An Increase in Dietary Supplement Exposures Reported to US Poison Control Centers

Introduction

The objective of this study was to investigate the epidemiology of dietary supplement exposures in the USA.

Methods

A retrospective analysis was conducted of out-of-hospital dietary supplement exposures reported to the National Poison Data System from 2000 through 2012.

Results

There were 274,998 dietary supplement exposures from 2000 through 2012. The annual rate of dietary supplement exposures per 100,000 population increased by 46.1% during 2000–2002, decreased 8.8% during 2002–2005, and then increased again by 49.3% from 2005 to 2012. These trends were influenced by the decrease in ma huang exposures starting in 2002. Miscellaneous dietary supplements accounted for 43.9% of all exposures, followed by botanicals (31.9%), hormonal products (15.1%), and other supplements (5.1%). The majority of dietary supplement exposures (70.0%) occurred among children younger than 6 years old and were acute (94.0%) and unintentional (82.9%). Serious medical outcomes accounted for 4.5% of exposures and most (95.0%) occurred among individuals 6 years and older. Ma huang products, yohimbe, and energy products were the categories associated with the greatest toxicity.

Conclusions

There was an overall increase in the rate of dietary supplement exposures from 2000 through 2012. Although the majority of these exposures did not require treatment at a health care facility or result in serious medical outcomes, exposures to yohimbe and energy products were associated with considerable toxicity. Our results demonstrate the success of the FDA ban on ma huang products and the need for FDA regulation of yohimbe and energy products in the USA.

     

Nationwide Scorpion Exposures Reported to US Poison Control Centers from 2005 to 2015

Introduction

Previous studies of scorpion envenomation in the United States (US) have focused on Arizona and the bark scorpion, Centruroides sculpturatus. Although many other scorpion species live in the US, information about envenomations in other states is lacking.

Methods

Nationwide scorpion exposures from 2005 to 2015 were analyzed using the National Poison Data System.

Results

Of the 185,402 total exposures, Arizona (68.2%), Texas (10.3%), and Nevada (4.2%) were the top contributors. However, six other southern states reported greater than 100 cases annually, primarily during the warmer months and evening hours. Envenomations occurred most often in a home (97.8%) and were typically managed on-site (90.1%). Pain was the most common effect nationwide (88.7%). Arizona had the highest frequencies of sensory, neuromuscular, and respiratory effects along with higher hospitalization and ICU admission rates, although the latter appeared to drop over the study period. In contrast, local skin effects such as erythema and edema were more common outside of Arizona. Children under 10 years of age in Arizona and Nevada had the highest rates of systemic effects, hospitalization, and ICU admission.

Conclusions

Scorpion envenomations occurred throughout the southern US with similar seasonal and daily variations. Common clinical effects included pain, local edema, and erythema, except in Arizona and Nevada where severe systemic symptoms were more common. Systemic effects correlated with high rates of ICU admissions and intubations, especially in children under 10 years of age.

     

Kratom Exposures Reported to Texas Poison Centers

Kratom use is a growing problem in the United States. Kratom exposures reported to Texas poison centers between January 1998 and September 2013 were identified. No kratom exposures were reported from 1998 to 2008 and 14 exposures were reported from 2009 to September 2013. Eleven patients were male, and 11 patients were in their 20s. The kratom was ingested in 12 patients, inhaled in 1, and both ingested and inhaled in 1. Twelve patients were managed at a healthcare facility and the remaining 2 were managed at home.     

Synthetic Cannabinoid Exposures Reported to Texas Poison Centers

ABSTRACT

Synthetic cannabinoid abuse is increasing in the United States. Synthetic cannabinoid exposures reported to Texas poison centers in 2010 were identified, and the distribution of exposures by selected factors was determined. There were 464 total cases. The number of exposures increased each month during January-July, then remained relatively constant for the next 5 months. The patients were 73.9% male and 57.3% were 20 years or older. Moderate or major effects or potentially toxic outcome occurred in 59.9% of the exposures. The most frequently reported clinical effects were tachycardia (37.3%), agitation (18.5%), drowsiness (18.5%), vomiting (15.7%), hallucinations (10.8%), and nausea (9.9%).     

NBOMe Designer Drug Exposures Reported to Texas Poison Centers

Use of 2-methoxybenzyl analogues of 2C-X phenethylamines (NBOMe) is increasing in the United States. Twenty-five NBOMe exposures reported to Texas poison centers during 2012–2013 were identified; 76% involved 25I-NBOMe, 12% involved 25C-NBOMe, and 12% involved an unknown NBOMe. Eighty-eight percent of the patients were men; mean age was 17 years (range, 14–25 years). The exposure route was 72% from ingestion alone, 12% from inhalation alone, 4% from ingestion and inhalation, and 12% from an unknown route. The most common clinical effects were tachycardia (52%), agitation (48%), hallucinations (32%), hypertension (32%), confusion (24%), and mydriasis (20%). Two patients died.     

