J Med Toxicol
· 2025 Apr · PMID 39821850
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BACKGROUND: Octreotide is commonly used to treat hypoglycemia due to sulfonylurea toxicity, but optimal dosing for this indication is not well defined. METHODS: We performed a systematic review to identify cases in the m...BACKGROUND: Octreotide is commonly used to treat hypoglycemia due to sulfonylurea toxicity, but optimal dosing for this indication is not well defined. METHODS: We performed a systematic review to identify cases in the medical literature of octreotide use for sulfonylurea poisoning. Literature published on octreotide and sulfonylureas between octreotide's FDA approval on 10/21/1988 and 8/15/2024 was reviewed. RESULTS: Eighty unique patient cases (66 adults/adolescents and 14 pediatric patients) from 61 sources were included in the final analysis. These included 41 octreotide dosing strategies that differed in dose, frequency, and/or route of administration. Subcutaneous dosing, primarily within the range of 50-100 mcg per dose at a frequency of every 6-8 h, was the most common regimen in adults while intravenous dosing of 1 mcg/kg was most prevalent in pediatrics. There were no significant differences in duration of therapy or total dose of octreotide in adults with intermittent subcutaneous vs intravenous dosing. Treatment of hypoglycemia and maintenance of euglycemia was similar among all routes of administration. Infusions had similar durations but higher total doses of octreotide. Higher intermittent bolus doses were associated with shorter durations of therapy. Intentional exposures were associated with higher doses and longer duration of treatment with octreotide. Three adverse reactions to octreotide were reported. Except for 2 cases, all patients survived without any long-term complications. CONCLUSION: Despite widespread variation in octreotide dosing and administration, our report showed similar efficacy and safety with various octreotide dosing practices.
Quadir M, Rine NI, Badeti J
… +4 more, Hays HL, Michaels NL, Yang J, Smith GA
J Med Toxicol
· 2025 Jan · PMID 39724478
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INTRODUCTION: Tianeptine is an atypical tricyclic antidepressant not approved for medical use in the US but is found in dietary supplements. This study investigates single-substance tianeptine exposures reported to US po...INTRODUCTION: Tianeptine is an atypical tricyclic antidepressant not approved for medical use in the US but is found in dietary supplements. This study investigates single-substance tianeptine exposures reported to US poison centers. METHODS: We analyzed cases involving tianeptine reported to the National Poison Data System from 2015 to 2023. RESULTS: There were 892 single-substance tianeptine exposures reported to US poison centers from 2015 to 2023, and the rate of exposures increased 1,400% from 2015 to 2023, including a 525% increase from 2018 to 2023. Most exposures were associated with moderate (51.5%) or major (12.0%) effects, and 40.1% required medical admission, including 22.9% to a critical care unit. Individuals 50 years and older were more likely to experience major effects (RR: 1.70, 95% CI: 1.13-2.56) or require medical admission (RR: 1.43, 95% CI: 1.20-1.72) than younger individuals. Tianeptine abuse accounted for 40.1% of exposures and was more likely to be associated with moderate or major effects (RR: 1.18, 95% CI: 1.06-1.31) than exposures not attributed to abuse. Withdrawal accounted for 22.5% of tianeptine exposures. Tianeptine exposure rates were highest in the US South. Alabama enacted legislation to regulate tianeptine as a controlled substance in 2021. Alabama's tianeptine exposure rate increased by 1,413.7% from 2018 to 2021, followed by a 74.6% decrease from 2021 to 2023, while the rate in other southern states continued to increase. CONCLUSIONS: This study demonstrates the toxicity and rapid increase of tianeptine exposures reported to US poison centers. Uniform regulation of tianeptine across all states may offer an important strategy to help mitigate this public health problem.
