Gastric pharmacobezoars in quetiapine extended-release overdose: A case series

Abstract

Objective. Although extended-release (XR) formulations are recognized to bear some risk of pharmacobezoar formation in overdose, there are no previously documented reports of this phenomenon with quetiapine. We describe nine cases of pharmacobezoar formation in acute quetiapine XR overdose. Methods. Observational case series of all patients who underwent gastroscopy after quetiapine XR overdose, which were reported by physicians to the Swiss Toxicological Information Centre between January 2010 and December 2012, with detailed analysis of cases with documented pharmacobezoar. Results. Gastric pharmacobezoars were detected in 9 out of 19 gastroscopic evaluations performed during the study period. All these patients ingested a large dose of quetiapine XR (10–61 tablets; 6–24.4 g quetiapine). All patients but one also coingested at least one other substance, and in three cases another XR drug formulation. Gastroscopic pharmacobezoar removal was achieved without complications in all patients, but was difficult due to the particular “gelatinous-sticky-pasty” consistency of the concretion. The subsequent clinical course was favorable. Conclusions. The possibility of pharmacobezoar formation following a large quetiapine XR overdose should be considered, as this may influence acute patient management. Complete endoscopic pharmacobezoar removal may be a promising approach in selected cases, but further studies are needed to define its role.     

Potential pharmacobezoar formation of large size extended-release tablets and their dissolution – an in vitro study

Objective: Extended release (ER) tablets/capsules in massive ingestion overdoses are prone to form pharmacobezoars potentially increasing the risk of late-appearing toxic effects and prolonged symptoms. Oral activated charcoal is often sufficient to prevent drug absorption, but in a recent massive ingestion of highly toxic substances, prior orogastric lavage might be considered. The disintegration characteristics of ER preparations in overdose situations is valuable to understand if the time line and course of the intoxication might be prolonged, but information on these characteristics are unavailable. Slow disintegration and/or pharmacobezoar formation, and the large size makes ER preparation impossible to evacuate using a 30F orogastric lavage tube. This study evaluates the disintegration and pharmacobezoar formation of a simulated massive ER tablet ingestion in an in vitro model, using a selection of extended release tablets, with different disintegrating characteristics when present in therapeutic numbers. Furthermore, the sizes of the formed pharmacobezoars were compared with the dimensions of a 30F orogastric lavage tube.

Method: A standardized model mimicking the physical effects on pharmaceutical preparations in simulated gastric fluid (SGF) was developed and tested on three mono-depot ER tablets (quetiapine/Seroquel^®XR 50?mg, paracetamol/Pinex^®Retard 500?mg, verapamil/Isoptin^®Retard 240?mg), one poly-depot ER tablet (carbamazepine/Tegretol^®Retard 200?mg), and one immediate-release tablet (paracetamol/Panodil^® 500mg). Thirty tablets were placed in polyamide mesh bags, either together in one bag or in separate bags, immersed in 1?L SGF, and incubated at 37?°C for 48?h. Released drugs were quantified at 0.5–48?h.

Results: Visual inspection showed that Seroquel^®XR, Pinex^®Retard, and Isoptin^®Retard tablets formed firm pharmacobezoars stable for more than 4?h and intact fractions remained for up to 24?h. Drug releases were reduced by 53%, 40%, and 31%, respectively, for up to 8?h compared to separated tablets. Light microscopy showed that contact with SGF transformed the coating of Seroquel^®XR and Pinex^®Retard to a diffusion-controlled swelled gel-layer, and the Isoptin^®Retard tablets into a rigid and slow-releasing matrix. Tegretol^®Retard disintegrated into microspheres within 30?min, and Panodil^® disintegrated within minutes.

Discussion: The developed pharmacobezoars of mono-depot ER tablets demonstrated prolonged drug release. Neither the formed pharmacobezoars, nor the single tablets of the tested mono-depot ER preparations, would pass through the lumen of a standard orogastric lavage tube, rendering this modality ineffective for tablet removal in gastrointestinal decontamination.     

