Valbenazine and Trazodone overdose in a patient taking LAI and oral Paliperidone (original) (raw)
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Coma After Quetiapine Fumarate Intentional Overdose in a 71-year-old Man: A Case Report
Drug Safety - Case Reports, 2015
A 71-year-old man developed coma with severe respiratory failure, hypotension, and tachycardia induced by the intentional ingestion of quetiapine fumarate extended release (XR) 20 g. At the time, he had been treated for bipolar depression with venlafaxine 75 mg/day, lamotrigine 100 mg/day, pregabalin 75 mg/day, and quetiapine XR 400 mg/day for approximately 1 year. Comorbidities were hypertension treated with metoprolol, diabetes mellitus type 2 treated with metformin, and benign prostatic hyperplasia treated with silodosin. In the emergency room, about 4 h after ingestion of quetiapine fumarate XR, the presenting symptomatology was characterized by coma (Glasgow Coma Scale score 3), hypotension (blood pressure [BP] 90/60 mmHg), tachycardia (electrocardiogram [ECG] showed sinus tachycardia with heart rate 120 beats per minute and a QTc of 499 ms). A gastric lavage was performed and activated charcoal 50 g and magnesium sulfate 30 g was administered. About 6 h after ingestion, he developed marked desaturation and underwent mechanical ventilation; 13 h after ingestion, a severe hypotensive episode followed (BP 70/40), which was treated with an infusion of ringer lactate 500 cc. On the 3rd day after intentional overdose, an episode of agitation occurred; 4 days after ingestion, the quetiapine plasma level was found to be 42 ng/ml (within therapeutic range). At 5 days after ingestion, the patient developed septicemia caused by staphylococci (probably originating from the central vein catheter), which was treated with antibiotic therapy. On days 10 and 18 after the suicide attempt, two episodes of paroxysmal supraventricular tachycardia (PSVT) occurred and were successfully treated with intravenous adenosine triphosphate. The patient recovered completely without residual symptoms. In line with literature data, in this case report, symptoms of quetiapine overdose were tachycardia, agitation, hypotension, QT interval prolongation, and coma. A causal relationship between PSVT and quetiapine intoxication seems quite unlikely due to the drug level. Key Points Quetiapine is included as a first-line recommendation in recent guidelines for bipolar depression, with evidence of possible benefit in elderly patients who otherwise have a high suicidal risk. In elderly patients, symptoms of quetiapine overdose are tachycardia, agitation, hypotension, QT interval prolongation, and coma. Early intervention, rapid transfer to an intensive care unit, and no evidence of co-ingestion of other drugs or alcohol could be associated with a good prognosis. In case of intoxication, the possibility of early screening of a broader group of drugs, including the widespread second-generation antipsychotics, could be useful to improve clinical practice.
Overdose of Quetiapine—A Case Report with QT Prolongation
Toxics, 2021
Quetiapine is an atypical antipsychotic drug used to treat bipolar disorder, schizophrenia, and major depressive disorder. Although several studies describe the adverse effects of intoxication with Quetiapine, only a few report an extreme overdose without comedications that lead to a life threat. We present a case of a 75-year-old male who tried to attempt suicide by ingesting 28 g of Quetiapine. During the management in the emergency department, both serum and urine samples were collected, allowing a complete pharmacokinetic analysis to be conducted, from the admission to the discharge.
American Journal of Therapeutics, 2010
Commonly used agents of drug poisoning among patients who come to the emergency services are tricyclic antidepressants (TCAs). These drugs may cause defect in cardiac conduction due to the slowdown in the cardiac depolarization and expansions in the QT interval. Selective serotonin reuptake inhibitors (SSRIs) are less expansion of the QT period and lower cardio toxic side effects. The aim of this study was to investigate QTc intervals and prognosis of the patients who come to the emergency service due to TCA and SSRI group antidepressant drug poisoning. In a study of 96 patients, 75 of whom were diagnosed to be poisoned by TCAs (TCA group) and 21 by SSRIs (SSRI group) were examined. Electrocardiographic alterations and QTc intervals all of patients were evaluated. QTc intervals of patients in TCA group were determined to be slightly more than those in SSRI group and it was not statistically significant. In the SSRI group, only one patient had QTc period more than 500 milliseconds (520 milliseconds); however, TCA overdose showed 9 (12%) patients with QTc interval over 500 milliseconds, and QTc values of 2 patients were over 600 milliseconds. In our study, it was determined that SSRI group drugs caused similar expansion of the QTc period as TCA drugs but they did not reach high values like TCA drugs, and their OTc intervals stayed in more innocent levels.
