Many more loperamide articles

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loptab3Loperamide-Induced Life-Threatening Ventricular Arrhythmia

Ankit Upadhyay, Vijaykumar Bodar, Mohammad Malekzadegan, Sharanjit Singh, William Frumkin, Aditya Mangla, and Kaushik Doshi
Jamaica Hospital Medical Center, Department of Medicine, Jamaica, NY 11418, USA

Abstract: Loperamide is over-the-counter antidiarrheal agent acting on peripherally located 𝜇 opioid receptors. It is gaining popularity among drug abusers as opioid substitute. We report a case of a 46-year-old male that was presented after cardiac arrest. After ruling out ischemia, cardiomyopathy, pulmonary embolism, central nervous system pathology, sepsis, and other drug toxicity, we found out that patient was using around 100mg of Loperamide to control his chronic diarrhea presumably because of irritable bowel syndrome for last five years and consumed up to 200mg of Loperamide daily for last two days before the cardiac arrest.We hypothesize that the patient’s QTc prolongation and subsequent cardiac arrest are due to Loperamide toxicity. Patient experienced gradual resolution of tachyarrhythmia and gradual decrease in QTc interval during hospitalization which supports the evidence of causal relationship between Loperamide overdose and potentially fatal arrhythmias. It also provided the clue that patient may have congenital long QT syndrome which was unmasked by Loperamide causing ventricular arrhythmias. This case adds one more pearl in the literature to support that Loperamide overdose related cardiac toxicity does exist and it raises concerns over Loperamide abuse in the community.

Hindawi Publishing Corporation
Case Reports in Cardiology
Volume 2016, Article ID 5040176, 3 pages

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loptab3Electrocardiographic Abnormalities, Malignant Ventricular Arrhythmias and Cardiomyopathy Associated with Loperamide Abuse

VAUGHN, P., SOLIK, M. M. K., BAGGA, S. and J. PADANILAM, B.
St. Vincent Medical Group, Indianapolis, IN

Abstract: A 20-year-old man presented with recurrent syncope and abnormal ECG. His evaluation revealed a prolonged QT interval > 600 ms, witnessed Torsades de Pointes (TdP) and dilated cardiomyopathy. At his initial admission, an ICD was implanted and atrial pacing at 80 beats per minute suppressed ventricular arrhythmias.  The patient was readmitted with device infection and recurrent TdP leading to intubation. This led to the discovery of a hitherto unrevealed loperamide abuse and his cardiac arrhythmias and LV dysfunction were determined to be related to large doses of loperamide. Following abstinence, his ejection fraction and ECG returned to normal.

Journal of Cardiac Electrophysiology
27 July 2016 Accepted Author Manuscript. doi:10.1111/jce.13052

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loptab3Loperamide-related Deaths in North Carolina

Sandra C. Bishop-Freeman, Marc S. Feaster, Jennifer Beal, Alison Miller, Robert L. Hargrove, Justin O. Brower and Ruth E. Winecker
North Carolina Office of the Chief Medical Examiner, Raleigh, NC 27607, USA

Abstract: Loperamide (Imodium®) has been accepted as a safe, effective, over-the-counter anti-diarrheal drug with low potential for abuse. It is a synthetic opioid that lacks central nervous system activity at prescribed doses, rendering it ineffective for abuse. Since 2012, however, the North Carolina Office of the Chief Medical Examiner has seen cases involving loperamide at supratherapeutic levels that indicate abuse. The recommended dose associated with loperamide should not exceed 16 mg per day, although users seeking an opioid-like high reportedly take it in excess of 100 mg per dose. When taken as directed, the laboratory organic base extraction screening method with gas chromatography-mass spectrometry/nitrogen phosphorus detector lacks the sensitivity to detect loperamide. When taken in excess, the screening method identifies loperamide followed by a separate technique to confirm and quantify the drug by liquid chromatography-tandem mass spectrometry. Of the 21 cases involving loperamide, the pathologist implicated the drug as either additive or primary to the cause of death in 19 cases. The mean and median peripheral blood concentrations for the drug overdose cases were 0.27 and 0.23 mg/L, respectively. Furthermore, an extensive review of the pharmacology associated with loperamide and its interaction with P-glycoprotein will be examined as it relates to the mechanism of toxicity.

