitation limits of 20.0 and 10.0 ng/mL and detection limits of 10.0 and 5.0 ng/mL, respectively. The method was successfully applied to the syrup dosage form. The two developed approaches were also applied to in-vitro plasma samples, showing good bioanalytical applicability and providing further insights for monitoring drug abuse. The proposed methods were validated according to ICHQ2(R1) guidelines. The proposed methodologies' greenness profiles were evaluated using two greenness assessment tools.
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Affiliation(s)
- Heba Elmansi
- Pharmaceutical Analytical Chemistry Department, Faculty of Pharmacy, Mansoura University, P.O. Box 35516, Mansoura, Egypt
| | - Fathalla Belal
- Pharmaceutical Analytical Chemistry Department, Faculty of Pharmacy, Mansoura University, P.O. Box 35516, Mansoura, Egypt
| | - Galal Magdy
- Pharmaceutical Analytical Chemistry Department, Faculty of Pharmacy, Kafrelsheikh University, P.O. Box 33511, Kafrelsheikh, Egypt.
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Acker JV, Ebo D, Faber M, Sabato V, Suys E, Coghe M, Aerts O. A bad cough: Delayed cutaneous hypersensitivity caused by pholcodine. J Allergy Clin Immunol Pract 2020; 8:1449-1451. [PMID: 31726230 DOI: 10.1016/j.jaip.2019.10.036] [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] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/10/2019] [Accepted: 10/28/2019] [Indexed: 06/10/2023]
Affiliation(s)
- Julie Van Acker
- Department of Dermatology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
| | - Didier Ebo
- Department of Immunology, Allergology, Rheumatology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium; Infla-Med Centre of Excellence, Antwerp University, Antwerp, Belgium
| | - Margriet Faber
- Department of Immunology, Allergology, Rheumatology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium; Infla-Med Centre of Excellence, Antwerp University, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium; Infla-Med Centre of Excellence, Antwerp University, Antwerp, Belgium
| | - Erwin Suys
- Private Dermatologist, Handelskaai 1/G, Kortrijk, Belgium
| | - Marjan Coghe
- Private Dermatologist, Masteneikstraat 61/1, Izegem, Belgium
| | - Olivier Aerts
- Department of Dermatology, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium.
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Yen YT, Chang YJ, Lai PJ, Chang CL, Chen TY, Chyueh SC. A Study of Opiate, Opiate Metabolites and Antihistamines in Urine after Consumption of Cold Syrups by LC-MS/MS. Molecules 2020; 25:molecules25040972. [PMID: 32098143 PMCID: PMC7070706 DOI: 10.3390/molecules25040972] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 11/16/2022]
Abstract
Studying the origin of opiate and/or opiate metabolites in individual urine specimens after consumption of cold syrups is vital for patients, doctors, and law enforcement. A rapid liquid chromatography-tandem mass spectrometry method using "dilute-and-shoot" analysis without the need for extraction, hydrolysis and/or derivatization has been developed and validated. The approach provides linear ranges of 2.5-1000 ng mL-1 for 6-acetylmorphine, codeine, chlorpheniramine, and carbinoxamine, 2.5-800 ng mL-1 for morphine and morphine-3-β-d-glucuronide, and 2.5-600 ng mL-1 for morphine-6-β-d-glucuronide and codeine-6-β-d-glucuronide, with excellent correlation coefficients (R2 > 0.995) and matrix effects (< 5%). Urine samples collected from the ten participants orally administered cold syrups were analyzed. The results concluded that participants consuming codeine-containing cold syrups did not routinely pass urine tests for opiates, and their morphine-codeine concentration ratios (M/C) were not always < 1. In addition, the distribution map of the clinical total concentration of the sum of morphine and codeine against the antihistamines (chlorpheniramine or carbinoxamine) were plotted for discrimination of people who used cold syrups. The 15 real cases have been studied by using M/C rule, cutoff value, and distribution map, further revealing a potential approach to determine opiate metabolite in urine originating from cold syrups.
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Affiliation(s)
- Yao-Te Yen
- Correspondence: ; Tel.: +886-2-2911-2241 (ext. 3714)
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Carney T, Van Hout MC, Norman I, Dada S, Siegfried N, Parry CDH. Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders. Cochrane Database Syst Rev 2020; 2:CD012254. [PMID: 32068247 PMCID: PMC7027221 DOI: 10.1002/14651858.cd012254.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders. OBJECTIVES To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy. SEARCH METHODS In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes. DATA COLLECTION AND ANALYSIS We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence. MAIN RESULTS We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose. AUTHORS' CONCLUSIONS We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries.
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Affiliation(s)
- Tara Carney
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl DriveTygerbergWestern CapeSouth Africa7505
| | - Marie Claire Van Hout
- Liverpool John Moores UniversityPublic Health Institute2nd Floor Henry Cotton Campus15‐21 Webster StreetLiverpoolUKL32ET
| | - Ian Norman
- King's College LondonFlorence Nightingale Faculty of Nursing and MidwiferyJames Clerk Maxwell Building , Waterloo RoadLondonUKSE1 8WA
| | - Siphokazi Dada
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl Drive, TygerbergCape TownWestern CapeSouth Africa7505
| | - Nandi Siegfried
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl Drive, TygerbergCape TownWestern CapeSouth Africa7505
| | - Charles DH Parry
- South African Medical Research CouncilAlcohol, Tobacco and Other Drug Research UnitFrancie Van Zijl DriveTygerbergWestern CapeSouth Africa7505
- University of StellenboschDepartment of PsychiatryTygerberg 7505South Africa
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Ramírez Fernández MDM, Wille SMR, Di Fazio V, Samyn N. Time course detection of dihydrocodeine in body hair after a single dose. Forensic Sci Int 2019; 302:109864. [PMID: 31261035 DOI: 10.1016/j.forsciint.2019.06.022] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/13/2019] [Accepted: 06/18/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND When head hair is not suitable or not available, body hair, such as leg or beard hair might be the most suitable sample for drug hair analysis. Information about the time course of drugs in hair, from the different anatomical body sites, should still be well documented. AIM The aim of this study was to determine and compare (a) the detection window of dihydrocodeine in frequently shaved legs and beard, (b) in unshaved hair from head hair, chest hair, leg hair, and/or arm hair, and (c) the distribution concentrations over the scalp, after a single dihydrocodeine intake. METHOD Before a single intake of 12 mg dihydrocodeine by subject 1 (woman), both legs hair were shaved in the morning. The subject 2 (man) shaved his beard in the morning and 30 min later he had a dose of 10 mg of dihydrocodeine. The samples were washed with water and shampoo, dried and collected as follows: Subject 1: every 3-days shaved leg hair (n = 9) and 1-month-later head hair (n = 1). Subject 2: daily shaved beard hair (n = 15), 2 months later head hair (n = 145), and every 20 days unshaved arm, leg and chest hair (from different areas) (n = 4/area). The samples were analysed for dihydrocodeine using a validated liquid chromatography-tandem mass spectrometry method with a limit of quantification (LOQ) of 15.6 pg/mg for dihydrocodeine. About 20 mg of hair samples were weighted, washed with dichloromethane, centrifuged, dried, and pulverized in the same disposable tubes. Then the samples were incubated with methanol (under sonication at 45 °C) during 4 h. After centrifugation, the supernatant was evaporated and a cation exchange solid phase extraction followed by separation and quantification using ultra performance liquid chromatography-tandem mass spectrometry (ULC-MS/MS) was carried out. Chromatographic separation was achieved using a BEH phenyl column eluted with 0.1% formic acid: methanol (0.1% formic acid). The UPLC-MS/MS method was validated and used in routine for drug hair analysis for already several years. RESULTS AND DISCUSSION In the present study leg hair was collected every 3 days, as an average of frequent shaved hair in western woman population. Shaved leg hair was very limited and only one hair sample was available per analysis. Beard was collected daily and in a higher amount. Dihydrocodeine was detected in leg hair from the first sample (3 days after the intake). Maximum concentration at 68 pg/mg for the single intake was obtained after 15 days (±2 days), decreasing later to the LOQ from the 21th day. Beard hair was positive from the first day sample, and the maximum concentration was observed at 66 pg/mg, 6 days after the intake, decreasing later to the LOQ from day 13. This may be explained by growth rate and the amount of growing hairs, in anagen phase. In other body hair samples, dihydrocodeine was negative or detected from 1 month after the intake. No significant differences in dihydrocodeine concentrations over the scalp in the different regions were observed (p > 0.05). CONCLUSION Body hair presents different time course window detection due to the different growth rates. Frequently shaved leg and beard hair may be suitable samples for recent single dihydrocodeine dose detection from the first days up to 2-3 weeks after the intake, respectively, when a LOQ of 15.6 pg/mg is applied.
