Tratamiento de la intoxicación digitálica. Bases para el uso de los anticuerpos antidigital / Digitalis poisoning: the basis for treatment with antidigoxin antibodies

La intoxicación digitálica, sobre todo asociada a un tratamiento crónico con este fármaco, es un motivo recurrente de consulta a los servicios de urgencias españoles. La intoxicación aguda es excepcional y podría presentarse tanto en una tentativa de suicidio como por la ingesta de plantas presentes en nuestro medio y que contienen glucósidos digitálicos. La insuficiencia renal, al modificar la cinética de la digoxina, es un importante factor precipitante de reacciones adversas y graves a este medicamento. Las manifestaciones clínicas son inespecíficas, y predominan las digestivas (náuseas, vómitos, diarreas, dolor abdominal) y circulatorios (inestabilidad, mareos, síncope, lipotimia). Las bradiarritmias (fibrilación auricular lenta, bloqueos de conducción) son frecuentes y pueden acabar en asistolia. Las taquiarritmias podrían conducir a la fibrilación ventricular. En las intoxicaciones agudas, la hiperpotasemia es un factor de riesgo de parada cardiaca. La concentración plasmática de digoxina permite evaluar la gravedad de una intoxicación, siempre y cuando se haya alcanzado el equilibrio de distribución entre las concentraciones plasmáticas y tisulares. El tratamiento de la intoxicación aguda precisa la administración de carbón activado en las primeras horas tras la ingesta. En las intoxicaciones agudas o por tratamiento crónico, es necesaria la monitorización electrocardiográfica continua y normalizar, en caso necesario, las concentraciones de potasio y magnesio. Las bradiarritmias se tratan con atropina como fármaco de primera elección y las arritmias ventriculares con fenitoína o lidocaína. Las situaciones de riesgo vital requieren eluso de anticuerpos antidigital, y se recomienda la disponibilidad de este antídoto en loshospitales considerados de referencia o alta tecnología, el cual deberá dosificarse en función de la carga corporal total de digoxina (AU)

Digitalis poisoning, particularly in persons under long-term digoxin therapy, is a reason for repeated visits to Spanish emergency departments. Acute poisoning is rare but may occur as a result of attempted suicide or the intake of plants that contain cardiac glycosides. Kidney failure modifies digoxin pharmacokinetics and is an important trigger for severe adverse reactions to the drug. Clinical manifestations are nonspecific but usually include gastrointestinal events (nausea, vomiting, diarrhea, and abdominal pain) along with circulatory effects (hemodynamic instability, dizziness or lightheadedness, and syncope). Bradycardia (slow atrial fibrillation, conduction blocks) is common and may cause systole. Tachyarrhythmias may lead to ventricular fibrillation. In acute digitalis poisoning, hyperkalemia is a risk factor for cardiac arrest. The digoxin plasma concentration can indicate the severity of the poisoning, provided the tissue-to plasma ratio is at steady state. To treat acute poisoning, administer activated charcoal within the first few hours after digitalis intake. In such cases, or in poisoning during long-term digoxin therapy, continuous electrocardiographic monitoring is essential and potassium and magnesium concentrations should be brought within the normal range. The first-line treatment for bradycardia is atropine. Ventricular arrhythmias are treated with phenytoin or lidocaine. In life threatening situations, antidigox in antibodies must be used. They should be available in all referral or high-level tertiary care facilities and are administered according to the total digoxin body load (AU)

Emulsión lipídica intravenosa: un nuevo antídoto para uso en reanimación / Intravenous lipid emulsion: a new antidote for use in resuscitation

Los objetivos de esta revisión han sido, por un lado examinar aspectos farmacológicos y cinéticos de la emulsión lipídica para el uso intravenoso y, por otro lado, revisar la literatura médica disponible sobre sus indicaciones en el campo de la terapéutica toxicológica. Aunque el nivel de evidencia científica es bajo, la emulsión lipídica de uso intravenoso parece tener hoy en día un papel indiscutible, no sólo en la reanimación de la cardiotoxicidad de los anestésicos locales, sino también la de otros tipos de efectos tóxicos sobre el aparato cardiovascular (AU)

This review examines the pharmacologic and pharmacokinetic aspects of the intravenous infusion of lipid emulsion and surveys the literature on the indications for using this treatment in cases of intoxication. Although the level of evidence is low, intravenous lipid emulsion seems now to occupy an undisputed position as an antidote, not only in cardiotoxicity induced by local anesthetics but also in resuscitation after other toxic insults affecting the cardiovascular system (AU)

Acrocyanosis induced by interferon alpha(2a).