Journal of Analytical Toxicology
doi: 10.1093/jat/bkw069; First published online: July 29, 2016

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loptab3Conduction Disturbances and Ventricular Arrhythmias Associated with High-Dose Loperamide

Galen Leung, Diana Altshuler, Ronald Goldenberg, David Fridman and Eugene Yuriditsky
New York University School of Medicine, New York, USA

Abstract: Although loperamide has been widely used for the treatment of diarrhea, there is growing popularity over its abuse potential in alleviating opioid-withdrawal symptoms and achieving euphoria. Toxic levels of loperamide have been associated with life-threatening ventricular tachyarrhythmias and cardiac arrest. We report a case of high-dose loperamide ingestion in a patient presenting initially with unstable bradycardia followed by episodes of polymorphic ventricular tachycardia, and an unmasked Brugada ECG pattern. This is the first such report of the Brugada pattern being unmasked on ECG with loperamide ingestion. The patient stabilized with supportive care without the need for inotropic support. We discuss potential mechanisms of toxicity leading to conduction abnormalities and provide a literature review of all published cases of loperamide toxicity to describe proposed treatment options. Recognition of the abuse potential and hazards of this over-the-counter anti-diarrheal therapy will alert the clinician of associated toxidromes and management strategies.

Journal of Clinical Toxicology
doi 10.4172/2161-0495.1000309; First published online: June 30, 2016

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Personally speaking

moiFor those among you who have missed my personal stories and adventures, I do apologize. For obvious reasons — namely, that people I know personally now know about this blog — I have to edit myself a bit. But I’d still like to provide an update on how things are going.

I can tell you that things are generally going well. There are some major issues going on behind the scenes, but I’m managing.

I continue to be employed at our local thrift store. Yay! Employment! Tonight I am changing over from morning crew hanger/pricer to night crew cashier in preparation for this fall’s onslaught of day classes at the local community college. It’s something of a step down, but I requested it. Much as I would have loved to keep my day hours at work, it simply wasn’t in the cards. The specific classes I require for Nursing (right now, chemistry and psychology) are only available during the day, and only in Utica. UGH. Then, once the nursing-proper classes begin, they don’t even begin to offer night classes, so I might as well get used to that now. And getting used to being paid a lot less at work (but at least I’ll be employed).

That’s the part I’m really worried about. Since one of my two jobs cut my paid hours in half back in April, my personal financial matters have started slumping south. And as a person already living on the poverty line, this additional loss in wages will bump me significantly below that poverty line. I will have to invent a way to make up the deficit. Suggestions are welcome!

chalazionPersonally, my health is good (and yes, I’m still clean) but I could be doing a lot better — I have not been taking my own health very seriously lately, and I really need to. I’m tired and worn down most of the time, and my depression has been slowly creeping back (so far so good though). One particularly bothersome problem is that I’ve been plagued by a rash of chalazions lately; they’re rather like styes that take a ridiculously long time to go away (months!). I have never experienced these before, but they’re rather disfiguring and deeply upsetting. While I need to address the issue (and some others), instead, I keep finding excuses why I don’t have time. My own hesitation to deal with it frustrates me!

I have also been working for a local non-profit as their Promotions Chair. I’m enjoying it very much (aside from the fact that I’m not being paid). I’m allowed to bring my dog to the office  — so he’s not home alone all day — and I get to do some work (that I’m actually good at) in the comfort of central air conditioning and big windows.

upstatehealthcover

I’ll probably be featured in the fall issue; this is the summer issue.