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Affiliation(s)
- María Del Mar Ramírez Fernández
- Federal Public Service Justice, National Institute of Criminalistics and Criminology, Chaussée de Vilvorde 100, 1120 Brussels, Belgium.
| | - Sarah M R Wille
- Federal Public Service Justice, National Institute of Criminalistics and Criminology, Chaussée de Vilvorde 100, 1120 Brussels, Belgium
| | - Vincent Di Fazio
- Federal Public Service Justice, National Institute of Criminalistics and Criminology, Chaussée de Vilvorde 100, 1120 Brussels, Belgium
| | - Nele Samyn
- Federal Public Service Justice, National Institute of Criminalistics and Criminology, Chaussée de Vilvorde 100, 1120 Brussels, Belgium
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Campos-Mañas MC, Ferrer I, Thurman EM, Sánchez Pérez JA, Agüera A. Identification of opioids in surface and wastewaters by LC/QTOF-MS using retrospective data analysis. Sci Total Environ 2019; 664:874-884. [PMID: 30769311 DOI: 10.1016/j.scitotenv.2019.01.389] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 06/09/2023]
Abstract
Opioids, both as prescription drugs and abuse substances, have been a hot topic and a focus of discussion in the media for the last few years. Although the literature published shows the occurrence of opioids and some of their metabolites in the aquatic environment, there are scarce data in the application of high resolution mass spectrometry (HRMS) for the analysis of these compounds in the environment. The use of HRMS allows increasing the number of opioids that can be studied as well as the detection of unknown opioids, their metabolites and potential transformation products. In this work, a retrospective analysis for the identification of opioids and their metabolites using a curated database was applied to surface water and wastewater samples taken in the state of Minnesota (U.S.) in 2009, which were previously analyzed by liquid chromatography/time-of-flight mass spectrometry (LC/TOF-MS) for antidepressants. The database comprised >200 opioids including natural opiates (e.g. morphine and codeine), their semi-synthetic derivatives (e.g. heroin, hydromorphone, hydrocodone, oxycodone, oxymorphone, meperidine and buprenorphine), fully synthetic opioids (e.g. fentanyl, methadone, tramadol, dextromethorphan and propoxyphene), as well as some of their metabolites (e.g. 6-monoacetylcodeine, dextrorphan, EDDP, normorphine and O-desmethyltramadol). Moreover, additional MS-MS experiments were performed to confirm their identification, as well as to recognize fragmentation patterns and diagnostic ions for several opioids. These data provide a better understanding of the historical occurrence of opioids and their metabolites in surface waters impacted by wastewater sources. The concentrations of individual opioids in surface water and wastewater effluent varied from 8.8 (EDDP) to 1640 (tramadol) ngL-1 and from 12 (dihydrocodeine) to 1288 (tramadol) ngL-1, respectively. The opioids with higher overall frequency detections were tramadol, dextromethorphan and its metabolite, dextrorphan.
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Affiliation(s)
- Marina Celia Campos-Mañas
- Solar Energy Research Centre (CIESOL), Joint Centre University of Almería-CIEMAT, Ctra de Sacramento s/n, 04120 Almería, Spain
| | - Imma Ferrer
- Center for Environmental Mass Spectrometry, Dpt. Environmental Engineering, University of Colorado, Boulder, CO 80303, USA.
| | - E Michael Thurman
- Center for Environmental Mass Spectrometry, Dpt. Environmental Engineering, University of Colorado, Boulder, CO 80303, USA
| | - José Antonio Sánchez Pérez
- Solar Energy Research Centre (CIESOL), Joint Centre University of Almería-CIEMAT, Ctra de Sacramento s/n, 04120 Almería, Spain
| | - Ana Agüera
- Solar Energy Research Centre (CIESOL), Joint Centre University of Almería-CIEMAT, Ctra de Sacramento s/n, 04120 Almería, Spain
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Abstract
BACKGROUND This review is one of a series on drugs used to treat chronic neuropathic pain. Estimates of the population prevalence of chronic pain with neuropathic components range between 6% and 10%. Current pharmacological treatment options for neuropathic pain afford substantial benefit for only a few people, often with adverse effects that outweigh the benefits. There is a need to explore other treatment options, with different mechanisms of action for treatment of conditions with chronic neuropathic pain. Cannabis has been used for millennia to reduce pain. Herbal cannabis is currently strongly promoted by some patients and their advocates to treat any type of chronic pain. OBJECTIVES To assess the efficacy, tolerability, and safety of cannabis-based medicines (herbal, plant-derived, synthetic) compared to placebo or conventional drugs for conditions with chronic neuropathic pain in adults. SEARCH METHODS In November 2017 we searched CENTRAL, MEDLINE, Embase, and two trials registries for published and ongoing trials, and examined the reference lists of reviewed articles. SELECTION CRITERIA We selected randomised, double-blind controlled trials of medical cannabis, plant-derived and synthetic cannabis-based medicines against placebo or any other active treatment of conditions with chronic neuropathic pain in adults, with a treatment duration of at least two weeks and at least 10 participants per treatment arm. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data of study characteristics and outcomes of efficacy, tolerability and safety, examined issues of study quality, and assessed risk of bias. We resolved discrepancies by discussion. For efficacy, we calculated the number needed to treat for an additional beneficial outcome (NNTB) for pain relief of 30% and 50% or greater, patient's global impression to be much or very much improved, dropout rates due to lack of efficacy, and the standardised mean differences for pain intensity, sleep problems, health-related quality of life (HRQoL), and psychological distress. For tolerability, we calculated number needed to treat for an additional harmful outcome (NNTH) for withdrawal due to adverse events and specific adverse events, nervous system disorders and psychiatric disorders. For safety, we calculated NNTH for serious adverse events. Meta-analysis was undertaken using a random-effects model. We assessed the quality of evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS We included 16 studies with 1750 participants. The studies were 2 to 26 weeks long and compared an oromucosal spray with a plant-derived combination of tetrahydrocannabinol (THC) and cannabidiol (CBD) (10 studies), a synthetic cannabinoid mimicking THC (nabilone) (two studies), inhaled herbal cannabis (two studies) and plant-derived THC (dronabinol) (two studies) against placebo (15 studies) and an analgesic (dihydrocodeine) (one study). We used the Cochrane 'Risk of bias' tool to assess study quality. We defined studies with zero to two unclear or high risks of bias judgements to be high-quality studies, with three to five unclear or high risks of bias to be moderate-quality studies, and with six to eight unclear or high risks of bias to be low-quality studies. Study quality was low in two studies, moderate in 12 studies and high in two studies. Nine studies were at high risk of bias for study size. We rated the quality of the evidence according to GRADE as very low to moderate.Primary outcomesCannabis-based medicines may increase the number of people achieving 50% or greater pain relief compared with placebo (21% versus 17%; risk difference (RD) 0.05 (95% confidence interval (CI) 0.00 to 0.09); NNTB 20 (95% CI 11 to 100); 1001 participants, eight studies, low-quality evidence). We rated the evidence for improvement in Patient Global Impression of Change (PGIC) with cannabis to be of very low quality (26% versus 21%;RD 0.09 (95% CI 0.01 to 0.17); NNTB 11 (95% CI 6 to 100); 1092 participants, six studies). More participants withdrew from the studies due to adverse events with cannabis-based medicines (10% of participants) than with placebo (5% of participants) (RD 0.04 (95% CI 0.02 to 0.07); NNTH 25 (95% CI 16 to 50); 1848 participants, 13 studies, moderate-quality evidence). We did not have enough evidence to determine if cannabis-based medicines increase the frequency of serious adverse events compared with placebo (RD 0.01 (95% CI -0.01 to 0.03); 1876 participants, 13 studies, low-quality evidence).Secondary outcomesCannabis-based medicines probably increase the number of people achieving pain relief of 30% or greater compared with placebo (39% versus 33%; RD 0.09 (95% CI 0.03 to 0.15); NNTB 11 (95% CI 7 to 33); 1586 participants, 10 studies, moderate quality evidence). Cannabis-based medicines may increase nervous system adverse events compared with placebo (61% versus 29%; RD 0.38 (95% CI 0.18 to 0.58); NNTH 3 (95% CI 2 to 6); 1304 participants, nine studies, low-quality evidence). Psychiatric disorders occurred in 17% of participants using cannabis-based medicines and in 5% using placebo (RD 0.10 (95% CI 0.06 to 0.15); NNTH 10 (95% CI 7 to 16); 1314 participants, nine studies, low-quality evidence).We found no information about long-term risks in the studies analysed.Subgroup analysesWe are uncertain whether herbal cannabis reduces mean pain intensity (very low-quality evidence). Herbal cannabis and placebo did not differ in tolerability (very low-quality evidence). AUTHORS' CONCLUSIONS The potential benefits of cannabis-based medicine (herbal cannabis, plant-derived or synthetic THC, THC/CBD oromucosal spray) in chronic neuropathic pain might be outweighed by their potential harms. The quality of evidence for pain relief outcomes reflects the exclusion of participants with a history of substance abuse and other significant comorbidities from the studies, together with their small sample sizes.
