Multiple drug ingestion for suicidal purpose alprazolam, citalopram.fh1

Multiple Drug Ingestion For Suicidal Purpose: Alprazolam,
Citalopram, Risperidone, Oxcarbazepine And Alcohol
Ýntihar Amacý Ýle Çoklu Ýlaç Ýçilmesi: Alprazolam, Citalopram, Risperidone, Oxcarbazepine Ve Alkol Yrd.Doç.Dr. Ayþe MIZRAK1, Yrd.Doç.Dr. Senem KORUK1, Ögr. Gör. Rauf GÜL1 Doç.Dr. Süleyman GANÝDAÐLI1, Prof.Dr. Ünsal ÖNER1 Doç.Dr. Aynur AKIN2, Prof.Dr. Aliye ESMAOÐLU2 1Gaziantep University Medical School Department of Anesthesiology and Reanimation 2Erciyes University Medical School Department of Anesthesiology and Reanimation Hipnotik ajanlar, antidepresan ve antipsikotik ilaçlar uykusuzluk, depresyon ve psikotik hastalýklarýn tedavisinde yaygýn olarak kullanýlmaktadýr. Bu ajanlarýn aþýrý dozda alýmýnýn rapor edilmesi giderek artmasýna raðmen alprazolam, citalopram, risperidone, oxcarbazepine ve alkolün hep birlikte alýmýný kapsayan bir vaka þu ana kadar gösterilmemiþtir. Geliþmekte olan ülkelerde bu ilaçlarýn reçete edilmesi artmaya devam ettiði için bu ilaçlarýn klinik toksisitelerini ve klinik yaklaþýmlarýný deðerlendirmek gereklidir. Biz, intihar amacý ile aþýrý dozda alprazolam, citalopram, risperidone, oxcarbazepine ve alkol alan ve destek tedavisi ile iyileþen 20 yaþýnda bir kadýn olguyu bildirdik. Kadýn hastanýn yüksek dozda alprazolam (18 mg), citolapram hydrobromur (80 mg), risperidone (16 mg), oxcarbazepine (600 mg) ve ayný zamanda alkol aldýðý ev arkadaþý ve uyanýk iken kendisi tarafýndan bildirilmiþtir. Hastaya standart detoksifikasyon prosedürü ve destek tedavisi uygulandý.
Anahtar Kelimeler: Alprazolam, citalopram, risperidone, oxcarbazepine, alkol, çoklu ilaç zehirlenmesi
Abstract
Hypnotic agents, antidepressant and antipsychotic drugs are commonly used for the treatment of sleeplessness, depression, and psychotic disorders. Although overdose intake with these agents is increasingly being reported, no case of co-ingestion including alprazolam, citalopram, risperidone, oxcarbazepine and alcohol has been demonstrated so far. As prescription of these drugs continues to increase in developing countries, it is necessary to evaluate their clinical toxicity and clinical approach. We reported a case of overdose with alprazolam, citalopram, risperidone, oxcarbazepine and alcohol in a 20-year-old female for suicidal purpose who recovered with supportive management. It was reported by her room-mate and patient when conscious that she had taken high doses of alprazolam (18 mg), citolapram hydrobromur (80 mg), risperidone (16 mg), oxcarbazepine (600 mg) and alcohol also. She was managed with standard detoxification procedures and supportive treatment.
Key Words: Alprazolam, citalopram, risperidone, oxcarbazepine, alcohol, multiple drug intoxication.
Gaziantep Týp Dergisi 2008, 14:50-52.
INTRODUCTION
Among young people, poisoning is a leading cause of Many variable medication combinations may be used in injury mortality in the United States. One of the major causes a suicidal attempt. Most commonly we see one or two kinds of death is a suicidal attempt. It is commonly seen in patients of drugs taken. We mentioned here is a patient under who take antidepressant medications (1). Prevention and antidepressant treatment who taken multiple drug combinations management of such overdose are of increasing clinical which are not seriously toxic if taken alone but may have be relevance as prescription of these kinds of drugs continues to severe toxic effects when taken together. Each drug has a increase (2). Though, little is known about these drugs (3), central nervous system (CNS) depressant effect. First of them several cases reported about overdose of these agents (4-7).
is alprazolam (an antidepressant), the second one is risperidone (a type of phenothiazines), third one is citalopram hydrobromur (a selective serotonine reuptake inhibitor–SSRI), fourth one is oxcarbazepine (an anticonvulsant and hypnotic agent) and There is a lack of knowledge in the literature about the Gaziantep Üniversitesi Anestezi ve Reanimasyon AD Adres: Gaziantep Üniversitesi Týp Fakültesi management of multiple drug ingestion in emergency and intensive care unit. The treatment was effective because of the rapidly introducing of patient to the hospital, emergent evaluation and routine medications done immediately. It is aimed to discuss a case of intoxication with the multiple drugs; all of them were almost depressants of CNS.
Gaziantep Týp Dergisi 2008, 14:50-52.