Pharmacobezoar of the esophagus

Esophageal medication bezoars are rare. We report a case presenting as esophageal obstruction following an alleged ingestion of 145 tablets. Abdominal X-ray suggested the presence of a large pharmacobezoar in the stomach, and endoscopy confirmed esophageal obstruction by pharmacobezoar.     

Pharmacobezoar of the esophagus

Esophageal medication bezoars are rare. We report a case presenting as esophageal obstruction following an alleged ingestion of 145 tablets. Abdominal X-ray suggested the presence of a large pharmacobezoar in the stomach, and endoscopy confirmed esophageal obstruction by pharmacobezoar.     

Adolescent with prolonged toxidrome

A 13-year-old female was presented to the emergency department following an intentional ingestion. The patient developed significant toxicity including multiple, discreet tonic-clonic seizures. Despite appropriate resuscitation and antidotal management, the patient’s symptoms persisted for more than 36?hours post-ingestion. An upright abdominal radiograph was performed revealing a radiopacity suggesting a pharmacobezoar. An esophagogastroduodenoscopy was performed with successful removal of a tennis ball-sized pharmacobezoar. The patient’s symptoms subsequently subsided and she recovered fully with no neurologic deficits. Diphenhydramine has not been previously identified as a medication likely to form a pharmacobezoar and has not been shown to be radiopaque. Though bezoar formation is a rare clinical scenario, it is one that toxicologists must consider in patients with clinical courses that persist far beyond expected based on known toxicokinetic principles.     

Sucralfate and bezoars: data from the system of pharmacologic vigilance and review of the literature

A bezoar is a mass of undigested material which may form within the lumen of the gut. Some drugs have the potential to form bezoars. In the majority of patients, there is a clear predisposing factor. We present here the data of the French System of Pharmacovigilance on sucralfate and a literature review. Two distinct populations were involved: 16 adults and 5 newborn babies. All were hospitalized in intensive care units. The children were very low birth weight newborn babies, all of whom presented with abdominal distension or acute occlusion. The abdominal radiograph revealed an opaque mass filling the contour of the stomach. Adults presented an oesophageal bezoar around a nasogastric tube. Risk factors for bezoar formation were severe illness, gut hypomotility, dehydration, overdosage, nasogastric tube feeding. Sucralfate is used in the management of peptic ulcer. At pH < 4, extensive polymerization occurs and a sticky viscid gel is formed. In view of this inquiry, the French System of Pharmacovigilance decided to advise caution for adults in intensive care unit being fed by nasogastric tube and contraindication in premature babies and dysmature newborn babies receiving sucralfate.     

Gastric bezoars. A technique of endoscopic removal

Gastric bezoar formation is an uncommon sequela of gastroduodenal surgery or unusual eating habits. Because they generally produce severe symptoms, their removal is always necessary. Previously, this required surgical extirpation or slow enzymatic dissolution. We present here an endoscopic procedure for bezoar removal utilized successfully in five patients with vegetable-mucus bezoars. This technique employs a jet spray of water under direct vision to mechanically disrupt the bezoar, which may then be removed using a large gastric lavage tube. This procedure is simple, safe, and rapid and is therefore recommended as an alternative to surgical removal or enzymatic dissolution of gastric bezoars.     

Identification of Drug Characteristics for Implementing Multiregional Clinical Trials Including Japan

Purpose

Multiregional clinical trials (MRCT) are a standard strategy used to improve global drug approval efficiency and the feasibility of clinical trials. Japan is the world's third largest drug market with a unique health care system, making it a key inclusion as an operational region for MRCT (MRCT-JP) for global drug development. We aimed to identify the factors required for efficient drug development by comprehensively reviewing the clinical trials of drugs approved in Japan to identify the factors associated with whether or not MRCT-JP is implemented.