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Affiliation(s)
- Martin Mücke
- Department of Palliative Medicine, University Hospital of Bonn, Sigmund-Freud-Str. 25, Bonn, Germany, 53127
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McCall AK, Palmitessa R, Blumensaat F, Morgenroth E, Ort C. Modeling in-sewer transformations at catchment scale - implications on drug consumption estimates in wastewater-based epidemiology. Water Res 2017; 122:655-668. [PMID: 28651217 DOI: 10.1016/j.watres.2017.05.034] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 05/20/2023]
Abstract
To which extent illicit drugs are transformed during in-sewer transport, depends on a number of factors: i) substance-specific transformation rates, ii) environmental conditions, iii) point of discharge (location of drug user) and iv) sewer network properties, primarily hydraulic residence time (HRT) and the ratio of biofilm contact area to wastewater volume (A/Veq). Assessing associated uncertainties typically requires numerous simulations. Therefore, we propose a new two-step modeling framework: 1) Quantify hydrodynamic conditions. This computationally demanding step was performed once in SWMM to derive HRT and A/Veq for each potential point of discharge (node) in three catchments of different size. 2) Estimate biomarker loss. In this step, Monte Carlo simulations were performed for defined scenarios. Depending on assumptions about drug user distribution and prevalence, a number of nodes was sampled. For each node an empirical first-order transformation model was applied with flow-path-corresponding HRT and A/Veq from step 1. Biotic and abiotic transformation rates were sampled from distributions combining variability of different biofilms. In our modeling study, median losses were >30% for amphetamine, 6-monoacetylmorphine and 6-acetylcodeine in all three catchments with high uncertainty (5%-100% loss), which would imply a systematic underestimation of consumption when neglecting in-sewer processes. Median losses for 21 other investigated biomarkers were <10% with different uncertainty ranges - "no substantial transformation" was confirmed for nine substances in a real sewer segment with a 2-h residence time. Transferability of these results must be tested for other catchments. To further reduce uncertainty, mainly additional knowledge on transformation rates, particularly in biofilm, and their distribution across a sewer network is needed to update model input objectively. Our approach allows efficient testing and, furthermore, can be expanded for many other human biomarkers. Accounting for biomarker stability during in-sewer transport will avoid biased estimates and further improve wastewater-based epidemiology.
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Affiliation(s)
- Ann-Kathrin McCall
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, CH 8600, Dübendorf, Switzerland
| | | | - Frank Blumensaat
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, CH 8600, Dübendorf, Switzerland; ETH Zürich, Institute of Environmental Engineering, 8093, Zürich, Switzerland
| | - Eberhard Morgenroth
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, CH 8600, Dübendorf, Switzerland; ETH Zürich, Institute of Environmental Engineering, 8093, Zürich, Switzerland
| | - Christoph Ort
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, CH 8600, Dübendorf, Switzerland.
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Moustafa AA, Hegazy MA, Mohamed D, Ali O. Novel Approach for the Simultaneous Determination of Carbinoxamine Maleate, Pholcodine, and Ephedrine Hydrochloride Without Interference from Coloring Matter in an Antitussive Preparation Using Smart Spectrophotometric Methods. J AOAC Int 2017; 101:414-426. [PMID: 28766478 DOI: 10.5740/jaoacint.17-0078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 11/17/2022]
Abstract
The presence of coloring matters in syrups usually interferes with the spectrophotometric determination of active pharmaceutical ingredients. A novel approach was introduced to eliminate the interference of sunset yellow (coloring matter) in Cyrinol syrup. Smart, simple, accurate, and selective spectrophotometric methods were developed and validated for the simultaneous determination of a ternary mixture of carbinoxamine maleate, pholcodine, and ephedrine hydrochloride in syrup. Four of the applied methods used ratio spectra: successive derivative subtraction coupled with constant multiplication, successive derivative of ratio spectra, ratio subtraction coupled with ratio difference, and ratio spectra continuous wavelet transforms zero-crossing. In addition, a method that was based on the presence of an isosbestic point, the amplitude summation method, was also established. A major advantage of the proposed methods is the simultaneous determination of the mentioned drugs without prior separation steps. These methods were successfully applied for the determination of laboratory-prepared mixtures and a commercial pharmaceutical preparation without interference from additives, thus proving the selectivity of the methods. No significant difference regarding both accuracy and precision was observed upon statistical comparison of the results obtained by the proposed methods with each other and with those of official or reported ones.
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Affiliation(s)
- Azza A Moustafa
- Cairo University, Faculty of Pharmacy, Analytical Chemistry Department, Kasr-El Aini St, 11562 Cairo, Egypt
| | - Maha A Hegazy
- Cairo University, Faculty of Pharmacy, Analytical Chemistry Department, Kasr-El Aini St, 11562 Cairo, Egypt
| | - Dalia Mohamed
- October University for Modern Sciences and Arts, Faculty of Pharmacy, Analytical Chemistry Department, 11787 6th of October City, Egypt Helwan University, Faculty of Pharmacy, Analytical Chemistry Department, Ein Helwan, 11795 Cairo, Egypt
| | - Omnia Ali
- October University for Modern Sciences and Arts, Faculty of Pharmacy, Analytical Chemistry Department, 11787 6th of October City, Egypt
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Hakobyan K, Poghosyan Y. Spontaneous bone formation after mandible segmental resection in "krokodil" drug-related jaw osteonecrosis patient: case report. Oral Maxillofac Surg 2017; 21:267-270. [PMID: 28251363 DOI: 10.1007/s10006-017-0613-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 12/24/2016] [Accepted: 02/20/2017] [Indexed: 06/06/2023]
Abstract
We report a case of a 48-year-old male patient with "krokodil" drug-related osteonecrosis of both jaws. Patient history included 1.5 years of "krokodil" use, with 8-month drug withdrawal prior to surgery. The patient was HCV positive. On the maxilla, sequestrectomy was performed. On the mandible, sequestrectomy was combined with bone resection. From ramus to ramus, segmental defect was formed, which was not reconstructed with any method. Post-operative follow-up period was 3 years and no disease recurrence was noted. On 3-year post-operative orthopantomogram, newly formed mandibular bone was found. This phenomenon shows that spontaneous bone formation is possible after mandible segmental resection in osteonecrosis patients.
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Affiliation(s)
- Koryun Hakobyan
- Department of Maxillofacial Surgery of "Kanaker-Zeytun" m/c, 7 H Nersisyan Str., 0014, Yerevan, Armenia.
| | - Yuri Poghosyan
- Chair of Postgraduate Maxillofacial Surgery, Yerevan State Medical University, 2 Koryun Str, 0025, Yerevan, Armenia
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Büker C. [In process]. Pflege Z 2017; 70:20-23. [PMID: 29426089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Wiffen PJ, Knaggs R, Derry S, Cole P, Phillips T, Moore RA. Paracetamol (acetaminophen) with or without codeine or dihydrocodeine for neuropathic pain in adults. Cochrane Database Syst Rev 2016; 12:CD012227. [PMID: 28027389 PMCID: PMC6463878 DOI: 10.1002/14651858.cd012227.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Paracetamol, either alone or in combination with codeine or dihydrocodeine, is commonly used to treat chronic neuropathic pain. This review sought evidence for efficacy and harm from randomised double-blind studies. OBJECTIVES To assess the analgesic efficacy and adverse events of paracetamol with or without codeine or dihydrocodeine for chronic neuropathic pain in adults. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to July 2016, together with reference lists of retrieved papers and reviews, and two online study registries. SELECTION CRITERIA We included randomised, double-blind studies of two weeks' duration or longer, comparing paracetamol, alone or in combination with codeine or dihydrocodeine, with placebo or another active treatment in chronic neuropathic pain. DATA COLLECTION AND ANALYSIS Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality and potential bias. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE. MAIN RESULTS No study satisfied the inclusion criteria. Effects of interventions were not assessed as there were no included studies. We have only very low quality evidence and have no reliable indication of the likely effect. AUTHORS' CONCLUSIONS There is insufficient evidence to support or refute the suggestion that paracetamol alone, or in combination with codeine or dihydrocodeine, works in any neuropathic pain condition.