I was interviewed this past week by University Hospital’s “Upstate Health” magazine staff regarding my experience with Loperamide abuse. They were wonderful! Jim Howe, the reporter, reassured me and listened while I chattered on during the interview itself. When it came to the photography part, I was worried about one new chalazion on my eye, but their photographers made me feel at ease, and with some good eyeliner, the bump should be hard to detect. Instead you’ll likely see a photo of me cross-eyed with my mouth agape while I’m blabbering on about something! Hah! (FYI: I also made sure to go easy on the eye makeup, avoiding that copper eyeshadow again. Eeeechh.) I still look like a dork though, so you’ll know it’s me.

And as always, I remain in touch with my doctors in Syracuse as well as my former therapist who you may recall was a regular and entertaining character on this blog. I miss him a lot — as I’m sure many of you do as well. In case you were wondering whatever happened to him, last I knew, he was doing very well for himself now and has a big office with an espresso machine and a big window. And a secretary! Woo!

I continue to regularly attend my 12-steppie meetings. We had a picnic this past week that was amazing! Way too much food! But lots of good times. It was kinda fun to attend an event where people weren’t getting slobbery drunk and acting like fools.

Speaking of which, a very dear friend of mine has fallen back into alcoholism (they may or may not ever see this blog). I pray for this person every day even though I’m absolutely certain they couldn’t care less. This person seems to equate my worry as if I’m being a pest, and I don’t know what to do about that. In the program, we often talk about dealing with loved ones who have active addiction issues. We remind ourselves that no addict/alcoholic can be helped unless they want it for themselves. This stand-by-and-watch attitude is extremely distressing for me though. I feel as if I am deserting this person in Hell. So, unable to follow them, I end up remaining in Limbo. Unfair.

I had a recurrent dream last night — the second dream in two days — where I’m back at my old house and my mother is there arranging to have her possessions moved out because she was leaving the house. She told me to gather my things, but there were too many to carry and I couldn’t choose what was important enough to take and what to leave behind. In the first dream, the house was being sold off; in the second, it was going to be torn down. I reacted to all this by being angry, yelling, screaming, pleading to be heard, but no one was listening. I was dismissed. I wanted to save the house — I insisted the house belonged to me! They can’t take it away — it’s mine! But nobody listened.

So that’s all the news that’s fit to print. Sadly, I must leave you now, dear reader, having completed my update. I have to get ready for my new night shift at work. Pleasant dreams, and well wishes!


“The fact that you live in a broken-down house in the midst of restoration makes everything more difficult. It removes the ease and simplicity of life. It requires you to be more thoughtful, more careful. It requires you to listen and see well. It requires you to look out for difficulty and to be aware of danger. It requires you to contemplate and plan. It requires you to do what you don;t really want to do and to accept what you find difficult to accept. You want to simply coast, but you can’t. Things are broken and they need to be fixed. There is work to do.”

— David Paul Tripp

 

 

 

 

 

 

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Loperamide Presentation ACMT 2016

For those among the unwashed masses, a lot of scientific research isn’t necessarily found in magazines and journals. A lot is presented during medical conferences. Sometimes it’s in presentation form before an audience (like an interactive power point presentation); sometimes it’s a poster session where the researchers stand around a poster explaining their work and taking questions. Sometimes both.

The first presentation regarding Loperamide abuse and its cardiac effects was presented as a poster session at the 2012 Annual Meeting of the North American Congress of Clinical Toxicology following my overdose in February of that same year. (See research page) The authors? Those smart and impossibly good-looking folks from Syracuse’s Upstate Poison Control Center. (Seriously, those docs from Upstate University Hospital are so good-looking, they’re like wandering bands of Grey’s Anatomy actors come to life.)

The following poster session, however, was presented by researchers from University of California, San Diego, who may or may not be as smart and as good-looking as the docs from Syracuse. Or are they?

