Review of the epidemiology and characteristics of intentional cyproheptadine overdose in Hong Kong.

OBJECTIVES: To identify the epidemiological characteristics and clinical outcome in patients who intentionally ingested cyproheptadine or cyproheptadine-containing sleeping pills, and to investigate any association between dose ingested and reported adverse effects. METHOD: A retrospective study was performed based on data from the Hong Kong Poison Information Centre from July 2005 to December 2009. Fifty-seven eligible patients were recruited. Patients' epidemiological data, type and dose of cyproheptadine or cyproheptadine-containing sleeping pills ingested, symptoms, clinical outcome, and length of stay in hospital were reviewed. RESULTS: The majority of patient with intentional overdose had no (42.1%) or mild (40.4%) sedative symptoms. Some 17% of patients developed anticholinergic symptoms, such as delirium, agitation, disorientation, and hallucination. The mean dose ingested was found to be significantly higher in patients who presented with delirium (188.6 mg) than those who were asymptomatic (49.8 mg) (p < 0.001). The time of symptom onset in all symptomatic patients was less than 6 h. CONCLUSIONS: The majority of patients with intentional cyproheptadine overdose had no or mild symptoms only. Patients who have ingested a significant amount of cyproheptadine are more prone to develop delirium. Patients who remain asymptomatic 6 h after exposure are unlikely to develop serious symptoms.

A fatality due to cyproheptadine and citalopram.

Cyproheptadine (Periactin) is a first-generation antihistamine available in over-the-counter cold medications and is used to treat allergic-type symptoms. Although antihistamines in general have long been known to cause serious side effects, especially when taken in overdose, few reports that specifically address cyproheptadine-related fatalities exist. A 42-year-old healthy female was found dead at her home with no anatomic cause of death and a recent history of suicidal ideations. Toxicology revealed cyproheptadine and citalopram in the femoral postmortem blood at concentrations of 0.49 and 2.3 mg/L, respectively. Vitreous, urine, and bile analysis were also performed, yielding concentrations of < 0.04 and 0.80 mg/L in the vitreous for cyproheptadine and citalopram, respectively; 0.23 and 8.2 mg/L in the urine; and 30.7 and 9.0 mg/L in the bile. The cause of death was determined to be cyproheptadine and citalopram intoxication, and the manner was ruled a suicide. Although cyproheptadine is widely available in the United States and Europe, there are only two published fatalities due to this antihistamine and only one that specifically cites blood and tissue concentrations. Therefore, this case study will be beneficial to the forensic toxicology community by providing additional information regarding postmortem interpretation.

Prolonged anticholinergic delirium following antihistamine overdose.

OBJECTIVE: A case of anticholinergic delirium in a female adolescent is described, exploring the pharmacokinetic reasons for the prolonged time course and reviewing the management provided. CONCLUSION: A 14 year old female hospitalised for depression ingested large quantities of promethazine and cyproheptadine. A severe anticholinergic delirium ensued which resolved after six days, much longer than the expected duration. The likely cause of the prolonged delirium was the interaction of promethazine and fluvoxamine through the inhibition of the CYP2D6 enzyme. The patient's young age, the severity of the poisoning and the use of drugs with anticholinergic properties to manage the delirium may also have contributed. The delirium may have been reversed had a cholinesterase inhibitor been provided soon after the overdose.

Acute anticholinergic poisoning in children.

We report two cases of unintentional poisoning with anticholinergic agents. The first patient, a 7-year-old girl, was prescribed four different medications by a general practitioner for treatment of abdominal colic and diarrhoea. All drugs had anticholinergic properties. The second patient, a 16-month-old boy, ingested his mother's cyproheptadine tablets. Both children presented with central and peripheral symptoms and signs compatible with acute anticholinergic syndrome. They recovered spontaneously following intravenous fluid replacement and close observation. Gastric lavage was also performed on the boy. Poisoning with cholinergic antagonists in children is a potentially serious hazard in Hong Kong. It may be avoided by careful prescribing on the part of general practitioners and safe storage of all medicinal products in the home environment.

Evaluation of tricyclic antidepressant false positivity in a pediatric case of cyproheptadine (periactin) overdose.

CASE REPORT: The authors report a case of pediatric cyproheptadine toxicity, initially misdiagnosed as tricyclic toxicity based on the results of a preliminary rapid toxicological serum screen. Although such cross-reactivity has been reported, the chemical basis of this observation has not yet been evaluated. By GC/MS methods and HPLC assays adapted for the detection of tricyclic compounds, the authors confirmed that cyproheptadine was indeed responsible for this patient's toxicity. In addition, the authors identified the presence of a cyproheptadine metabolite in the patient's serum. Further testing in an immunoassay-based toxicologic screen demonstrated some cross-reactivity exhibited by the patient's serum, but not the parent compound. These findings showed that the cross-reactivity correlated with the presence of the cyproheptadine metabolite, highlighting the value of confirmatory toxicologic testing of routine rapid toxicologic screens.

Intoxicación por ciproheptadina / Intoxication by cyproheptadine

La intoxicación por ciproheptadina, principal componente de los estimulantes del apetito, se ha transformado en un importante motivo de consulta en los servicios de urgencia a lo largo del país. Estos fármacos, utilizados muchas veces sin prescripción médica, dado su agradable sabor resultan atractivos para los preescolares quienes los ingieren en dosis que sobrepasan el nivel terapéutico, desencadenando cuadros muy variados, que van desde excitación psicomotora hasta la muerte

A cyproheptadine fatality.