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Affiliation(s)
| | - Roger Knaggs
- University of NottinghamSchool of PharmacyUniversity ParkNottinghamUKNG7 2RD
| | | | - Peter Cole
- Churchill Hospital, Oxford University Hospitals NHS TrustOxford Pain Relief UnitOld Road HeadingtonOxfordUKOX3 7LE
| | - Tudor Phillips
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Churchill HospitalOxfordUKOX3 7LJ
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Moustafa AA, Hegazy MA, Mohamed D, Ali O. Evaluation of multivariate calibration models with different pre-processing and processing algorithms for a novel resolution and quantitation of spectrally overlapped quaternary mixture in syrup. Spectrochim Acta A Mol Biomol Spectrosc 2016; 154:76-83. [PMID: 26519913 DOI: 10.1016/j.saa.2015.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/06/2015] [Accepted: 10/19/2015] [Indexed: 06/05/2023]
Abstract
A novel approach for the resolution and quantitation of severely overlapped quaternary mixture of carbinoxamine maleate (CAR), pholcodine (PHL), ephedrine hydrochloride (EPH) and sunset yellow (SUN) in syrup was demonstrated utilizing different spectrophotometric assisted multivariate calibration methods. The applied methods have used different processing and pre-processing algorithms. The proposed methods were partial least squares (PLS), concentration residuals augmented classical least squares (CRACLS), and a novel method; continuous wavelet transforms coupled with partial least squares (CWT-PLS). These methods were applied to a training set in the concentration ranges of 40-100 μg/mL, 40-160 μg/mL, 100-500 μg/mL and 8-24 μg/mL for the four components, respectively. The utilized methods have not required any preliminary separation step or chemical pretreatment. The validity of the methods was evaluated by an external validation set. The selectivity of the developed methods was demonstrated by analyzing the drugs in their combined pharmaceutical formulation without any interference from additives. The obtained results were statistically compared with the official and reported methods where no significant difference was observed regarding both accuracy and precision.
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Affiliation(s)
- Azza A Moustafa
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr-El Aini Street, 11562 Cairo, Egypt
| | - Maha A Hegazy
- Analytical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr-El Aini Street, 11562 Cairo, Egypt
| | - Dalia Mohamed
- Analytical Chemistry Department, Faculty of Pharmacy, October University for Modern Sciences and Arts (MSA), 11787 6th October City, Egypt; Analytical Chemistry Department, Faculty of Pharmacy, Helwan University, Ein Helwan, 11795, Cairo, Egypt
| | - Omnia Ali
- Analytical Chemistry Department, Faculty of Pharmacy, October University for Modern Sciences and Arts (MSA), 11787 6th October City, Egypt.
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Abstract
This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39 % tested positive for HIV, including 45 % of krokodile injectors. In the past 30 days, 25 % reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85 % (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than nonkrokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.
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Affiliation(s)
- Robert E Booth
- University of Colorado Denver, Denver, CO, USA.
- Psychiatry, University of Colorado School of Medicine, Project Safe 1557 Ogden Street, Denver, CO, 80218, USA.
| | | | | | - Oksana Lisovska
- Ukrainian Institute on Public Health Policy, Kiev, 01001, Ukraine
| | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, Kiev, 01001, Ukraine
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"Weak" opioid analgesics. Codeine, dihydrocodeine and tramadol: no less risky than morphine. Prescrire Int 2016; 25:45-50. [PMID: 27042732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
So-called weak opioid analgesics are often used to treat severe pain, or when paracetamol or a nonsteroidal anti-inflammatory drug (NSAID) proves inadequate. But are weak opioids any more effective than paracetamol or NSAIDs on nociceptive pain, and are they better tolerated than morphine? To answer these questions, we conducted a review of literature using the standard Prescrire methodology. The potency of codeine and tramadol is strongly influenced by the cytochrome P450 isoenzyme CYP2D6 genotype, which varies widely from one person to another. This explains reports of overdosing or underdosing after administration of standard doses of the two drugs. The potency of morphine and that of buprenorphine, an opioid receptor agonist-antagonist, appears to be independent of CYP2D6 activity. All "weak" opioids can have the same dose-dependent adverse effects as morphine. There is no evidence that, at equivalent analgesic efficacy, weak opioids carry a lower risk of addiction than low-dose morphine. Respiratory depression can occur in ultrarapid metabolisers after brief exposure to standard doses of codeine or tramadol. Similar cases have been reported with dihydrocodeine in patients with renal failure. In addition, tramadol can cause a serotonin syndrome, hypoglycaemia, hyponatraemia and seizures. Several trials have compared different weak opioids in patients with post-operative pain. A single dose of a weak opioid, possibly combined with paracetamol, has greater analgesic efficacy than paracetamol alone but is not more effective than an NSAID alone. There is a dearth of evidence on weak opioids in patients with chronic pain. Available trials fail to show that a weak opioid has markedly superior analgesic efficacy to paracetamol or an NSAID. Sublingual buprenorphine at analgesic doses appears less likely to cause respiratory depression, but it seems to have weak analgesic efficacy. In practice, when opioid therapy is needed, there is no evidence that codeine, dihydrocodeine or tramadol is less risky than morphine at its lowest effective dose. Compared to morphine, the efficacy of these drugs varies more from one patient to another, and their multiple pharmacokinetic interactions can be difficult to manage. There is also a sometimes unpredictable risk of serious over-dose. Tramadol has additional adverse effects unrelated to its opioid effects. Weak opioids require at least as much vigilance as morphine, despite the major differences in their reputation and regulation.
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Serova NS, Kureshova DN, Babkova AA, Basin EM. [Multislice computed tomography in the diagnosis of toxic phosphorus necrosis of the jaw]. Vestn Rentgenol Radiol 2015:11-16. [PMID: 30247009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To estimate the possibilities of using and systematizing computed tomographic findings in patients with toxic phosphorus necrosis of the jaw. MATERIAL AND METHODS The investigation enrolled 87 patients diagnosed as having toxic phosphorus osteonecrosis. Radiation examination consisted of two stages: primary and repeated radiologic examinations in the postoperative period (final examination before hospital discharge). All the patients underwent skull X-ray and multislice computed tomography (MSCT). RESULTS Clinical and radiation examination revealed toxic phosphorus osteonecrosis of the maxilla and mandible in 29 (33%) cases. Osteonecrosis affected only the mandible in 40 (46%) cases and only the maxilla in 18 (21%) cases. In all the patients, computed tomography showed main trends in the X-ray semiotics of toxic phosphorus necrosis of the facial skeleton, such as periostitis; osteosclerosis; development a lesion having a “soap-bubble” appearance; nonspecific and inflammatory bone destruction. The bone, being destroyed, was replaced by pus; inflammatory granulations were absent; osteonecrosis occurred. These processes were characterized by the absence of an obvious demarcation zone along the edges of the process. Sequestration commonly occurred to form sinus tracts. The process involved the adjacent bones; there were reactive changes in the accessory sinuses. CONCLUSION MSCT data are of highly informative value in evaluating the status of bone tissue and teeth and in detecting a concomitant abnormality in patients with osteonecrosis of the facial skeleton and may be used to plan surgical treatment for this category of patients.