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loptab3Poster Session: Life-threatening Arrhythmias Associated with Loperamide and Cimetidine Abuse

Charles W. O’Connell 1, 2; Amir A. Schricker 3; Aaron B. Schneir 1; Imir G. Metushi 4; Ulrika Birgersdotter-Green 3;  Alicia B. Minns 1,2
1. Division of Medical Toxicology, Department of Emergency Medicine, UCSD
2. Department of Emergency Medicine, VA San Diego
3. Division of Cardiovascular Medicine, UCSD
4. Center for Advanced Laboratory Medicine, UCSD

Conclusions: Loperamide, taken chronically and and in high doses, can cause life- threatening cardiac conduction dysfunction and ventricular arrhythmias. The effects can be seen many days after discontinuation. Isopreterenol used to increase heart rate may be a useful medicinal modality to limit arrhythmogenic effects in the setting of loperamide overdose.

2016 American College of Medical Toxicology
ACMT Annual Scientific Meeting
Bench to Bedside: Neurologic and Metabolic Toxins
March 18-20, 2016
SOURCE

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FW: Condemnation, or Compassion?

elmerhill

Pastor Sam, of Rome’s First Presbyterian Church, is one of the coolest people I know here in Rome. Wise and compassionate, he wrote this terrific blog post regarding a recent tragedy to befall our city — not far, in fact, from where I used to live. A state trooper headed home after a long day at work with his 4-month-old son in the child seat in the back of the car. The man forgot, and went inside; sadly, the infant was dead by the time he remembered the child was still in the car.

These things happen. They are accidents — cold and cruel — but still accidents. Yet people comment shameful cruelties from the safety of their computer keyboards and are fast to judge! Don’t you think that man is wracked with grief now? Do we really need to plan his lynching before all the facts are in?

It reminds me of all the negativity surrounding people with addiction problems. Especially from those in the medical community (surprise!) as well as those in government. Don’t get me wrong — addicts can be a pain in the ass — demanding, selfish, fussy assholes. But that doesn’t mean that those with such problems don’t warrant compassionate care rather than further criminalization.

Sam’s blog, while not about addiction, is well worth the read.

To quote Sam:

“But condemnation will not heal. Condemnation will not bring the dead back to life. Condemnation will only divide people. We need compassion. Compassion understands that we are all human, that we can identify with the mistakes of another person, even when it horrifies us to imagine ourselves in that same position. “

PLEASE READ: Source: Condemnation, or Compassion?

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Another tragic death from Loperamide Overdose

evanbrownfbThese stories float by my mailbox so often and haunt my thoughts like ghosts. So many have died from this, and the worst tragedy is the number of people who dismiss it.

This young man, Evan Brown, of Oregon, studied computer science. He had a beautiful girlfriend. And a family who loved him. He liked music and had fun with his friends. Then one day, he died. Among the many victims of our nation’s drug abuse crisis — and as in so many cases lately, he died from a loperamide addiction.

Like many, Evan started using Loperamide to help his withdrawal from opiates. And like so many, he became addicted to it, eventually losing his life to it.

His family adds:

“This was a tragic accident, he was trying as best as he could to live a clean life for those he loved most…. Evan’s family would like you to please think twice before trying anything on your own, and to seek professional help, if you are struggling with any addiction, not the internet! You have family and friends who love you no matter what.”

My deepest sympathies go out to Evan’s family. Nobody should have to go through this. Nobody. Now that Loperamide Abuse is getting the attention it needs from the scientific community, the press, and now the FDA, perhaps we can agree to treat these patients with the dignity they deserve as humans on this earth.

https://www.facebook.com/EvanBrownstone?pnref=story

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FDA Issues Loperamide Warning

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Handful of loperamide tablets. Pic © Sobrietyland 2016

FDA Drug Safety Communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse

The U.S. Food and Drug Administration (FDA) is warning that taking higher than recommended doses of the common over-the-counter (OTC) and prescription diarrhea medicine loperamide (Imodium), including through abuse or misuse of the product, can cause serious heart problems that can lead to death. The risk of these serious heart problems, including abnormal heart rhythms, may also be increased when high doses of loperamide are taken with several kinds of medicines that interact with loperamide (see Examples of Drugs that Can Potentially Interact with Loperamide).