J Med Toxicol
· 2025 Jan · PMID 39695044
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INTRODUCTION: Diazoxide is the first-line treatment for children with hyperinsulinemic hypoglycemia (HI). In these cases, diazoxide raises blood glucose levels by suppressing insulin release, preventing hypoglycemia, and...INTRODUCTION: Diazoxide is the first-line treatment for children with hyperinsulinemic hypoglycemia (HI). In these cases, diazoxide raises blood glucose levels by suppressing insulin release, preventing hypoglycemia, and potentially devastating end-organ sequelae. Hyperosmolar hyperglycemic state (HHS) is an exceedingly rare side effect of diazoxide. This complication has been described in neonates and in adults, but few children. CASE REPORT: An 8-year-old female with genetic duplication of glucokinase, and consequent hyperinsulinemia, presented to the emergency department with evidence of hypovolemic shock secondary to severe dehydration with signs of encephalopathy. Point-of-care glucose was > 600 mg/dL. Additional labs were consistent with HHS complicated by acute kidney injury, sodium 106 mEq/L, potassium 2.5 mEq/L, chloride < 60 mEq/L, carbon dioxide 20 mEq/L, glucose 2105 mg/dL, BUN 107 mg/dL, and creatinine 3.99 mg/dL. The patient received aggressive fluid resuscitation and vasopressor support, and was admitted to the pediatric intensive care unit. A diazoxide level was obtained during admission revealing serum concentration previously shown to be associated with hyperglycemia. DISCUSSION: We posit the patient was predisposed to hyperglycemia based on elevated diazoxide serum concentration. We hypothesize severe dehydration led to renal impairment, which decreased diazoxide clearance, causing worsening hyperglycemia and ultimately, HHS. The differential diagnosis also included diabetic ketoacidosis, surreptitious administration of diazoxide, spontaneous resolution of genetic condition, and malabsorption or excretory crisis but none of these adequately explained the patient's presentation. Regardless, this case highlights the potentially lethal complication of HHS as a side effect of diazoxide therapy.
Wolfe CE, Sund LJ, Archer JR
… +4 more, Rowe A, Hudson S, Wood DM, Dargan PI
J Med Toxicol
· 2025 Jan · PMID 39663285
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INTRODUCTION: Novel Psychoactive Substance (NPS) use is increasingly prevalent and is often associated with severe acute recreational drug toxicity (ARDT). 258 UK deaths were attributed to NPS use in 2021. Confirmatory t...INTRODUCTION: Novel Psychoactive Substance (NPS) use is increasingly prevalent and is often associated with severe acute recreational drug toxicity (ARDT). 258 UK deaths were attributed to NPS use in 2021. Confirmatory testing which identifies NPS is limited by expense and timeliness. We aimed to identify NPS and other recreational drugs in a sample of 1000 ARDT presentations to a central London hospital in 2019/20 and to compare these drugs to those identified from a previous cohort in 2016/2017. METHODS: We prospectively enrolled 1000 serum samples from ARDT presentations to St Thomas' Hospital between February 2019 and February 2020. Serum samples were deidentified and underwent qualitative analysis via mass spectrometry. Results were returned at the conclusion of testing and statistical analysis performed using 'R' (R Foundation for Statistical Computing). RESULTS: Twenty-eight unique NPS were detected in 2019/20, compared to 31 in 2016/17. Eight new NPS were detected in 2019/20: four benzodiazepines, two synthetic cannabinoid receptor agonists, one cathinone and one ketamine-analogue. No NPS opioids were detected in either cohort. Cannabis (16%,11% p = 0.02), ketamine (12%,7% p < 0.01) and opioids (57%,24% p < 0.01) were detected significantly more frequently in 2019/20 than in 2016/17, while alcohol (22%,49% p < 0.01), cathinones (1%,15% p < 0.01), GHB (14%,20% p < 0.01) and MDMA (9%,18% p < 0.01) were detected less frequently. CONCLUSIONS: Studies that utilise confirmatory testing to detect NPS in presentations of ARDT provide important information for public health interventions. More NPS benzodiazepines and fewer NPS cathinones were detected in 2019/20, following temporal trends of forensic detection throughout Europe and reinforcing the importance of identifying emerging drugs.
Zitek T, Raciti C, Nguyen A
… +4 more, Roa V, Lopez E, Oliva G, Farcy DA
J Med Toxicol
· 2025 Jan · PMID 39612151
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INTRODUCTION: Cannabinoid-related emergency department (ED) visits are increasing, yet little has been published about how the route of cannabinoid use (inhaled versus oral) affects ED presentations. We sought to compare...INTRODUCTION: Cannabinoid-related emergency department (ED) visits are increasing, yet little has been published about how the route of cannabinoid use (inhaled versus oral) affects ED presentations. We sought to compare ED visits from inhaled versus oral cannabinoid use. METHODS: We performed a retrospective cohort study using ED patients with a cannabinoid related diagnosis from January 1, 2020 and May 31, 2023 from a single hospital system in Florida. We performed manual chart review to categorize visits into "unlikely", "possibly", or "highly likely" to be due to acute cannabinoid use. For our primary analysis, we used the "highly likely" group to compare the presentations and outcomes of patients who had used oral cannabinoids versus inhaled. Our primary outcome was hospital admission. RESULTS: We deemed 303 patient visits "highly likely" to be from acute cannabinoids: 59 (19.5%) inhaled and 244 (80.5%) oral. Zero patients in the inhaled group were admitted compared to 15 (6.2%) in the oral group, a difference of 6.2% (95% CI 3.1-9.2%), p = 0.05. Additionally, 65 (26.7%) of the oral group reported using cannabinoids unintentionally including 8 housekeepers who ate food products left by hotel guests. Comparatively, 4 (6.8%) of the inhaled group unintentionally used cannabinoids (difference 19.9% [95% CI 11.4-28.3]). CONCLUSIONS: Most patients who presented to the ED for the effects of acute cannabinoids had used them orally. Compared to patients who had inhaled cannabinoids, those who used them orally required more ED diagnostic resources and were more likely to be admitted to the hospital for additional evaluation or treatment. From a public health perspective, increased regulation of edible cannabinoid products may be needed.