A 28-year-old man was found dead by his girlfriend. No anatomic cause of death was identified at autopsy. The heart-blood ethanol concentration was 0.09 g/dL. Comprehensive testing for abused and therapeutic drugs in the blood and urine identified cyproheptadine, a serotonin and histamine antagonist. This was one of the medications prescribed for the girlfriend, who admitted that several tablets were missing from the vial. The heart blood contained 0.46 mg/L of cyproheptadine. A review of the literature indicated that only trace amounts of parent drug are identified in the blood following therapeutic use of cyproheptadine. Therefore, the medical examiner concluded that the cause of death in this case was ethanol and cyproheptadine intoxication.

Cyproheptadine-induced central anticholinergic syndrome in a child: a case report.

A 16-year-old female patient presented to our emergency department with anticholinergic psychosis after an ingestion of cyproheptadine. The central anticholinergic syndrome occurs frequently but often goes unrecognized because many patients do not fit into a well defined clinical pattern. The diagnosis depends on the suspicion and recognition of the psychiatric manifestations, including agitation, confusion, and hallucinations. A high index of suspicion is necessary in children in particular, since central effects seem to predominate in many anticholinergic overdoses.

Poisoning due to an over-the-counter hypnotic, Sleep-Qik (hyoscine, cyproheptadine, valerian).

The clinical features and risk of hepatotoxicity of 'Sleep-Qik' (valerian dry extract 75 mg, hyoscine hydrobromide 0.25 mg, cyproheptadine hydrochloride 2 mg) were determined in 23 patients treated in our hospital between 1988 and 1991. The main clinical problems were central nervous system depression and anticholinergic poisoning. There was no clinical evidence of acute hepatitis in the 23 patients after taking an average of 2.5 g of valerian (range 0.5 to 12 g). There was no evidence of subclinical liver damage in 12 patients who had routine liver function tests performed approximately 6-12 hours after ingestion. Delayed onset of severe liver damage was excluded in 10 patients in whom a telephone follow-up was possible. However, subclinical liver dysfunction in the acute stage (onset after 12-24 hours) and in the intervening period after discharge from hospital could not be excluded. To establish the risk of hepatotoxicity in long-term users and in those taking an overdosage of valerian, a much larger study of longer duration with serial liver function tests is clearly needed.

Choreoathetosis induced by cyproheptadine.

Cyproheptadine is an antihistamine with antiserotoninergic and anticholinergic properties. It is a relatively safe drug with many varied indications for usage, which rarely produces serious adverse neurologic sequelae. Reports of involuntary movement disorder secondary to cyproheptadine are rare. We present the case of a 17-year-old overdose victim which may be the first documented instance of cyproheptadine intoxication resulting in choreoathetosis. This hyperkinesia was most likely resultant from the anticholinergic properties of cyproheptadine. Although the choreoathetoid movement resolved spontaneously, the delirious state disappeared after administration of physostigmine.

An unusual case of cyproheptadine (Periactin) overdose in an adolescent female.

A 13-year-old female ingested an acute overdose of cyproheptadine hydrochloride (Periactin) and presented for treatment. She manifested all the classic signs and symptoms of an acute antihistamine overdose, including psychosis, except for miotic, minimally reactive pupils. The patient was supportively managed. All sequelae of the ingestion resolved within four days, and the child was released from the hospital. We discuss the unusual presentation of miotic pupils in an acute cyproheptadine overdose.

Pseudoephedrine-induced hypertensive emergency: treatment with labetalol.

The case of a young man in hypertensive emergency following the ingestion of 840 mg of pseudoephedrine is reported. The hypertension, which peaked at 200/160 mm Hg and was associated with severe headache and diaphoresis, responded expeditiously to two initial intravenous doses of labetalol. No rebound was observed following the administration of an additional dose in the intensive care unit, after which an uneventful one-day hospitalization ensued. The toxicity of pseudoephedrine is briefly reviewed along with the pharmacology and use of labetalol. On the basis of previous experimental studies and the present report, labetalol is suggested as a promising agent in the treatment of hyperadrenergic-induced hypertensive emergencies.

Central anticholinergic syndrome in a child: a case report.

A 2-year-old boy developed classical signs and symptoms of the central anticholinergic syndrome after ingesting twenty 4-mg tablets of the antihistamine cyproheptadine (Periactin). His symptoms were dramatically reversed by the intravenous administration of physostigmine. The physiology of the anticholinergic system and physostigmine are discussed along with the indications, toxicity, and dosing of physostigmine.

[Toxicity of cyproheptadine. Side effects and accidental overdosage (author's transl)]. / Zur Toxizität von Cyproheptadin (Nuran). Nebenwirkungen und akzidentielle Intoxikationen.

113 cases of accidental ingestion of cyproheptadine (Nuran) by children have been evaluated. Life threatening alterations have not been observed after doses ranging from 0.3-6.15 (x:1.89) mg per kg of body weight. Somnolence, excitation, hallucinations, ataxia, tachycardia, and muscle twitchings were observed frequently, and occasionally gastric pain, dry mucuous surfaces, mydriasis, and rubeosis of the face were present. Symptoms appeared rapidly after ingestion and generally did not last longer than 6-12 h. When given in therapeutic doses, cyproheptadine reduces the secretion of ACTH, cortisol, prolactin, and growth hormone, lowers blood glucose concentrations, and raises the levels of unesterified free fatty acids. Parents frequently complain about unsatisfactory eating habits of their children, but chronic lack of appetite needing therapeutical attention, in healthy children, is the rare exception. Cyproheptadine is an agent with considerable side effects, and it should be prescribed to children only after very careful deliberation.