CASE REPORT
Alprazolam has been shown to produce improvement in patients with panic disorder (4). It has also been reported A 20-year-old girl was taken to the emergency unit with useful in alcohol withdrawal (5) and in some types of pain an semi-unconscious situation. It was learned from her room- mate and patient when conscious that she took high doses of alprazolam (18 mg), citolapram hydrobromur (80 mg), Although alcohol increases simple reaction it has much risperidone (16 mg), oxcarbazepine (600 mg) and alcohol more effect on central activity at this dose. Combination of approximately 90 minutes before being admitted to the benzodiazepines and alcohol has more effect on tests of motor function and coordination than would be predicted from the sum of the single effects and that alcohol is the dominant On the initial examination she had a heart rate of 150 beats/min, respiratory rate of 22 breaths/ min. Body temperature was 36.8 C. Systemic blood pressure was 90/50 mm Hg. Pupils Patients receiving psychotropic medications are often were mydriatic and positive to light reflexes. She was semi- cautioned against the use of ethanol. 2 mg alprazolam in conscious and Glasgow Coma Scale Score was 9. Her arterial combinations with ethanol produced additive decrements in blood gas analysis showed metabolic acidosis with a-13.5 base performance on all cognitive and psychomotor tasks (8).
excess, and PaO2 87 mm Hg, PaCO2 52 mm Hg and SpO2 Benzodiazepines and ethanol may act partially on the same 80%. She was administered 100% oxygen via the face mask.
receptor; the lack of the interaction may be due in part to acute In the pulmonary examination, wheezing was auscultated in the basal zones. For the radiological assessment, chest X-ray examination was applied and it showed a pneumonic infiltration In our case chemical causes of CNS depression were which was thought to be a pulmonary aspiration in the lung.
alprazolam (Xanax), risperidone (Risperdal), citalopram hydrobromur (Cipram), oxcarbazepine (Trileptal) and alcohol.
Pulmonary aspiration may have happened while vomiting She wasn’t tolerant to the effect of that dose alcohol. Although before transfered to hospital. Blood glucose level was 75 doses of all drugs ingested were not toxic level, their doses mg/dl. Serum CPK enzyme level was normal.
higher than their therapeutic doses. Their combination resulted Electrocardiogram showed negative T waves in the V2 and in clinical toxicity. This may be due additive or potential effects V3 derivations. It was thought to be the result of co-ingestion of drugs ingested together. These drugs have a potential of of these drugs . In order to exclude an intracranial pathology, cranial CT scan was performed and was reported as normal.
Risperidone (Risperdal) (a phenotiazine) is used for its As she was not unconscious completely and was able to antiemetic, antipsychotic and sometimes analgesic and hypnotic obey our commands, gastric lavage was performed via a naso- effects. Serious symptoms may be occur after 1mg/kg dose.
gastric catheter of 14 G. As the aspiration material was not Higher doses can cause liver injury, cirrhosis, and enough, we decided to give 50 grams of active charcoal and agranulocytosis. Risperidone toxicity manifests primarily with laxafenol (300 mg, 2x1) via the naso-gastric catheter in the mild central nervous system effects and reversible supine-sitting position. It was repeated for every six hours.
neuromuscular and cardiovascular effects (11).
Flumazenil, the antagonist of alprazolam, was given in titrated doses of 0.5 mg intravenously. For supportive treatment fluid Citalopram hydrobromur (Cipram) is a selective serotonin replacement therapy, antibiotics (seftriaxone;1 grX1, reuptake inhibitor drug and may be efficacious in the treatment clindamycine;600 mg, 1X1), gastric acid inhibitor agent of depression, senile dementia, alcohol withdrawal syndrome (ranitidine, 150 mg X2), bronchodilator agents and n-acetyl and bipolar disorder. Minimum lethal level of its blood cystein (Asist; 4X1) applied in routine doses.
concentration was reported 5200 mg. After using with other CNS depressant agent risk of arrhythmia and convulsion After six hours from the beginning of the treatment she increases. Acute toxicity with this drug results in became conscious completely and orally cooperated. Blood rhabdomyolysis, renal failure, hypoxia and seizures (12).
pressure was improved and arterial oxygen saturation increased to 81% at the sixth and 96% at the twelfth hours. T waves in Oxcarbazepine (Trileptal) has an anticonvulsant and the V2 and V3 derivations and other abnormal parameters hypnotic effect via CNS depressant effect. Overuse causes returned to normal in 48 hours. Oral feeding was begun on respiratory insufficiency and coma. There is no antidote agent the second day and she referred to psychiatry clinic on the to use in oxcarbazepine toxicity (13).
Flumazenil is a benzodiazepine antagonist and can be used in addition to supportive care at iv doses of 0.01 mg/kg. It binds to the benzodiazepine receptor, where it competitively DISCUSSION
displaces benzodiazepines and reverses sedative and anxiolytic Alprazolam is a triazolobenzodiazepine that appears both effects (14). It reverses sedation, respiratory depression, to exhibit a high affinity for BZ receptors and activate brain amnesia and psychomotor effects of benzodiazepines (e.g., a2-adrenoceptors. Because it acts as benzodiazepine and a2- midazolam, alprazolam, diazepam, flurazepam, lorazepam) drenoceptor agonist also it may be particularly efficacious in (15). Flumazenil only has a 1 hour half-life and may need to the treatment of the alcohol withdrawal syndrome (1).