J Med Toxicol
· 2025 Jan · PMID 39514164
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The 2024 ACMT Ward and Ryan Donovan Memorial Fund lecture was presented by Dr. Nora Volkow, the director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH). This article in an edite...The 2024 ACMT Ward and Ryan Donovan Memorial Fund lecture was presented by Dr. Nora Volkow, the director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH). This article in an edited version of her keynote address during ACMT's 2024 Annual Scientific Meeting. During the course of her talk, Dr. Volkow discussed the historical factors contributing to the ongoing global opioid epidemic, examined the evidence behind different front-line and policy strategies used to battle the opioid epidemic, and highlighted the importance of recent cultural changes that support more deliberate screening for substance use disorders and pathways for initiating treatment of opioid use disorders in vulnerable populations. An urgent need exists to improve inclusion of social and structural determinants of health in implementation science addressing opioid use disorders, with better attention to special populations, including Native American Indians and Alaskan Natives, African Americans, those over 65 years of age, and teenagers.
Kristensen K, Alhatali B, Zahran TE
… +1 more, Kazzi Z
J Med Toxicol
· 2025 Jan · PMID 39453583
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INTRODUCTION: Poison Centers are vital to prevent and manage exposures to chemicals, toxins, and ionizing radiation. However, many countries still lack sufficient poison information center services. Within the World Heal...INTRODUCTION: Poison Centers are vital to prevent and manage exposures to chemicals, toxins, and ionizing radiation. However, many countries still lack sufficient poison information center services. Within the World Health Organization's Eastern Mediterranean Regional Office (EMRO) region, we were not able to identify a formal assessment of its toxicological resources. We sought to assess the clinical toxicological resources in the EMRO region and the attitudes, needs, and perspective of the workforce in that region. METHODS: This was a two part survey study. First, we developed a poison center questionnaire and scoring system based on the World Health Organization's Guidelines for Establishing a Poison Center; this instrument was administered by phone to poison center directors and faculty in the EMRO region. Questions assessed for the presence or absence of important poison center capabilities listed in the WHO guidelines, and points were assigned based on response. Secondly, we administered an electronic workforce survey to clinical toxicology professionals in the region; participant eligibility for the workforce survey was based on the membership roster of MENATOX. RESULTS: Out of 22 EMRO countries, 16 countries have an established poison center, and 14 of 16 participated in the poison center survey. The results reflected a wide variability in capabilities among countries. Areas such as call centers, clinical toxicology units, laboratory services, and data management were relatively lacking while some other areas including toxicovigilance, chemical incidents and emergencies, antidotes/antivenoms, poisoning information sources, and the availability of free services were relatively stronger. Twenty-seven out of 32 workforce respondents were physicians. Results from that survey highlighted a desire for more support from government and better compensation. CONCLUSIONS: Our study identified areas of need for the EMRO region. The poison center survey results reflect large disparities among countries with some areas being stronger than others. The workforce survey highlighted issues such as compensation and government recognition. Overall, a formal assessment of individual poison centers can provide benchmarks to drive improvement of services, but further research is needed to identify and characterize country-specific needs.
J Med Toxicol
· 2025 Jan · PMID 39446308
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Digital health refers to the use of information and communication technologies in medicine (including smartphone apps, wearables, other non-invasive sensors, informatics and telehealth platforms) to prevent illness, deli...Digital health refers to the use of information and communication technologies in medicine (including smartphone apps, wearables, other non-invasive sensors, informatics and telehealth platforms) to prevent illness, deliver treatment, and promote wellness. This rapidly proliferating group of technologies has the potential to reduce harm for people with opioid use disorder (OUD) and facilitate the recovery process; however, development in this space for OUD has been slower compared to that for other medical conditions. Unique issues with OUD management surrounding patient provider relationships, interaction with the healthcare system, autonomy and trust sometimes hinder care approaches, including those in digital health. The trauma informed care framework (TIC), developed for use by organizations to support individuals who have experienced trauma, has particular applicability for digital health interventions in OUD care. This manuscript will serve as a review of TIC principles and how they can be applied to digital health interventions to increase access, equity, and empowerment for people with OUD. We will highlight representative current and pipeline digital technologies for OUD, challenges with these technologies, TIC models for OUD, and the integration of TIC principles into digital technology development to better serve people with OUD. Finally, we will posit strategies to incorporate the aforementioned principles into future research efforts. We ultimately aim to use TIC as a lens through which to develop digital technologies to help individuals with OUD while minimizing harm.