The majority of reported serious heart problems occurred in individuals who were intentionally misusing and abusing high doses of loperamide in attempts to self-treat opioid withdrawal symptoms or to achieve a feeling of euphoria. We continue to evaluate this safety issue and will determine if additional FDA actions are needed.

Health care professionals should be aware that use of higher than recommended doses of loperamide can result in serious cardiac adverse events. Consider loperamide as a possible cause of unexplained cardiac events including QT interval prolongation, Torsades de Pointes or other ventricular arrhythmias, syncope, and cardiac arrest. In cases of abuse, individuals often use other drugs together with loperamide in attempts to increase its absorption and penetration across the blood-brain barrier, inhibit loperamide metabolism, and enhance its euphoric effects. If loperamide toxicity is suspected, promptly discontinue the drug and start necessary therapy. If loperamide ingestion is suspected, measure blood levels, which may require specific testing. For some cases of Torsades de Pointes in which drug treatment is ineffective, electrical pacing or cardioversion may be required.

Advise patients taking loperamide to follow the dosing recommendations on the label because taking higher than recommended doses, either intentionally or unintentionally, may lead to abnormal heart rhythms and serious cardiac events leading to death. Also advise patients that drug interactions with commonly used medicines also increase the risk of serious cardiac adverse events. Refer patients with opioid use disorders for treatment (see Additional Information for Health Care Professionals).

Patients and consumers should only take loperamide in the dose directed by their health care professionals or according to the OTC Drug Facts label. Do not use more than the dose prescribed or listed on the label, as doing so can cause severe heart rhythm problems or death. If your diarrhea lasts more than 2 days, stop taking loperamide and contact your health care professional. Seek medical attention immediately by calling 911 if you or someone taking loperamide experiences any of the following:

  • Fainting
  • Rapid heartbeat or irregular heart rhythm
  • Unresponsiveness, meaning that you can’t wake the person up or the person doesn’t answer or react normally

Ask a pharmacist or your health care professional if you are not sure how much loperamide to take, how often to take it, or whether a medicine you are taking may interact with loperamide. Always tell your health care professionals about all the medicines you are taking, including OTC medicines (see Examples of Drugs that Can Potentially Interact with Loperamide).

Loperamide is approved to help control symptoms of diarrhea, including Travelers’ Diarrhea. The maximum approved daily dose for adults is 8 mg per day for OTC use and 16 mg per day for prescription use. It is sold under the OTC brand name Imodium A-D, as store brands, and as generics.

In the 39 years from when loperamide was first approved in 1976 through 2015, FDA received reports* of 48 cases of serious heart problems associated with use of loperamide. This number includes only reports submitted to FDA, so there are likely additional cases about which we are unaware. Thirty-one of these cases resulted in hospitalizations, and 10 patients died. More than half of the 48 cases were reported after 2010. The serious heart problems occurred mostly in patients who were taking doses that were much higher than recommended. In other cases, patients were taking the recommended dose of loperamide, but they were also taking interacting medicines, causing an increase in loperamide levels. Additional cases of serious heart problems associated with the use of loperamide were reported in the medical literature.1-9 Cases reported to FDA and in the medical literature indicate that individuals are taking significantly high doses of loperamide in situations of both misuse and abuse, often attempting to achieve euphoria or self-treat opioid withdrawal. They are also combining loperamide with interacting drugs in attempts to increase these effects.

We urge patients, consumers, and health care professionals to report side effects involving loperamide or other medicines to the FDA MedWatch program, using the information in the “Contact FDA” box at the bottom of the page.

*The cases were reported to the FDA Adverse Event Reporting System (FAERS).

 

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SOURCE

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