A systematic review of cardiovascular effects after atypical antipsychotic medication overdose
The American Journal of Emergency Medicine, 2009
As the use of atypical antipsychotic medications (AAPM) increases, the number of overdoses continues to grow. Cardiovascular toxicity was common with older psychiatric medications, but appears uncommon with AAPM. We conducted a systematic literature review to describe the cardiovascular effects reported following overdose of 5 common AAPM: Aripiprazole, olanzapine, quetiapine, risperidone and ziprasidone. We included case reports and case series describing overdose of these 5 medications identified in a search of MEDLINE, EMBASE and abstracts from major toxicology meetings. We found 13 pediatric cases (<7 yr), 22 adolescent cases (7-16 years) and 185 adult cases. No pediatric case described a ventricular dysrhythmia or a cardiovascular death. In the adolescent and adult cases we found numerous reports of prolonged QTC interval and hypotension, but there were only three cases of ventricular dysrhythmia and three deaths that may have been due to direct cardiovascular toxicity. The results from case series reports were similar to the single case report data. Our review suggests that overdose of AAPM is unlikely to cause significant cardiovascular toxicity.
Survival from coma induced by an intentional 36-g overdose of extended-release quetiapine
Drug and Chemical Toxicology, 2011
Quetiapine is a second-generation antipsychotic drug approved for the treatment of bipolar disorders and schizophrenia. Acute quetiapine overdose is rare, and quetiapine has long been thought to be safer than other antipsychotics. Nevertheless, as reported in the literature, the severity of the effect of quetiapine overdose has not been associated with a high serum concentration of the drug or with the reported ingested dose. In this article, we report a case of survival from coma induced by a massive extended-release (XR) quetiapine ingestion at a dose greater than reported in some previous fatal cases. A 34-year-old woman with chronic schizophrenia ingested 36 g of quetiapine fumarate XR for attempted suicide. She was initially lethargic, but her clinical conditions rapidly deteriorated and she collapsed unconscious. The woman was taken to the nearest hospital, where the medical emergency team found her in deep coma with response only to deep painful stimuli (Glasgow Coma Scale 9). An endotracheal tube was inserted for airway protection, and the patient was transferred to a critical care area for ventilatory support and maintenance of hydration status and electrolytic balance. Spontaneous breathing was restored in approximately 36 hours, and a few days later, she was discharged without reporting clinical complications. This is the first case of coma induced by an intentional 36-g overdose of quetiapine XR. Given the widespread use of quetiapine and the lack of information about its toxicity in overdose, this case report reinforces the importance of closely monitoring patients taking quetiapine and helps to better define the safety of this drug.
2003
Objective The aim of the present study was to examine the relationship between serious arrhythmias in patients with psychotropic drug overdose and electrocardiography (ECG) findings that have been suggested previously to predict this complication. Methods Thirty-nine patients with serious arrhythmias (ventricular tachycardia, supraventricular tachycardia or cardiac arrest) after tricyclic antidepressant overdose or thioridazine overdose were compared with 117 controls with clinically significant overdose matched to each case for the drug ingested. These patients with psychotropic drug overdose had presented for treatment to the Department of Clinical Toxicology, Newcastle and to the Princess Alexandra Hospital, Brisbane. The heart rate, the QRS width, the QTc and QT intervals, the QT dispersion, and the R wave and R/S ratios in aVR on the initial ECGs were compared in cases and controls. Results The cases had taken dothiepin (16 patients), doxepin (six patients), thioridazine (five patients), amitriptyline (five patients), nortriptyline (three patients), imipramine (one patient) and a combination of dothiepin and thioridazine (three patients). In 20 of the 39 patients with arrhythmias, the arrhythmia had been a presumed ventricular tachycardia. Of the other 19 patients, 15 patients had a supraventricular tachycardia, two patients had cardiac arrests (one asystole, one without ECG monitoring) and two patients had insufficient data recorded to make classification of the arrhythmias possible. The QRS was ≥ 100 ms in 82% of cases but also in 76% of controls. QRS ≥ 160 ms had a sensitivity of only 13% and occurred in 2% of controls. QRS > 120 ms, QTc > 500 and the R/S ratio in aVR appeared to have a stronger association with the occurrence of arrhythmia: QRS > 120 ms (odds ratio [OR], 3.56; 95% confidence interval [CI], 1.46-8.68), QTc > 500 (OR, 3.07; 95% CI, 1.33-7.07), and R/S ratio in aVR > 0.7 (OR, 16; 95% CI, 3.47-74). Excluding thioridazine overdoses and performing the analysis for tricyclic antidepressant overdoses alone gave increased odds ratios for QRS > 120 ms (OR, 4.83; 95% CI, 1.73-13.5) and QTc > 500 (OR, 4.5; 95% CI, 1.56-13) but had little effect on that for the R/S ratio in aVR > 0.7 (OR, 14.5; 95% CI, 3.10-68). Conclusion ECG measurements were generally weakly related to the occurrence of arrhythmia and should not be used as the sole criteria for risk assessment in tricyclic antidepressant overdose. The frequently recommended practice of using either QRS ≥ 100 ms or QRS ≥ 160 ms to predict arrhythmias is not supported by our study. R/S ratio in aVR > 0.7 was most strongly related to arrhythmia but had estimated positive and negative predictive values of only 41% and 95%, respectively. The use of these specific predictors in other drug overdoses is not recommended without specific studies.
