A Tale of Unequal Substitution: Minocycline and Acute Autoimmune Hepatitis.

Objective: In this case report, we describe the development of an acute autoimmune hepatitis associated with a short course of minocycline prescribed for a skin infection. Due to a drug shortage, minocycline was substituted for doxycycline. Conclusions: It is imperative that practitioners be aware of the different risks that accompany switching between drugs in the tetracycline class, particularly the risk of autoimmune conditions including hepatitis.

Sodium Oxybate for Narcolepsy: Explaining Untoward Effects and Recommending New Approaches in Light of Prevailing Receptor Pharmacology.

Objective: Gamma-hydroxybutyrate (GHB) has been an abused and illicit substance for decades, but the antinarcoleptic medication Xyrem (sodium oxybate), the sodium salt of GHB, was approved just in 2002 for increasing wakefulness. We present a case of coma induced by co-ingestion of prescription GHB and ethanol and describe the response to naloxone treatment, by first responders, without evidence of opiate exposure. The purpose of this report is to bridge updated knowledge on GHB and ethanol pharmacology with the clinical sequence of events in a patient co-ingesting these compounds and to theorize on a potentially better pharmacological approach to narcolepsy. Case Summary: The patient was a 25-year-old woman with a history of narcolepsy. She suddenly collapsed at home but became transiently responsive after being administered naloxone in the ambulance. She presented to the emergency department with apnea, poor responsiveness with a Glasgow Coma Score of 7, and urinary incontinence. While undergoing intubation, the patient spontaneously and abruptly awoke. Labs were unremarkable except a blood alcohol concentration of 0.123%. The dosage of, and adherence to, GHB was unknown in this case. Discussion: The case is described in light of the most recent pharmacological advancements on these co-ingestants. A conceptual dose-response curve is shown to facilitate understanding of the complex pharmacology of GHB. Conclusions: Approved and potential alternatives to GHB, for achieving wakefulness, are discussed. Potential new strategies should bear low to no risk of coma with accidental overdose or co-ingestion of ethanol. In addition, promising antidotes for future consideration are discussed.