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Manicke NE, Belford M. Separation of opiate isomers using electrospray ionization and paper spray coupled to high-field asymmetric waveform ion mobility spectrometry. J Am Soc Mass Spectrom 2015; 26:701-5. [PMID: 25801584 DOI: 10.1007/s13361-015-1096-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/06/2015] [Accepted: 02/09/2015] [Indexed: 05/21/2023]
Abstract
One limitation in the growing field of ambient or direct analysis methods is reduced selectivity caused by the elimination of chromatographic separations prior to mass spectrometric analysis. We explored the use of high-field asymmetric waveform ion mobility spectrometry (FAIMS), an ambient pressure ion mobility technique, to separate the closely related opiate isomers of morphine, hydromorphone, and norcodeine. These isomers cannot be distinguished by tandem mass spectrometry. Separation prior to MS analysis is, therefore, required to distinguish these compounds, which are important in clinical chemistry and toxicology. FAIMS was coupled to a triple quadrupole mass spectrometer, and ionization was performed using either a pneumatically assisted heated electrospray ionization source (H-ESI) or paper spray, a direct analysis method that has been applied to the direct analysis of dried blood spots and other complex samples. We found that FAIMS was capable of separating the three opiate structural isomers using both H-ESI and paper spray as the ionization source.
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Affiliation(s)
- Nicholas E Manicke
- Department of Chemistry and Chemical Biology, Indiana University-Purdue University Indianapolis, Indianapolis, IN, 46202, USA,
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Long Q, Li J, Wen Y. [Clinical observation of auricular point sticking combined with western medicine for preventing and treating postoperative complications of external excision and internal ligation on mixed hemorrhoid]. Zhongguo Zhen Jiu 2015; 35:237-240. [PMID: 26062190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To explore the effect of auricular point sticking before operation for postoperative complications of external excision and internal ligation on mixed hemorrhoid. METHODS Eighty patients with mixed hemorrhoid were randomly divided into an observation group and a control group, 40 cases in each group. In the control group, paracetamol and dihydrocodeine tartrate tablets were applied with oral administration 1 h after operation, 510 mg each time, twice a day; at the same time, diosmin tablets were treated with oral administration, 0.9 g each time, twice a day. Three days' treatments were required successively. In the observation group, auricular point sticking was used before operation based on the treatment in the control group. The auricular points of Shen (Co10), Pangguang (CO9), Shenmen (TF4), Pizhixia (AT4), Jiaogan (AH6a) and Gangmen (HX5) were selected. The patients were asked to press the points 3-6 times per day, 3-5 min each time, 3 days' treatment in total. The scores of the postoperative complications in the 1st and the 2nd days were compared between the two groups such as pain, edema, hematochezia, retention of urine, etc. RESULTS After operation, the scores of pain, edema, hematochezia, retention of urine in the 2nd day were all decreased obviously than those in the 1st day in the two groups (all P<0.05); and the scores of pain, edema, hematochezia, retention of urine in the 1st and the 2nd days of the observation group were lower than those in the control group (all P<0.05). CONCLUSION Auricular point sticking before operation combined with conventional western medicine with oral administration for preventing and treating postoperative complications of external excision and internal ligation on mixed hemorrhoid achieves positive and reliable efficacy.
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Mattia C, Coluzzi F. A look inside the association codeine-paracetamol: clinical pharmacology supports analgesic efficacy. Eur Rev Med Pharmacol Sci 2015; 19:507-516. [PMID: 25720726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acute and chronic pain often requires a multimodal approach. Combination therapy reduces the number of individual daily administrations and improves patient's compliance with the prescribed analgesic treatment. Despite the association codeine/paracetamol is one of the most widely used central analgesic, the exact mechanism of action, particularly of paracetamol, is still object of pharmacological research. Recent findings showed that paracetamol may act through cerebral cyclo-oxygenase, descending opioidergic inhibitory pathways, serotonin pathway, and the endocannabinoid system; while codeine activity seems to related not only to its conversion to morphine, as previously known, but also by itself and through its metabolites, such as norcodeine (NORC) and codeine-6-glucuronide (C-6-G). The addition of codeine to paracetamol significantly improves the analgesic action and reduces the number needed to treat (NNT) from 5 to 2.3-3.1. Recent warnings about the risk of its metabolism related to CYP450 and its genetic variability in general population should be mainly considered when the association is used in paediatric patients undergoing tonsillectomy and/or adenoidectomy procedures for obstructive sleep apnoea syndrome (OSAS). In adults, the association codeine/paracetamol has been shown to be effective and safe in different settings: acute pain, trauma patients, and chronic nociceptive pain.
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Affiliation(s)
- C Mattia
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anesthesiology, Intensive Care Medicine and Pain Therapy, Faculty of Pharmacy and Medicine Polo Pontino, Sapienza University of Rome, Rome, Italy.
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Luong S, Ung AT, Kalman J, Fu S. Transformation of codeine and codeine-6-glucuronide to opioid analogues by urine adulteration with pyridinium chlorochromate: potential issue for urine drug testing. Rapid Commun Mass Spectrom 2014; 28:1609-20. [PMID: 24895258 DOI: 10.1002/rcm.6935] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 04/14/2014] [Accepted: 04/27/2014] [Indexed: 05/22/2023]
Abstract
RATIONALE Pyridinium chlorochromate (PCC) is the active ingredient of 'Urine Luck', a commercially available in vitro adulterating agent used to conceal the presence of drugs in a urine specimen. The exposure of codeine and its major glucuronide metabolite codeine-6-glucuronide (C6G) to PCC was investigated to determine whether PCC is an effective masking agent for these opiate compounds. METHODS Following the addition of PCC to both spiked and authentic codeine and C6G-positive urine specimens, the samples were monitored using liquid chromatography/mass spectrometry (LC/MS). Stable reaction products were identified and characterized using high-resolution MS analysis and, where possible, nuclear magnetic resonance (NMR) analysis. RESULTS It was determined that PCC effectively oxidizes codeine and C6G, thus altering the original codeine-to-C6G ratio in the urine specimen. Four reaction products were identified for codeine: codeinone, 14-hydroxycodeinone, 6-O-methylcodeine and 8-hydroxy-7,8-dihydrocodeinone. Similarly, three reaction products were identified for C6G: codeinone, codeine and a lactone of C6G (tentative assignment). CONCLUSIONS Besides addressing the complications added to interpretation, more investigation is warranted to further determine their potential for use as markers for monitoring the presence of codeine and C6G in urine specimens adulterated with PCC.
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Affiliation(s)
- Susan Luong
- Centre for Forensic Science, School of Chemistry and Forensic Science, University of Technology, Sydney (UTS), PO Box 123 Broadway, NSW 2007, Australia
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Leysen J, Bridts C, Ebo DG. Reply to Chirumbolo. Cytometry B Clin Cytom 2014; 86:78-79. [PMID: 24127291 DOI: 10.1002/cytob.21137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 10/03/2013] [Indexed: 06/02/2023]
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Chirumbolo S. Opioid non-IgE mediated effects in a BAT assay on drug hypersensitivity to pholcodine. Cytometry B Clin Cytom 2014; 86:77. [PMID: 24030936 DOI: 10.1002/cyto.b.21127] [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] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 07/13/2013] [Accepted: 08/20/2013] [Indexed: 06/02/2023]
Affiliation(s)
- Salvatore Chirumbolo
- Department of Medicine, University of Verona, LURM-Est Policlinico GB Rossi, Piazzale AL Scuro 10, Verona, 37134, Italy
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Esnault P, Prunet B, Lacroix G, D'Aranda E, Gaillard Y, Boret H. Instantaneous rigor after fatal pholcodine intoxication. Br J Clin Pharmacol 2014; 77:578-9. [PMID: 23772895 PMCID: PMC4371536 DOI: 10.1111/bcp.12183] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 06/04/2013] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | | | | | - Yvan Gaillard
- Toxicological Analysis LaboratoryLa Voulte sur Rhône, France
| | - Henry Boret
- Military Teaching Hospital Sainte AnneToulon, France
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Okabayashi S, Goto M, Kawamura T, Watanabe H, Kimura A, Uruma R, Takahashi Y, Taneichi S, Musashi M, Miyaki K. Non-superiority of Kakkonto, a Japanese herbal medicine, to a representative multiple cold medicine with respect to anti-aggravation effects on the common cold: a randomized controlled trial. Intern Med 2014; 53:949-56. [PMID: 24785885 DOI: 10.2169/internalmedicine.53.1783] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Kakkonto, a Japanese herbal medicine, is frequently used to treat the common cold not only with a physician's prescription, but also in self-medication situations. This study aimed to examine whether Kakkonto prevents the aggravation of cold symptoms if taken at an early stage of illness compared with a well-selected Western-style multiple cold medicine. METHODS This study was a multicenter, active drug-controlled, randomized trial. Adults 18 to 65 years of age who felt a touch of cold symptoms and visited 15 outpatient healthcare facilities within 48 hours of symptoms onset were enrolled. The participants were randomly assigned to two groups: one treated with Kakkonto (Kakkonto Extract-A, 6 g/day) (n=209) and one treated with a Western-style multiple cold medicine (Pabron Gold-A, 3.6 g/day) (n=198) for at most four days. The primary outcome of this study was the aggravation of cold, nasal, throat or bronchial symptoms, scored as moderate or severe and lasting for at least two days within five days after entry into the study. RESULTS Among the 410 enrollees, 340 (168 in the Kakkonto group and 172 in the Pabron group) were included in the analyses. The proportion of participants whose colds were aggravated was 22.6% in the Kakkonto group and 25.0% in the Pabron group (p=0.66). The overall severity of the cold symptoms was not significantly different between the groups. No harmful adverse events occurred in either group. CONCLUSION Kakkonto did not significantly prevent the progression of cold symptoms, even when prescribed at an early stage of the disease.