Confessions of contemporary English opium-eaters: a netnographic study of consumer negotiation of over-the-counter morphine for misuse

Global increases in misuse of pharmaceutical opioids are a public health concern. Over-the-counter (OTC) morphine preparations are sold in the UK. A netnographic study explored online reporting of misuse of OTC morphine-based medicines. A systematic internet search was conducted using the terms; “J Collis Browne’s Mixture”; “J Collis Browne”; “Chlorodyne”; “Gee's Linctus”; “Morphine Squill”; “Kaolin & Morphine Mixture”; and “Opiate Squill Linctus” in combination with “forum”. Following application of exclusion criteria and removal of duplicates, 105 fora threads on 11 publically available online fora were analysed using the EPP method. Key decision-making factors for misuse was grounded in legal availability, curiosity and when in withdrawal. Consumptive effects included euphoria, nausea, vomiting and sedation, and were dependent on tolerance. Concern for harm associated with product additives (squill, kaolin) was reported. Decantation extracted morphine from kaolin-based products. Concerted sourcing efforts included multiple pharmacy accessing, appropriate customer profiling and falsifying medical screening. Displacement to online purchasing occurred, with concern for online sharing of customer information. Development of real-time pharmacy monitoring should incorporate national online pharmacy chains. Continued surveillance of internet drug fora as medium for knowledge exchange and indigenous harm reduction for the misuse of OTC medicines is warranted.     

Cecal vitamin bezoar formation inducing abdominal discomfort.

OBJECTIVE: To document a case of cecal lecithin-vitamin B12 bezoar formation inducing abdominal discomfort. DESIGN: Case study. SETTING: 500-bed, community teaching hospital. PATIENT: 81-year-old man with a history of multiple abdominal surgeries who presented with a chief complaint of abdominal pain. Flat plate X-ray of the abdomen revealed multiple capsule-shaped objects lodged in the cecum. INTERVENTIONS: Catharsis with bisacodyl, magnesium citrate, NaCl 0.9%; dissolution with heated, dilute barium administered rectally in conjunction with external manipulation; laparotomy. MAIN OUTCOME MEASURES: None planned; dissolution or transit of bezoar through gastrointestinal tract desired outcome. RESULTS/DISCUSSION: Classification of bezoars and treatment discussed in relation to this case report. CONCLUSIONS: Medicinal agents have been implicated in bezoar formation. Treatment options have included: cathartics, heated solvent enemas, and external manipulation and surgery.     

Scoping Review of Telehealth for Musculoskeletal Disorders: Applications for the COVID-19 Pandemic

ObjectiveThe purpose of this scoping review was to identify information about telehealth and rehabilitation for the evaluation and management of musculoskeletal disorders, patient satisfaction, cost, and access as may be applicable during the COVID-19 pandemic.MethodsWe searched MEDLINE for studies published between January 1, 2000, and June 1, 2019. Search terms consisted of MEDLINE medical subject headings and other words relevant to this review, including “telerehabilitation,” “musculoskeletal,” “telemedicine,” “therapy,” “chiropractic,” “ergonomics,” and “exercise.” This review targeted studies of people aged 18 years and older with musculoskeletal concerns. Articles on diagnostic tests, effectiveness of treatment, patient satisfaction, access to care, and cost were included.ResultsEleven studies were included in this review. Interrater reliability and agreement were moderate to high for several assessment procedures for the lower limb, elbow, and low back. Two clinical trials demonstrated that provider and patient simultaneous telehealth were equally as effective as in-office care. Patient and provider satisfaction with telehealth were reported to be equal to or higher than for conventional rehabilitation. We found no studies reporting cost or access.ConclusionIn the COVID-19 pandemic environment, telehealth is feasible for health care providers to provide rehabilitation services for their patients with various musculoskeletal conditions. Current evidence suggests that for some musculoskeletal disorders, telehealth evaluation may be reliable, treatment may be effective, and patient satisfaction may be good or better than for in-office care. Results from this study may help physiatry, physical therapy, and chiropractic health care providers in their decisions to implement telehealth during and after the COVID-19 pandemic.     