Gaziantep Týp Dergisi 2008, 14:50-52.
In this case use of alprazolam, ethanol, Risperidone, 5.Kolin IS, Linet QT. Double-blind comparison of the anxiolytic citalopram and Oxcarbazepine together and in overdoses efficacy of alprazolam and chlordiazepoxide hydrochloride in produced syncope, hypotension, tachycardia, metabolic acidosis, the chronic withdrawal period from alcohol. Curr Ther Res.
Our goal in treating those drugs’ overdoses was to prevent 6.Fernandez F, Adams F, Holms VF. Analgesic effect of hypotension and severe CNS depression. Gastric lavage was alprazolam in patients with chronic, organic pain of malignant performed and activated charcoal was given for the ingestion of large doses. If the patient had been unconscious we wouldn’t perform gastric lavage because of the aspiration possibility.
7.Sellers EM, Busto U. Benzodiazepines and alcohol: Rajkumar et al. Reported an other multi-drug overdose and Assessment of the effects and consequences of psychotropic they intubated the unconscious patient without performing drug interactions. J Clin Psychopharmacol. 1982;2:249-262.
gastric lavage and then they started the supportive treatment (17). Heart rate, blood pressure, body temperature, and 8.Linnoila M, Stapleton JM, Lister R, Moss H, Lane E, Granger respiration rates were monitorized. Intravenous fluid was A. Effect of single doses of alprazolam and diazepam, alone needed for prevention of hypotension. The unique antidote, and in combination with ethanol, on psychomotor and cognitive flumazenil, was used treating alprazolam overdose. However, performance and on autonomic nervous system reactivity in toxicity may be worsened by extremes of age (18), substance healty volunteers. Eur J Clin Pharmacol. 1990;39:21-28.
abuse, medical co-morbidity, co-ingestion of other agents (2) and obesity, our patient had none of these worsening factors 9.Palva ES, Linnoila M, Scario I, Mattila MJ. Acute and and co-ingestion of alprazolam (18 mg), citolapram subacute effects of diazepam on psychomotor skills: Interactions hydrobromur (80 mg), risperidone (16 mg), oxcarbazepine with alcohol. Acta Pharmacol Toxicol. 1979;45:257-264.
(600 mg) and alcohol didn’t prove fatal. As multiple overdoses may be common, our report provides an information regarding 10.Fu K, Konrad RJ, Hardy RW, Brisie RM, Robinson CA.
An unusual multiple drug intoxication case involving It is rare to see a patient who had taken overdoses of these citalopram. J Anal Toxicol. 2000;24(7):648-50.
kinds of drugs together. Probably the doses taken for each drugs alone may not have toxic effects but when they are taken 11.Acri AA, Henretig FM. Effects of Risperidone in overdose.
together they have synergistic effects and cause severe toxicity.
12.Rothenhaeusler HB, Rothenhäusler HB, Hoberl C, IN CONCLUSION
Ehrentrout S, Kapfhammer HP, Weber MM, et al Suicide attempt by pure citalopram overdose causing longlasting severe The multiple drug overdose reported here showed that sinus bradycardia, hypotension and syncopes: successful prompt supportive treatment, early detection of overdose, the therapy with a temporary pacemaker. Pharmacopsychiatry.
rapid, correct and optimal management can provide a successful 13.Wong ICK, Lhatoo SD. Adverse reactions to new anticonvulsant drugs. Drug Safety. 2000;23(1)35-36.
REFERENCES
14.Haddad LM, Shannon MW, Winchester JF Clinical Management of poisoning and Drug Overdose 3rd Ed. WB Saunders, Philadelphia. 1998;610-618.
1.Eriksson E, Carlsson M, Nilsson C, Soderpalm B. Does 15.Omoigui S. The Anesthesia Drugs Handbook 2 nd ed.
alprazolam, in contrast to diazepam, activate a2 adrenoceptors Susan M Gay. USA 1995;134-137.
involved in the regulation of rat growth hormone secretion? 16.Lemke KA. Ability of flumazenil, butorphanol, and naloxone to reverse the anesthetic effects of oxymorphone-diazepam in 2.Trenton A, Currier G, Zwemer F. Fatalities associated with therapeutic use and overdose of atypical anti psychotics. CNS 17.Rajkumar AP, Jebaraj P, Tharyan P. Multi-drug overdose risperidone, ziprasidone, valproate, trihexyphenidyl, and 3.Capel MM, ColbridgeMG, Henry JA. Overdose profiles of new antipsychotic agents. Int J Neu. 2000;3:51-4.
18.Dubois D. Toxicology and overdose of atypical antipsychotic 4.Charney DS, Woods SW, Boodman WK, Rifkin B, Kinch medications in children: does newer necessarily mean safer? M, Aiken B, et al. Drug treatment of panic disorder: The comparative efficacy of imipramine, alprazolam, and trazodone.
Gaziantep Týp Dergisi 2008, 14:50-52.

Source: http://www.gaziantepmedicaljournal.com/volumes/Volume14/Issue2/GMJ-2008-14-2-13.pdf