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Armentia A, Ruiz-Muñoz P, Quesada JM, Postigo I, Herrero M, Martín-Gil FJ, Gonzalez-Sagrado M, Martín B, Castrodeza J. Clinical value of morphine, pholcodine and poppy seed IgE assays in drug-abusers and allergic people. Allergol Immunopathol (Madr) 2013; 41:37-44. [PMID: 21940094 DOI: 10.1016/j.aller.2011.05.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [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: 04/05/2011] [Revised: 05/07/2011] [Accepted: 05/16/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnosis of anaphylactic reactions due to opiates during anaesthesia can be difficult, since in most cases various drugs may have been administered. Detection of specific IgE to poppy seed might be a marker for sensitisation to opiates in allergic people and heroin-abusers. This study assessed the clinical value of morphine, pholcodine and poppy seed skin-prick and IgE determination in people suffering hypersensitivity reactions during anaesthesia or analgesia and drug-abusers with allergic symptoms. METHODS We selected heroin abusers and patients who suffered severe reactions during anaesthesia and analgesia from a database of 23,873 patients. The diagnostic yield (sensitivity, specificity and predictive value) of prick and IgE tests in determining opiate allergy was analysed. RESULTS Overall, 149 patients and 200 controls, mean age 32.9 ± 14.7 years, were included. All patients with positive prick to opiates showed positive prick and IgE to poppy seeds, but not to morphine or pholcodine IgE. Among drug-abusers, 13/42 patients (31%) presented opium hypersensitivity confirmed by challenge tests. Among non-drug abusers, sensitisation to opiates was higher in people allergic to tobacco (25%), P<.001. Prick tests and IgE against poppy seed had a good sensitivity (95.6% and 82.6%, respectively) and specificity (98.5% and 100%, respectively) in the diagnosis of opiate allergy. CONCLUSIONS Opiates may be significant allergens. Drug-abusers and people sensitised to tobacco are at risk. Both the prick and specific IgE tests efficiently detected sensitisation to opiates. The highest levels were related to more-severe clinical profiles.
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Affiliation(s)
- A Armentia
- Allergy Unit, Rio Hortega University Hospital, UMDAI, Valladolid, Spain.
| | - P Ruiz-Muñoz
- San Juan de Dios Centre, Palencia and Castile-Leon Association For the Aid of Drug Abusers (ACLAD), Valladolid, Spain
| | - J M Quesada
- Immunology, Microbiology and Parasitology Department, University of the Basque Country, Vitoria, Spain
| | - I Postigo
- Immunology, Microbiology and Parasitology Department, University of the Basque Country, Vitoria, Spain
| | - M Herrero
- Allergy Unit, Rio Hortega University Hospital, UMDAI, Valladolid, Spain
| | - F J Martín-Gil
- Clinical Chemistry Service, Hospital Universitario Rio Hortega, Valladolid, Spain
| | | | - B Martín
- Research Unit, IEN, Rio Hortega University Hospital, Valladolid, Spain
| | - J Castrodeza
- Direction of Public Health, Investigation, Development and Innovation, SACYL, Valladolid, Spain
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Davey J. The advantages and limitations of the analgesics available for control of postoperative pain after a dental procedure. SAAD Dig 2013; 29:70-81. [PMID: 23544224] [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] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Bu J, Zhan CS. [Comparison of morphine and codeine concentration in urines of heroin abusers and codeine users]. Fa Yi Xue Za Zhi 2012; 28:426-428. [PMID: 23484322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To compare morphine and codeine concentration in urines of heroin abusers and codeine users and to discuss the judgment index to distinguish between heroin abuser and codeine user. METHODS The urines of heroin abusers and codeine users were collected at different time periods. After protein precipitation, the urine samples were conducted for the qualitative and quantitative analysis of morphine and codeine by UPLC-MS/MS. And the results were all statistically analyzed. RESULTS Statistical analysis showed that morphine and codeine concentration in urines of heroin abusers and codeine users were both abnormal distributions. The probability of the heroin abuser would be more than 95% and less than 5% for the codeine user when the concentration of morphine in urine sample was more than 67 ng/mL. The probability of the codeine user would be more than 95% and less than 5% for the heroin abuser when the concentration of morphine in urine sample was less than 67 ng/mL. CONCLUSION The morphine concentration in urine could be used as a criterion to distinguish the heroin abuser from the codeine user, while the codeine concentration could not.
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Affiliation(s)
- Jun Bu
- Shanghai Key Laboratory of Forensic Medicine, Institute of Forensic Science, Ministry of Justice, P.R.China, Shanghai 200063, China.
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Kinoshita H, Tanaka N, Jamal M, Kumihashi M, Okuzono R, Ameno K. A fatal case due to cough syrup abuse. Soud Lek 2012; 57:69-70. [PMID: 23121038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
UNLABELLED We describe here a fatal abused case of cough syrup, containing chlorpheniramine and dihydrocodeine. Postmortem blood concentration of chlorpheniramine was above fatal levels, but dihydrocodeine concentration was within a therapeutic ranges, and those drug levels in blood were discussed from the viewpoint of forensic pharmacokinetics. We concluded that the cause death was due to the chlorpheniramine poisoning. KEYWORDS cough syrup abuse - chlorpheniramine - dihydrocodeine.
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Affiliation(s)
- H Kinoshita
- Department of Forensic Medicine, Faculty of Medicine, Kagawa University, Japan.
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Dumancić J, Marković AS. [Correlation between pholcodine and perioperative anaphylaxis]. Acta Med Croatica 2012; 66:111-114. [PMID: 23437637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A large number of individuals experiencing anaphylactic reaction to neuromuscular blocking agents have not previously been in contact with them. The search for a substance inducing sensitization to muscle relaxants has led Norwegian and Swedish scientists to pholcodine, a cough suppressant, which is widely used in Europe and worldwide. Ammonium ion is an epitope common to pholcodine and neuromuscular blocking agents and it is the basis of their cross-reactivity. Based on the results of published studies that pointed to a connection of the use of pholcodine and perioperative anaphylactic reaction, pholcodine was withdrawn from the Norwegian market and subsequent research revealed a reduction of anaphylactic reactions in that country. In its latest report, the European Medicines Agency made a decision not to withdraw pholcodine mixtures from the market but it urged further research with the aim to clarify the cross-reactivity between pholcodine and neuromuscular blocking agents.
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Affiliation(s)
- Jelena Dumancić
- Department of Clinical Immunology, Pulmonology and Rheumatology, University Department of Internal Medicine, Sveti Duh University Hospital, Zagreb, Croatia.
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Sun YY, Xiang P, Shen M. [Simultaneous determination of 11 opiates in hair by liquid chromatography-tandem mass spectrometry]. Yao Xue Xue Bao 2011; 46:1501-1506. [PMID: 22375426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The paper reports the establishment of a liquid chromatography-tandem mass spectrometry (LC-MS/MS) for simultaneous analysis of 11 opiates in hair samples, and the study of presence of opiates in the hair of active heroin addicts. About 20 mg of decontaminated and pulverized hair sample was hydrolyzed with buffer solution for 30 min, in the presence of morphine-d3 and acetylmorphine-d6 used as internal standards, and then extracted with the mixture of dichlormethane and isopropanol, separated by the Allure PFP propyl column with a mobile phase consisting of acetonitrile and 20 mmol L(-1) ammonium acetate buffer, and then analyzed by LC-MS/MS. Multiple reaction monitoring (MRM) mode was used to analyze 11 opiates. Eleven opiates showed a fairly good linearity over the corresponding range (r > 0.996 0). The detection limits were less than 0.05 ng mg(-1). The recoveries were between 47.2% and 110%, and the deviations of intra- and inter-day precision were less than 14%. Heroin, acetylmorphine, morphine, codeine, acetylcodeine and hydrocodone were detected in hair samples of 21 herion addicts. The developed method shows high sensitivity and selectivity, and is suitable for the simultaneous analysis of 11 opiates in hair samples and identify legal and illegal use of opiates.