Endoscopic Removal of Pharmacobezoar in Case of Intentional Potassium Overdose

Background

Hyperkalemia is a potentially life-threatening electrolyte abnormality commonly seen in the emergency department (ED). Intentional overdose of potassium supplements is an uncommon occurrence.

Objective

This case illustrates a novel approach to treatment of pharmacobezoar with esophagogastroduodenoscopy (EGD) and demonstrates its effectiveness in the setting of extended-release potassium chloride overdose.

Case Report

A 44-year-old female presented to the ED with intentional ingestion of an unknown amount of extended-release potassium chloride (K-Dur®) tablets and alprazolam (Xanax®). The patient's serum potassium was initially 7.3 mmol/L and she was treated with standard treatments, including albuterol, calcium gluconate, insulin, dextrose, and sodium bicarbonate. Radiographic investigation showed a pharmacobezoar in the gastric fundus. Treatment was then augmented with whole bowel irrigation (WBI) using polyethylene glycol solution via nasogastric tube. Patient did not tolerate the nasogastric tube, became combative with increasing alteration in her level of consciousness, and WBI therapy was stopped. After discussion with the gastroenterologist, the patient was treated with EGD to remove the pharmacobezoar. The EGD was successful in the removal of the pharmacobezoar and the patient's potassium normalized without complications.

Conclusions

We recommend that in cases of suspected or confirmed potassium drug bezoar in the stomach, physicians consider EGD for removal. This allows for normalization of potassium level while preventing adverse sequelae.     

Nonoperative treatment of gastric bezoars using electrohydraulic lithotripsy.

BACKGROUND AND STUDY AIMS: Bezoars are collections of indigestible foreign material that are found within the gastrointestinal tract. Nonoperative approaches such as dietary therapy, enzymatic dissolution, and endoscopic removal have been regarded as the mainstays of therapy. The purpose of this paper is to determine the efficacy of electrohydraulic lithotripsy (EHL) as an alternative form of treatment of gastric bezoars. PATIENTS AND METHODS: Between July 1988 and May 1996, 11 patients with large gastric bezoars, defined as those greater than 5 cm in diameter, received endoscopic-guided fragmentation using electrohydraulic lithotripsy. Nine of our patients had a history of ingestion of "Pho Pu Zi", (Cordia dichotoma Frost. f.), one of orange pitch, and one of ingestion of persimmon. RESULTS: The 11 patients in the study underwent EHL for the treatment of their gastric bezoars, with a 100% success rate, which was defined as the lack of residual bezoar seen on post-procedure barium study or endoscopy done 2 days after the procedure. Patients were followed-up clinically for 30-68 months, with seven of the 11 patients undergoing a barium study with no residual bezoar noted. No procedure-related complications were seen, except for pharyngeal pain which was most probably secondary to the placement of the silicon overtube. CONCLUSIONS: Endoscopically guided electrohydraulic lithotripsy is a safe, highly effective, alternative nonsurgical technique for the treatment of gastric bezoars.     

A crunching colon: rectal bezoar caused by pumpkin seed consumption

Rectal seed bezoars are an uncommon cause of fecal impaction, particularly in the United States. Although the literature has reported several cases of phytobezoars composed of various types of seeds, bezoars formed of pumpkin seeds have rarely been reported. We report a case of a man, aged 62 years, with a rectal bezoar composed of pumpkin seeds with complications necessitating extensive treatment, including manual disimpaction and colonoscopy.     

