Intoxicación por antidepresivos tricíclicos / Tricyclic antidepressant poisoning

Introducción: el paciente intoxicado sigue siendo un desafío para el personal de salud. La intoxicación por antidepresivos tricíclicos (ATC) es un diagnóstico frecuente y una patología que puede llegar a ser muy grave. A pesar de que ha cambiado el objetivo terapéutico de estos fármacos a lo largo de los años, la alta disponibilidad de estos hace que su uso para intento de autolisis siga presentándose. Su presentación clínica es variada y dado el riesgo de mortalidad asociada, es importante que esta patología sea rápidamente reconocida por los médicos que los reciben para iniciar un manejo oportuno y eficaz. Objetivo: presentar el enfrentamiento inicial y manejo terapéutico de la intoxicación por ATC desde la perspectiva de la medicina de urgencia. Método: se realizó una revisión bibliográfica de la literatura científica sobre el manejo de un paciente intoxicado por ATC. Se presenta la evidencia actual de las intervenciones terapéuticas más utilizadas. respecto al manejo inicial y enfrentamiento de la intoxicación por antidepresivos tricíclicos, en el contexto de la atención en un servicio de urgencia. Conclusión: la intoxicación por ATC puede presentarse con síntomas leves y signos precoces, así como con síntomas graves e incluso fatales, dados principalmente por complicaciones cardiovasculres y neurológicas. Su manejo se basa en el reconocimiento precoz, medidas de soporte y terapias específicas según la clínica que presente.

Managing poisoned patients continues to be a challenge for health personnel. Tricyclic antidepressant are a frequent diagnosis, and a pathology their can be very serious. Although the therapeutic indications for these drugs have changed over the years, their high availability means that their use for suicidal attempts continues to be present. Its clinical presentation is varied and given the mortality risk, it is crucial that this entity must be rapidly recognized by the physicians who care for them to initiate timely and effective treatment. Objective: Present the initial management and therapeutic strategies for tricyclic antidepressant intoxication, from emergency medicine perspective. Method: Bibliographic review of the scientific literature on this subject. Current evidence of the most widely used therapeutic interventions is described regarding the initial management and disposition of tricyclic antidepressant intoxication in the emergency department.

Serotonin syndrome caused by interaction between fentanyl and amoxapine in a patient with cancer pain

<b>Objective</b>:To report a case of serotonin syndrome induced by an interaction between fentanyl and amoxapine in a patient treated for cancer pain. <b>Case:A</b> 37-year-old woman with recurrence of cervical cancer was treated with oxycodone and etodolac for her cancer pain in the gluteal region. She developed acute abdominal pain and received emergency surgery under the diagnosis of upper gastrointestinal tract perforation.Continuous fentanyl infusion was initiated during surgery and was continued postoperatively to control postsurgical and cancer pain. The route of fentanyl was changed to transdermal patch the next day, and dose was escalated during the following days in attempt to control her gluteal pain. Eight days after the operation, amoxapine was prescribed as an adjuvant analgesic. Five days later, the fentanyl dose was further escalated to 2100μg/day. The following day, the patient developed tremors of the extremities, confusion and hallucinations, followed by fever and involuntary movements of the lower extremities. Amoxapine was discontinued and the symptoms subsided within 4 days.<b>Conclusion</b>:Co-administration of a tricyclic antidepressant and high doses of fentanyl precipitated serotonin syndrome in this patient.

Intoxicación por antidepresivos tricíclicos en pediatría: aproximación y manejo / Pediatric Tricyclic Antidepressant Poisoning: Approach and Management

Los antidepresivos son agentes que causan una importante morbilidad y mortalidadcon presentación de un espectro de toxicidad único, principalmente cardiovasculary neurológico, el cual se basa principalmente en su farmacología y que determina sutratamiento específico. Por desgracia, los niños son una población vulnerable, y con elaumento de patologías psiquiátricas que son tratadas con este tipo de medicamentos,cada vez es más probable encontrar toxicidad en esta población. El propósito de estapublicación es revisar la farmacocinética, la presentación clínica y el tratamiento de laintoxicación aguda por antidepresivos tricíclicos...

Antidepressants are agents that cause significant morbidity and mortality with importanttoxicity particularly on cardiovascular and neurological systems, which is mainly basedon their pharmacology and is that determines specific treatment. Unfortunately, childrenare vulnerable population because the increase in psychiatric disorders which are treatedwith these drugs. The purpose of this article is to review the pharmacokinetics, clinicalpresentation and treatment of acute poisoning with tricyclic antidepressants...