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Affiliation(s)
- Ying-Ying Sun
- Department of Forensic Medicine, Institute of Preclinical Medicine and Biological Science, Soochow University, Suzhou 215123, China
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Zamparutti G, Schifano F, Corkery JM, Oyefeso A, Ghodse AH. Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007. Br J Clin Pharmacol 2011; 72:330-7. [PMID: 21235617 PMCID: PMC3162662 DOI: 10.1111/j.1365-2125.2011.03908.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [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: 06/14/2010] [Accepted: 12/18/2010] [Indexed: 01/04/2023] Open
Abstract
WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Dihydrocodeine (DHC) is an opioid analgesic sometimes prescribed as an alternative to other medications (e.g. methadone and buprenorphine) for opioid misuse. Its effectiveness is, however, still controversial. DHC prescription rates seem to be related to levels of DHC fatalities, possibly in relation to levels of disregard of the availability of supervised or interval dispensing of opioids, but no large-scale analysis of DHC fatalities has been carried out. We analysed here involvement of DHC in fatalities that occurred between 1997 and 2007 among individuals with a history of opiate/opioid misuse reported to the National Programme on Substance Abuse Deaths (np-SAD). WHAT THIS STUDY ADDS DHC, either alone or in combination, was identified in 584 fatalities. Typical cases identified were males in their early thirties. In accidental overdoses, DHC, which had been prescribed to 45% of the victims, was typically identified in combination with other drugs, such as heroin/morphine, methadone and hypnotics/sedatives. Both paracetamol and antidepressants were more typically identified in combination with DHC in suicides. Opiate/opioid misusers should be educated about risks associated with polydrug intake and prescribers should carefully consider a pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. AIMS Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction. METHODS Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database. RESULTS Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases. CONCLUSIONS Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.
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Affiliation(s)
- Giuliano Zamparutti
- Department of Addiction, ASL N° 4, and Department of Psychiatry, University of Udine Medical School UdineItaly
| | | | - John M Corkery
- International Centre for Drug Policy; St George's, University of LondonLondon, UK
| | - Adenekan Oyefeso
- International Centre for Drug Policy; St George's, University of LondonLondon, UK
| | - A Hamid Ghodse
- International Centre for Drug Policy; St George's, University of LondonLondon, UK
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Florvaag E, Johansson SGO, Irgens Å, de Pater GH. IgE-sensitization to the cough suppressant pholcodine and the effects of its withdrawal from the Norwegian market. Allergy 2011; 66:955-60. [PMID: 21241314 DOI: 10.1111/j.1398-9995.2010.02518.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [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: 11/27/2022]
Abstract
BACKGROUND IgE-mediated anaphylaxis to neuromuscular blocking agents (NMBA), frequent in Norway, was proposed to be caused by exposure to pholcodine (PHO) carrying the allergenic quarternary ammonium ion epitope. Consequently, the PHO-containing drug was withdrawn from the market in March 2007. OBJECTIVE Describe the effects of withdrawal of PHO on IgE, IgE-antibodies and reported frequencies of anaphylaxis to NMBAs. METHODS Three hundred sera from supposedly allergic patients sampled yearly through 2006 to 2010 were analysed for IgE antibodies to PHO, suxamethonium (SUX) and morphine (MOR). Furthermore, IgE and preliminary reports from the Norwegian Network for Anaphylaxis under Anaesthesia (NARA) were monitored. RESULTS PHO exposure was associated with IgE sensitization to PHO, MOR and SUX. However, after withdrawal, within 1 year, antibody prevalences to PHO and SUX fell significantly from 11.0% to 5.0% and from 3.7% to 0.7%, respectively. At 3 years, SUX had fallen to 0.3%, PHO to 2.7% and MOR to 1.3%. By 2 years, the prevalence of elevated IgE was significantly reduced. After 3 years, the incidence of reported suspected anaesthetic anaphylaxis fell significantly, both the total number, the reactions related to NMBAs and those with IgE antibodies to SUX. CONCLUSIONS Withdrawing of PHO lowered significantly within 1-2 years levels of IgE and IgE antibodies to PHO, MOR and SUX, and, within 3 years, the frequency of NMBA suspected anaphylaxis. The results strengthen the PHO hypothesis considerably and equally the need to question the existence of cough depressants containing PHO.
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Affiliation(s)
- E Florvaag
- Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
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Abstract
PURPOSE OF REVIEW During the preoperative evaluation, patients frequently indicate 'multiple drug allergies', most of which have not been validated. Potential allergic cross-reactivity between drugs and foods is frequently considered as a risk factor for perioperative hypersensitivity. The aim of this review is to facilitate the recognition of risk factors for perioperative anaphylaxis and help the management of patients with 'multiple drug allergies' during the perioperative period. RECENT FINDINGS Neuromuscular blocking agents (NMBAs) and antibiotics are the most common drugs triggering perioperative anaphylaxis. Quaternary ammonium ions have been suggested to be the allergenic determinant of NMBAs. Even though the 'pholcodine hypothesis' has been suggested to explain the occurrence of NMBA-induced allergy, this concept remains unclear. Although many practitioners believe that certain food allergies present an issue with the use of propofol, there is no role to contraindicate propofol in egg-allergic, soy-allergic or peanut-allergic patients. IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, but there is no cross-reactivity between them. The allergenic determinants have been characterized for fish, shellfish and povidone iodine and remain unknown for contrast agents. SUMMARY There are many false assumptions regarding drug allergies. The main goal of this article is to review the potential cross-reactivity among specific families of drugs and foods in order to facilitate the anesthetic management of patients with 'multiple drug allergies'.
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Affiliation(s)
- Pascale Dewachter
- Pôle d'Anesthésie-Réanimation, Hôpital Gabriel Montpied, Clermont-Ferrand, France.
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Tanaka M, Sasaki Y. [Q & A. A patient brought in a comatose state, displaying acute hepatic disorder and an area of high absorption in the stomach in CT images]. Nihon Shokakibyo Gakkai Zasshi 2011; 108:665-669. [PMID: 21696021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Abstract
BACKGROUND Tramadol and dihydrocodeine (DHC) are analgesics of step 2 WHO analgesic ladder (opioids for mild to moderate pain, weak opioids) frequently used in the treatment of cancer pain of moderate intensity. The aim of the study was to assess the impact of tramadol and DHC treatment on quality of life (QL) and performance status (PS) of patients with cancer pain. PATIENTS AND METHODS Randomised, cross-over, clinical study of 40 opioid-naive patients with nociceptive cancer pain who received tramadol or DHC controlled release tablets for 7 days, and then drugs were switched and administered for another 7 days. Pain was assessed by visual analogue scale (VAS), QL by EORTC QLQ C 30, and PS by Eastern Cooperative Oncology Group (ECOG) and Karnofsky. RESULTS From 40 patients recruited, 30 completed the study. DHC treatment provided better analgesia (VAS). In QL functional scales, better emotional functioning in tramadol group and better global QL and cognitive functioning in DHC group were observed. In symptom scales, less fatigue, pain and sleep disturbances, less nausea and vomiting and better appetite in DHC group were noted. In tramadol group, less constipation and less financial problems were observed. No differences in dyspnoea and diarrhoea were noted. ECOG and Karnofsky PS were low and did not differ between tramadol and DHC groups. CONCLUSIONS Dihydrocodeine treatment was associated with better global QL, cognitive functioning, analgesia and appetite, less fatigue, sleep disturbances, nausea and vomiting. Tramadol therapy was connected with better emotional functioning, less constipation and financial problems. PS deteriorated in both tramadol and DHC groups.
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Affiliation(s)
- W Leppert
- Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland.