QT interval prolongation after sertraline overdose: a case report
BMC emergency medicine, 2005
Selective serotonin reuptake inhibitors (SSRIs) are the most common antidepressants used in first-world countries and are generally well tolerated. Specifically, less cardiovascular toxicity has been reported in comparison with tricyclic antidepressants. Here we report QT interval prolongation after an overdose of the SSRI sertraline. A previously healthy female patient presented with an attempted suicide with overdoses sertraline (2250 mg), diazepam (200 mg), and temazepam (400 mg). Routine laboratory studies were normal and her ECG upon admission showed a normal QT interval. The next day, her ECG showed prolongation of the QTc interval up to 525 ms. After discontinuation of sertraline the QT interval normalized. Echocardiography and exercise electrocardiography were normal. After hospitalization, the patient resumed sertraline in the normally recommended dose and QT interval remained within normal ranges. It seems that the SSRI sertraline in overdose may cause QT interval prolonga...
Valproate overdose: a comparative cohort study of self poisonings
British Journal of Clinical Pharmacology, 2003
Aims Based on individual case reports of massive overdoses, valproate is often regarded as having significant toxicity. This study aimed to describe the epidemiology of valproate poisoning and the spectrum of its clinical effects. Methods Consecutive valproate poisonings were identified and compared with other anticonvulsant overdoses and all other poisonings, from a prospective database of poisoning admissions presenting to a regional toxicology service. National prescription data for the same period were obtained. Results There were 79 patients with valproate poisoning from January 1991 to November 2001, 15 cases with valproate alone. Of the 15 cases, drowsiness occurred in two patients (both taking > 200 mg kg-1), vomiting occurred in four and tachycardia in five. In patients co-ingesting other medications, moderate to severe effects were consistent with the co-ingestants. There was one death not directly related to valproate. One patient had metabolic acidosis and thrombocytopaenia consistent with severe valproate toxicity. Comparison of valproate, carbamazepine, phenytoin and control groups showed that length of stay for both phenytoin and carbamazepine was significantly longer than for valproate (P < 0.0001), and there was a significantly increased risk of intensive care unit admission for carbamazepine vs valproate (OR 2.73; 95% CI 1.22, 6.28; P = 0.015). Although valproate prescriptions increased over the 10 years, there was relatively greater increase in the incidence of valproate poisoning. The odds of a valproate overdose in 1992 compared with carbamazepine were 0.29 (95% CI 0.07, 1.28; P = 0.141), but in 2001 were 2.73 (95% CI 1.38, 5.39; P = 0.004). Conclusions Valproate causes mild toxicity in the majority of cases. Massive overdoses of greater than 400 mg kg-1 can cause severe toxicity, but these are uncommon. The older anticonvulsants phenytoin and carbamazepine remain a greater problem than valproate in overdose.
Italian Journal of Medicine, 2015
Paliperidone is a new atypical antipsychotic agent. There are few literature reports of paliperidone overdoses and we report a case of these. A 32-year-old man was admitted to Emergency Department for occurrence of opisthotonus, muscular spasms and rigidity. Twenty hours before, he had an ingestion of 168 mg of paliperidone. He had hypotension and tachycardia. The dystonic reaction completely resolved within a few minutes after diazepam. Nine hours after admission, he sudden showed a right hemisoma partial seizure. The peculiar interest of our case is that three different and rare symptoms occurred in successive times after overdose. Some symptoms occurred after several hours following overdose. Oral paliperidone is available as an <em>osmotic release delivery system</em> that results in a gradual rise in plasma concentrations. According to this limited experience in which delayed onset of toxicity has been observed, it may be prudent to recommend prolonged observation a...
Annals of Emergency Medicine, 1983
Two case reports of overdose with the triazolopyridine antidepressant, trazodone (Desyrel®), are reported. Both ingestions were documented with trazodone serum concentration determinations. Major complaints of both patients were drowsiness and nausea. The cardiotoxicity, neurotoxicity, and respiratory depression commonly encountered during tricyclic antidepressant overdoses did not occur. The comparative toxicity of trazodone and tricyclics is discussed in terms of the pharmacologic profiles of these drugs.