Serial Monitoring of Lead aVR in Patients with Prolonged Unconsciousness Following Tricyclic Antidepressant Overdose

Severe cardiac and neurologic toxicities of tricyclic antidepressant (TCA) overdose have been reported since the introduction of TCAs in 1950s. Despite the decreased numbers of TCA overdoses, the mortality and morbidity rates of TCA overdose have remained constantly high. Clinical manifestations of TCA overdose are characterized by unconsciousness and specific electrocardiography (ECG) abnormalities such as prolongation of the PR and QTc intervals, widening of the QRS duration, and an increased R wave and R/S ratio in lead aVR. We report a case with unusually prolonged unconsciousness without initial stem reflexes for 7 days and multiple ECG abnormalities following TCA overdose. It is suggested that the serial monitoring of R wave and R/S ratio in lead aVR might be informative in predicting recovery from toxicity following TCA overdose.

The Utility of Amitryptiline in Female Overactive Bladder Patients with Nocturia / 대한비뇨기과학회지

PURPOSE: Anticholinergics suppress the muscarinic receptors in the bladder smooth muscle and, increase the level of urine storage. Their side effects include dry mouth, dry eyes, constipation, drowsiness, and tachycardia. These adverse effects limit the dosing and often decrease patient compliance. This study examined the effect of amitryptline as one of the first- line treatments for overactive bladder patients with nocturia. MATERIALS AND METHODS: Between June 2005 and June 2006, a prospective randomized study was carried out on 45 female patients with an overactive bladder. The mean age was 57.6 years and the patients were treated with doxazosin(Group I), doxazosin with tolterodine(Group II), doxazosin with amitriptyline(Group III). All 45(Group I: 15, Group II: 15, Group III: 15) were followed up for 4 weeks. The treatment efficacy was measured using the 3 days of voiding diaries. RESULTS: The actual number diurnal voids showed considerable improvement after treatment(p0.05). The actual number of nightly voids improved after treatment(p0.05). There was no difference in the total voiding volume, functional bladder capacity, nocturnal bladder capacity index, nocturia index between pre-treatment and post-treatment in each group(p>0.05). CONCLUSIONS: There are some enhanced effects with the actual number of diurnal voids and the actual number nightly voids in patients treated with doxazosin with amitriptyline. Therefore, amitripyline is helpful as a first- line treatment in female overactive bladder patients with nocturia.

A case of imipramine induced toxicity with Brugada electrocardiographic pattern in a toddler / 소아과

Imipramine, a tricyclic antidepressant (TCA), is used for the treatment of non-polar depression and nocturnal enuresis in children in whom an organic pathology has been excluded, anxiety disorders, and neuropathic pain. Clinical toxicity following the treatment of TCAs, including imipramine, is well known. The anticholinergic effects initially present include a dry mouth, ileus, dilated pupils, urinary retention, and mild sinus tachycardia. The central nervous system toxicity includes delirium, agitation, restlessness, hallucinations, convulsions, and CNS depression or coma. However, the most life-threatening toxicity remains the development of cardiac dysrhythmias. Conduction delays such as QRS and corrected QT prolongation, wide QRS complex tachycardia, and the Brugada electrocardiographic pattern have been reported. Sodium bicarbonate decreases QRS widening and suppresses dysrhythmias by providing excess sodium to reverse the TCA-induced sodium-channel blockade and possibly by binding directly to the myocardium. There are no pediatric case reports on imipramine or other TCA associated toxicity in Korea. Here, we describe a patient who presented with convulsions, tachycardia with a wide QRS complex, a Brugada electrocardiographic pattern, and anuresis associated with an accidental overdose of imipramine and the outcome of treatment with sodium bicarbonate.

Resting Tremor during Low-dose Tricyclic Antidepressant Treatment: A case report / 대한통증학회지

Tricyclic antidepressant (TCA) is a useful drug for treating neuropathic pain. However, tremors are one of the relatively frequent side effects of TCA. A female patient, who was suffering from postherpetic neuralgia, was treated with amitriptyline starting with 10 mg/day. She developed resting tremors on the second day after increasing the dose to 30 mg/day. This case highlights the need for the careful use of amitriptyline in the treatment of neuropathic pain in elderly patients.