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Johansson SGO, Florvaag E, Oman H, Poulsen LK, Mertes PM, Harper NJN, Garvey LH, Gerth van Wijk R, Metso T, Irgens A, Dybendal T, Halsey J, Seneviratne SL, Guttormsen AB. National pholcodine consumption and prevalence of IgE-sensitization: a multicentre study. Allergy 2010; 65:498-502. [PMID: 19796197 DOI: 10.1111/j.1398-9995.2009.02193.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [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: 11/29/2022]
Abstract
BACKGROUND The aim of this study was to test, on a multinational level, the pholcodine (PHO) hypothesis, i.e. that the consumption of PHO-containing cough mixtures could cause higher prevalence of IgE antibodies to PHO, morphine (MOR) and suxamethonium (SUX). As a consequence the risk of anaphylaxis to neuromuscular blocking agents (NMBA) will be increased. METHODS National PHO consumptions were derived from the United Nations International Narcotics Control Board (INCB) database. IgE and IgE antibodies to PHO, MOR, SUX and P-aminophenyl-phosphoryl choline (PAPPC) were measured in sera from atopic individuals, defined by a positive Phadiatop test (>0.35 kU(A)/l), collected in nine countries representing high and low PHO-consuming nations. RESULTS There was a significant positive association between PHO consumption and prevalences of IgE-sensitization to PHO and MOR, but not to SUX and PAPPC, as calculated both by exposure group comparisons and linear regression analysis. The Netherlands and the USA, did not have PHO-containing drugs on the markets, although the former had a considerable PHO consumption. Both countries had high figures of IgE-sensitization. CONCLUSION This international prevalence study lends additional support to the PHO hypothesis and, consequently, that continued use of drugs containing this substance should be seriously questioned. The results also indicate that other, yet unknown, substances may lead to IgE-sensitization towards NMBAs.
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Affiliation(s)
- S G O Johansson
- Department of Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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Seidel RW, Bakalska BR, Kolev T, Vassilev D, Mayer-Figge H, Spiteller M, Sheldrick WS, Koleva BB. N-methylcodeinium iodide--crystal structure and spectroscopic elucidation. Spectrochim Acta A Mol Biomol Spectrosc 2009; 73:61-66. [PMID: 19233715 DOI: 10.1016/j.saa.2009.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Revised: 12/31/2008] [Accepted: 01/20/2009] [Indexed: 05/27/2023]
Abstract
The correlation between the structure and the spectroscopic properties of N-methylcodeinium iodide (1) has been studied, using the methods of single crystal X-ray diffraction, IR-LD spectroscopy of oriented samples as a suspension in nematic liquid crystals, UV-vis spectroscopy and 1H and 13C NMR spectroscopy. HPLC tandem mass spectrometry (HPLC ESI MS/MS) and thermal methods were also employed. Quantum chemical calculations have been performed with a view to obtaining the electronic structure and vibrational properties of the title compound. Compound (1) crystallizes in the space group P2(1)2(1)2(1) and its cations and anions are joined by moderate intermolecular OH...I- interaction of length 3.442A. The codeine molecule exhibits the classical T-shape for opiates. A dihedral angle value of 86.4(5) degrees between the A/B/C and D/E planes is obtained. Rings A and B are effectively coplanar with an interplanar angle of 3.6(3) degrees.
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Affiliation(s)
- R W Seidel
- Lehrstuhl für Analytische Chemie, Ruhr-Universität Bochum, Universitätsstrasse 150, 44780 Bochum, Germany
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Affiliation(s)
- S G O Johansson
- Clinical Immunology and Allergy Unit, Karolinska University Hospital L2:04, S-17176 Stockholm, Sweden.
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Abstract
BACKGROUND Opioid overdose is an increasing health problem worldwide. The cardiovascular toxicity of opioids contributes to morbidity and mortality in overdose but the hemodynamic effects of opioids reported in animal and human studies are contradictory. METHODS We performed a prospective observational study of patients admitted to hospital following an overdose of methadone, dihydrocodeine, or low dose paracetamol (10 each). Basic cardiovascular indices including peripheral blood pressure, pulse rate, radial augmentation index and derived measures of aortic systolic, diastolic, pulse, and mean and end systolic pressures were measured every six hours for up to 18-23 hours after exposure or until hospital discharge. RESULTS Dihydrocodeine and methadone significantly reduced peripheral and aortic systolic, mean and end systolic pressures. Both opioids significantly decreased peripheral pulse pressure, but only methadone decreased aortic blood pressure. Dihydrocodeine reduced systemic and aortic diastolic blood pressure, an effect not induced by methadone. Methadone significantly reduced peripheral pulse pressure. Augmentation index and heart rate, however, did not change. Both opioids decreased arterial oxygen saturation. CONCLUSION These results suggest that dihydrocodeine and methadone in overdose both have a significant effect on central and peripheral hemodynamics. These effects might be expected to reduce cardiac afterload, providing a pharmacological explanation for the apparent benefit of opioids in cardiovascular diseases.
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Affiliation(s)
- R Afshari
- Medical Toxicology Centre, Imam Reza (P) Hospital, Mashhad, Iran.
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Windhövel L. Cautious advice. Dtsch Arztebl Int 2009; 106:57-58. [PMID: 19564974 PMCID: PMC2695310 DOI: 10.3238/arztebl.2009.0057b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Saeki S. [Indication and usage of opioids except morphine for chronic non-malignant intractable pain]. Masui 2008; 57:1351-1358. [PMID: 19039961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Indication and usage of opioids except morphine for chronic non-malignant intractable pain were reviewed. In Japan, other than morphine, we can use only two opioids, codeine phosphate (codeine), and dihydrocodeine phosphate (dihydrocodeine) for non-malignant pain management according to medical insurance system. But in western countries sustained-release opioids such as MS contine, transdermal fentanyl, oxycontin were used for the management of non-malignant chronic pain. The WHO ladder for cancer management should also be used for the management of non-malignant pain. Initial dose of codeine is 60 mg x day(-1) and the dosage should be increased or decreased according to pain intensity, patients' general condition and age. In most cases pain is controlled at the dose of 80-310 mg x day(-1). If pain intensity does not decrease or change, codeine should be changed to morphine. In our clinic, starting dose of codeine was 40-480 mg x day(-1) (average dose: 107.8 mg x day(-1)), maximum dose was 60-1280 mg x day (average dose: 310 mg x day(-1)). Average period for administration of codeine was 294.4 days. Dihydrocodeine has twice analgesic efficacy compared to codeine. The initial dose is the same as codeine. We hope that sustained release opioids such as transdermal fentanyl, oxycontin, tramadol etc will be used in Japan for management of non-malignant chronic pain in the near future.
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Affiliation(s)
- Shigeru Saeki
- Department of Anesthesiology, Surugadai Nihon University Hospital, Tokyo
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McKean SA, Lee MSW, Hussain SSM. Comparative study of posttonsillectomy hemorrhage with the use of diclofenac versus dihydrocodeine for postoperative analgesia and review of the literature. J Otolaryngol Head Neck Surg 2008; 37:577-581. [PMID: 19128596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To assess the effect of postoperative diclofenac on the posttonsillectomy hemorrhage rate in adults. DESIGN Retrospective chart review with Caldicott Guardian approval of patients before and after a change in the postoperative drug regimen. One hundred ninety-three adults between 16 and 56 years, American Society of Anesthesiologists Grade I, listed for elective tonsillectomy, were included in the analysis. SETTING A tertiary referral centre in the United Kingdom. METHODS One hundred ten adults had cold dissection tonsillectomy and had been prescribed soluble diclofenac postoperatively. This group was compared with 83 adult patients who underwent cold dissection tonsillectomy and had been prescribed dihydrocodeine solution postoperatively. Our hypothesis was that the postoperative use of diclofenac made no difference to the incidence of secondary hemorrhage. The Fisher exact test was used for analysis. MAIN OUTCOME MEASURES Comparison of a previously reported posttonsillectomy hemorrhage rate with the rate for the year after the addition of diclofenac. The occurrence of primary or secondary postoperative hemorrhage and its management was recorded. RESULTS Three of 110 (2.73%) patients who used postoperative diclofenac had secondary hemorrhage compared with 6 of 83 (7.23%) of those patients treated with dihydrocodeine. The Fisher exact test for secondary hemorrhage therefore gives a p value of .131, and there is no significant difference. CONCLUSIONS Diclofenac is a useful and safe addition to postoperative analgesia for adult tonsillectomy. There was an apparent reduction in secondary hemorrhage with the postoperative use of diclofenac.
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Affiliation(s)
- Simon A McKean
- Department of Otolaryngology, Ninewells Hospital and Medical School, Dundee, Scotland.
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