A review on adherence management in patients on oral cancer therapies

PurposeThere is currently an ongoing paradigm shift in cancer treatment from intravenous (IV) chemotherapeutics to oral therapies. Additionally, the increased use of long-term maintenance therapy with oral targeted agents or chemotherapy is contributing to a shift toward a chronic-disease model. This shift is creating challenges and responsibilities for health care professionals in patient adherence management. This article will inform health care professionals of current trends and describe ways that they can overcome common barriers to adherence. A comprehensive review of recommendations and evidence derived from oncological studies describing adherence to oral targeted therapies and maintenance chemotherapy will provide guidance for the use of emerging oral maintenance therapies.MethodsArticles in the scientific literature were reviewed if published between January 1985 and November 2010. Searches were conducted using the PubMed database—search terms included “oral therapy,” “chemotherapy,” “cancer,” and “adherence” or “compliance.”ResultsThe change from IV therapy administered and monitored in hospitals or clinics to self-administered outpatient oral treatments decreases the likelihood of adherence. Methods, such as patient education and monitoring and involvement of family or caretakers, can improve adherence in patients undergoing treatment.ConclusionsAt treatment onset, oncology nurses can engage patients directly in a collaborative dialogue, and when issues affecting adherence arise, oncology nurses may limit nonadherence by providing individually tailored educational material. A practical approach to patient education, along with building strong health care provider–patient relationships, can help patients overcome nonadherence to new oral anticancer therapies and treatment paradigms.     

Drug-related Problems in Home-dwelling Older Adults: A Systematic Review

PurposeThe complex combination of medicines associated with age-related physiological alterations leads older adults to experience drug-related problems (DRPs). The goal of this study was to review the frequency and type of DRPs and DRP risk factors in home-dwelling older adults.MethodsA MEDLINE PubMed and EMBASE scientific databases search was performed. Articles published from January 2000 through December 2018 reporting DRPs in home-dwelling older adults were included.FindingsFrom 668 articles screened, 13 met the inclusion criteria and were included in this study. Overall, the studies included 8935 home-dwelling patients. The mean number of DRPs per patient observed was 4.16 (1.37–10). The main causes of DRPs were “drug selection” (51.41%), “dose selection” (11.62%), and “patient related” (10.70%) problems. The drug classes more frequently associated with DRPs were “cardiovascular system,” “alimentary tract and metabolism,” and “nervous system,” and they represented 32.1%, 29.4%, and 16.5% of all drug selection problems, respectively. Respiratory system medicines accounted for 6.65% of all DRPs, of which “patient related” problems accounted for 97.28%.ImplicationsDespite the heterogeneity of methodology of the included studies and the heterogeneity of tools used to identify DRPs, this analysis clearly shows the high prevalence of DRPs in home-dwelling older adults and highlights the need for interventions to improve medicine use in this population. This work also provides useful information for the development of strategies to improve medication use in home-dwelling older adults.     

A rare giant gastric trichobezoar in a young female patient: Case report and review of the literature

A bezoar is an aggregate of undigested foreign materials that accumulate in the gastrointestinal tract and may cause serious symptoms or even life‐threatening complications. Trichobezoars, a subtype of bezoars, are a rare condition usually occurring in females with psychiatric disorders, with Rapunzel syndrome being an uncommon form of trichobezoar.     

Effect of exercise on premenstrual symptoms: A systematic review

Introduction and purposeThe aim of this systematic review is to examine the effect of exercise on premenstrual symptoms.MethodsIn this systematic review, international databases (EBSCO Host, ScienceDirect PubMed, Google Scholar) were searched from the start of databases to 30 April 2018. Keywords used included “premenstrual syndrome” and “exercise”. For the keywords, “Medical Subject Headings” were used. Articles were screened by the two authors independently, and in case of disagreements, items were discussed until consensus was reached. All studies evaluating the effect of exercise on premenstrual symptoms were extracted from included studies without limiting the type of exercise.ResultsA total of 361 studies on the subject were examined, and 17 publications in accordance with the inclusion criteria were included in the study and evaluated. It can be said that exercise is effective in improving physical symptoms such as pain, constipation, breast sensitivity, and psychological symptoms such as anxiety and anger. However, although there is no clarity regarding other symptoms, exercise has a symptom-reducing effect.ConclusionExercise is an effective intervention for alleviating premenstrual symptoms in women with premenstrual syndrome.     

The effective needle stick injury prevention strategies for nursing students in the clinical settings: a literature review

Objective

Nursing students are prone to needle stick injuries (NSIs) during their practice in the hospitals. This study aimed to identify the effective NSI prevention strategies for nursing students in the clinical settings.