The Effect of Tricyclic Antidepressant(Dothiepin) on Sleep in Depressed Patients: A Polysomnographic Study / 신경정신의학

OBJECTIVE: This study was designed to investigate 1) sleep changes after antidepressant(dothiepin) treatment, and 2) sleep variables which seem to be associated with clinical response in the depressed patients. METHODS: The subjects consisted of 16 patients who fullfilled the criteria for major depression by the Diagnostic and Statistical Manual,(4th edition). Their sleep was recorded using polysomnography at the baseline and after one week and three weeks of dothiepin treatment. All subjects were further interviewed using Hamilton Rating Scale for Depression (HRSD) to rate the severity of their depression. High response to the drug was defined as a reduction of more than 50% of the HRSD score. Result : The results were as follows : 1) Depressed patients after dothiepin treatment showed more total sleep time(p=0.019), shorter sleep latency(p=0.05), less awake time(p=0.033), more sleep efficiency(p=0.018), more stage 2 sleep(p=0.002), less REM time(p=0.000), and longer REM sleep latency(p=0.004) than before treatment. 2) There were no differences in sleep variables between those who received 1 week and 3 weeks of dothiepin treatment except of th shortening of sleep latency after 3 weeks(p<0.05). 3) Depressive symptom scores on HRSD were reduced after 1 week and 3 weeks of dothiepin treatment as compared with the baseline. 4) High responers showed a tendency of increased wake time(p=0.054), while their stage 4 sleep decreased after 1 week of dothiepin treatment as compared with the low responders(p=0.0136). Conclusions : These results suggest that sleep of the depressed patients after dothiepin treatment tends to be nomalized and sleep chages seem to appear early in the treatment phase. In addition, clinical response might be associated with greater wake time at the baseline and lesser atage 4 sleep 1 week of dothiepin treatment.

A Case of Clomipramine-Induced Chronic Dilated Cardiomyopathy

Dilated cardiomyopathy is a primary myocardial disease characterized by ventricular dilatation and impaired ventricular contractility. The etiology of dilated cardiomyopathy has not been known yet, but toxin such as alcohol, thiamine deficiency, endocrine disorder, viral or bacterial infection, hereditary disorder, and muscular dystrophy may be related to dilated cardiomyopathy. Cocaine abuse and anticancer drugs (especially doxorubicin) were reported as the causes of drugs of dilated cardiomyopathy also. Recently we experinced a case of dilated cardiomyopathy in 30 years old man who developed dilated cardiomyopathy on chronic clomipramine (one of trcyclic antidepressant drugs) treatment for a obsessive-compulsive disorder. He became asymptomatic and normalization of left ventricular diameters and function was evidenced echocardiographically after withdrawal of the drug. The possible association of cardiomyopathy and tricyclic antidepressant drugs and possibility of functional improvement after tricyclic antidepressant drugs withdrawal should be kept in mind.

Combined Therapy of Paroxetine and Tricyclic Antidepressant in Depression of Schizophrenic Patients / 신경정신의학

Depression is well-known to comorbid with several psychiatric disorders. Many schizophrenics also suffer from depression in the course of their illness. Combined therapy of SSRI and tricyclic antidepressants were reported to have benefits in some depressed patients. Paroxetine, a potent CYP2D6 inhibitor, increases the blood levels of tricyclic antidepressant markedly, Using paroxetine, we tried this combined therapy in the treatment of depressive symptoms in 10 chronic schizophrenic inpatients and evaluated its efficacy and drug interactions between paroxetine and tricyclic antidepressants. The following results were obtained: 1) The mean score of Hamilton's Depression Rating Scale(HDRS) was reduced significantly after 6 weeks-trials of this combined therapy for the mild depressive symptoms in 10 chronic schizophrenics. In four patients, 50% or more reductions in the scores of HDRS were noticed at final evaluation. 2) Two among our 10 subjects experienced severe toxic behavioral problems. Anticholinergic crisis with toxic confusion due to high blood levels of tricyclics was fecund in one patient and the other showed rapid clinical deterioration in his psychotic symptoms such as delusion and hallucination without any consciousness alternation. 3) Baseline plasma levels of tricyclics before adding paroxetine were higher or than expected in our chronic schizophrenic subjects maintained with their antipsychotic medications. Several antipsychotics were also known as a potent CYF2D6 inhibitors and to increase the blood levels of tricyclics. Because the blood levels of tricyclics had already increased significantly by the use of antipsychotics, adding paroxetine to antipsychotics and tricyclic antidepressant In our subjects could increase the blood levels of tricyclics not so much as previously reported in the literatures.