Renny MH, Berger JC, Mei C
… +4 more, Loo GT, Ansah JA, Severe AD, Merchant RC
J Med Toxicol
· 2025 Jan · PMID 39406980
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OBJECTIVE: Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk...OBJECTIVE: Our primary objective was to determine the frequency and type of substance use in youth presenting to our pediatric ED (PED). Our secondary objective was to identify characteristics associated with higher-risk substance use. METHODS: We conducted a tablet-based, anonymous, self-administered screening for substance use using a modified version of the Screening to Brief Intervention (S2BI) tool among a convenience sample of 383 patients 12-21 years presenting to an urban, academic PED from February to July 2023. Patients' attitudes toward ED screening and interventions for substance use also were collected. The frequency and type of substance use was analyzed by age group. Ordinal logistic regression was used to identify characteristics associated with higher-risk use (monthly or more substance use) and lower-risk use (past year use), as compared to no past year use. RESULTS: Among 14-17-year-olds (n = 144), 38% reported substance use in the past year; 25% had higher-risk use. Among 18-21-year-olds (n = 172), 67% reported substance use in the past year; 48% had higher-risk use. Alcohol, cannabis, and tobacco were most commonly used. Substance use was rare for 12-13-year-olds. Compared to youth 14-17 years, youth 18-21 years were more likely to have either higher-risk use (aOR 3.81, 95% CI (2.24-6.47)) or lower-risk use (aOR 2.74 (1.41-5.35)), rather than no use. Compared to Asian patients, Non-Hispanic White patients (aOR 5.23 (1.07-25.66)) and Hispanic patients (aOR 3.18 (1.06-9.58)) were more likely to have higher-risk use than no use. Most patients reported that it was important for youth to be asked about substance use in the ED and to be offered help for substance use. CONCLUSION: Youth substance use was common in this urban, academic PED, and many patients reported higher-risk use. These findings support future research to determine the best practices for ED substance use screening and ED-based interventions for youth.
Ng PC, Paredes RM, Mireles AA
… +5 more, Hendry-Hofer T, Bebarta VS, Boss GR, Choi JH, Maddry CJK
J Med Toxicol
· 2025 Jan · PMID 39375309
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INTRODUCTION: Given its availability and lethality, cyanide has potential for weaponization and thus has the attention of several governmental agencies. In large scale exposure scenarios, an effective countermeasure that...INTRODUCTION: Given its availability and lethality, cyanide has potential for weaponization and thus has the attention of several governmental agencies. In large scale exposure scenarios, an effective countermeasure that can be administered quickly and in low volume intramuscularly may prove valuable because IV medications may have limited practical applications in these situations. Sodium tetrathionate, a potential cyanide antidote, is a compound that provides sulfur to rhodanese, the enzyme that detoxifies cyanide endogenously. Additionally, sodium tetrathionate has been reported to directly react with cyanide and is effective when administered intramuscularly. In this study, we assess the efficacy of sodium tetrathionate, when administered intramuscularly for the treatment of acute, oral cyanide poisoning in swine. METHODS: We conducted a prospective trial approved by the 59th Medical Wing Institutional Animal Care and Use Committee comparing intramuscular sodium tetrathionate (n=6) to no treatment control (n=4) in animals (Sus scrofa) exposed to a lethal dose of oral potassium cyanide. Survival at 120 minutes was the primary outcome. Lactate, a cyanide toxicity biomarker, was measured. At the study end, all animals were euthanized in compliance with the Animal Welfare Act and the American Association for Accreditation of Laboratory Animal Care. Survival between groups was summarized using a Kaplan-Meier survival curve after comparing survival by log-rank, Mantel-Cox analysis. The Mann-Whitney U test was used for comparison of other variables between groups. RESULTS: At baseline animals were similar. There was 100% survival in the treatment group and 0% survival in the control group (P=0.0011). Serum lactate significantly increased in the control group (control: 5±0.9 vs. treatment: 2.1 ± 0.5 mmol/L at 20 minutes). CONCLUSION: Sodium tetrathionate (intramuscular) significantly improved survival in a large, swine model of acute, oral cyanide poisoning. Future studies will be directed at further assessing sodium tetrathionate as a potential medical countermeasure for cyanide poisoning.