A 56-year-old woman with mycosis fungoides developed acrocyanosis each time treatment with interferon alpha(2a) was started. Acrocyanosis disappeared after discontinuing therapy. Immunological study performed while acrocyanosis was present showed elevated antinuclear antibody (ANA) titers and circulating immune-complex levels. Long-term interferon treatment has been related to autoimmune side effects. Raynaud's phenomenon has been observed in patients undergoing interferon treatment associated with elevated ANA titers, to cryoglobulinemia or to arterial occlusion. Acrocyanosis has never before been described as side effect in patients undergoing this treatment. We believe that our patient's acrocyanosis must be considered a side effect of interferon.

[Adverse effects associated with antimalarial chemoprophylaxis]. / Reacciones adversas asociadas a la quimioprofilaxis antipalúdica.

BACKGROUND: To evaluate the frequency and type of adverse drug reactions associated to the antimalarial chemoprophylaxis advised to travellers visiting endemic areas. SUBJECTS AND METHODS: We included the travellers who from july 1992 to june 1994 came to the Travellers Advise Department and made short-term travels to areas with malarial infection risk. The adverse drug reactions were reported by the travellers through a questionnaire handed at the consulting room. The pharmacological regimens advised were: a) chloroquine base 5 mg/kg/week. b) chloroquine base 5 mg/kg/week + proguanil 100 mg/day if weight less than 55 kg and 200 mg/day if weight more than 55 kg. c) mefloquine 250 mg/week. RESULTS: We evaluated 1,054 questionnaires for the study. The 18.4% of the travellers reported adverse drug reactions. The 12.4% of the travellers who were on chloroquine, the 17.2% of those who were on chloroquine + proguanil and the 20.3% from mefloquine group presented adverse drug reactions (differences without significance). Comparing the regimens studied, we observed that neuropsychiatric reactions were more frequent in the mefloquine group (p < 0.01), the gastrointestinal reactions were less common in the chloroquine group (p = 0.04) and the transitory eye disorders were more frequent in the chloroquine + proguanil group (p = 0.01). In the mefloquine group the travellers with adverse drug reactions had a significantly lower weight than those who did not present them (p < 0.01). CONCLUSIONS: The adverse drug reactions reported agree with the toxicologic profile described in the literature about these drugs. Mefloquine presents an outstanding neuropsychiatric toxicity and is worse tolerated in low weight patients.

[Comparative study of an expert system application in the prescription of medications]. / Estudio comparativo de la aplicación de un sistema experto en la prescripción de medicamentos.

BACKGROUND: The aim of this study was to evaluate the impact of a expert drug system implementation on the drug prescription habits and on drug cost in an university hospital. MATERIAL AND METHODS: During a 3 months period, the drug prescriptions to patients admitted to the Internal medicine, lung, gastroenterology and hepatology units, have been evaluated through the expert drug system (Medisource). This expert drug system functions in according to patients characteristics such as age, weight, height, sex, renal function and liver function. It recommends the correct dose, detects interactions and adverse effects and makes suggestions in pregnancy and lactation. It also offers alternative drugs with their cost. During the study period physicians were unaware of the investigation being performed. RESULTS: 836 patients (63.9 +/- 16.5 years) with an average hospital stay length of 11.6 +/- 6.7 days were studied. The most common diagnoses were: lung obstructive chronic disease, cirrhosis, gastrointestinal hemorrhage and cancer. The total amount of drug prescribed was 6,308. The expert system detected 458 overdosages and 33 underdosages, mainly in antibiotics and antiulcer drugs, and 1,722 interactions. The drug costs reduction that could be obtained following the expert system recommendations was 4.5% in antibiotic drugs and 23% in antiulcer drugs. CONCLUSION: The frequency of drug overdosage and underdosage in patients admitted in an university hospital is relatively high. The expert systems available for drug decisions could solve this problem.

Hydrocortisone anaphylaxis: a new case report.

In this report we describe a case of a nonatopic patient who developed an anaphylactoid reaction immediately after receiving intravenous hydrocortisone. The patient recovered after reanimation techniques and intravenous administration of atropine, epinephrine and plasma expanders. Although allergic reactions to corticosteroids appear to be rare there are a few case reports in the literature. This case is presented to draw the attention of clinicians to the occasional hazard of intravenous corticosteroid preparations, specially hydrocortisone.