Ayahuasca Exposure: Descriptive Analysis of Calls to US Poison Control Centers from 2005 to 2015

Background

Ayahuasca is a hallucinogenic plant preparation which usually contains the vine Banisteriopsis caapi and the shrub Psychotria viridis. This tea originates from the Amazon Basin where it is used in religious ceremonies. Because interest in these religious groups spreading as well as awareness of use of ayahuasca for therapeutic and recreational purposes, its use is increasing. Banisteriopsis caapi is rich in β-carbolines, especially harmine, tetrahydroharmine and harmaline, which have monoamine oxidase inhibiting (MAOI) activity. Psychotria viridis contains the 5HT2A/2C/1A receptor agonist hallucinogen N,N-dimethyltryptamine (DMT). Usual desired effects include hallucination, dissociation, mood alteration and perception change. Undesired findings previously reported are nausea, vomiting, hypertension, and tachycardia.

Methods

All human exposure calls reported to the American Association of Poison Controls Centers' (AAPCC) National Poison Data System (NPDS) between September 1, 2005 and September 1, 2015 were reviewed. Cases were filtered for specific plant derived ayahuasca-related product codes. Abstracted data included the following: case age and gender, exposure reason, exposure route, clinical manifestations, treatments given, medical outcomes and fatality.

Results

Five hundred and thirty-eight exposures to ayahuasca botanical products were reported. The majority of the calls to poison control centers came from healthcare facilities (83%). The most common route of exposure was ingestion. Most cases were men (437, 81%, 95% CI 77.7% - 84.3%). The median age was 21 (IQR 18-29). Most exposures were acute. Three hundred thirty-seven (63%) were reported to have a major or moderate clinical effect. The most common clinical manifestations reported were hallucinations (35%), tachycardia (34%), agitation (34%), hypertension (16%), mydriasis (13%) and vomiting (6%). Benzodiazepines were commonly given (30%). There were 28 cases in the series who required endotracheal intubation (5%). Four cases were reported to have had a cardiac arrest and 7 a respiratory arrest. Twelve cases had a seizure. Reports of exposures called to poison centers appeared to increase during this period based on annual estimates. Three fatalities were reported.

Conclusions

Ayahuasca use appears to be rising in the United States based on calls to poison control centers. While most use is reported to be safe and well tolerated, with possible beneficial effects, serious and life threatening adverse manifestations are possible. Most of the exposures reported to poison control centers were young people, more likely to be men and already in a healthcare facility. Further research, which includes comprehensive drug testing, will be needed to better identify the risks and effects of ayahuasca use.

     

Human Exposures to N,N-diethyl-m-toluamide insect repellents reported to the American Association of Poison Control Centers 1993-1997

This study analyzed 20,764 exposures involving insect repellants containing N,N-diethyl-m-toluamide (DEET) that were reported to poison control centers from 1993 to 1997. Nearly 70% of the cases reported no symptoms related to the exposure. The occurrence of symptoms was related to the route of exposure, with the highest rates associated with ocular exposures, followed by inhalation, multiple exposure routes, dermal, and ingestion. Two deaths were reported, one in a 26-year-old male and one in a 34-year-old female, both following a dermal exposure. Twenty-six subjects experienced major effects. The greatest number of reported exposures involved infants and children, but this group experienced lower rates of adverse effects than teens or adults. There was no clear relationship between DEET concentration and presence or severity of clinical effects. For the cases reported to poison control centers and included in this analysis, the risk of serious medical effects for labeled use of insect repellants containing N,N-diethyl-m-toluamide appears to be low.     

Ingestions of Hydrocodone,Carisoprodol, and Alprazolam in Combination Reported to Texas Poison Centers

ABSTRACT

The combination of hydrocodone, carisoprodol, and alprazolam is subject to abuse. Ingestions of this drug combination reported to Texas poison centers during 1998–2009 were identified (totaling 1,295 cases) and the distribution of ingestions by selected factors was determined. The number of cases increased from 0 in 1998 to 200 in 2007, and then decreased to 132 in 2009. The counties in eastern and southeastern Texas accounted for 80.9% of the cases. Of the patients, 57.3% were women and 94.6% were age 20 or older. Suspected attempted suicide accounted for 59.3% of the cases and intentional misuse or abuse for 27.3%.     

Clinical Effects of Exposure to DPP-4 Inhibitors as Reported to the National Poison Data System

DPP-4 inhibitors (sitagliptin, saxagliptin, and linagliptin) are approved for the treatment of diabetes. They are considered safe due to their hyperglycemia dependent mechanism of action. We examined all isolated exposures to DPP-4 inhibitors reported to the National Poison Database System since 2006 to determine if significant toxicity occurs after exposure with attention to pediatric and intentional overdoses. NPDS data regarding DPP-4 ingestions in all age groups between January 2006 and March 2013 was collected. Cases were reviewed, and the following inclusion criteria applied: (1) reported ingestion of a DPP-4 inhibitor and (2) known clinical outcome. Exclusion criteria included the following: (1) exposure to more than a single substance, (2) no known outcome, and (3) clinical outcome judged to be unrelated to the exposure. One thousand four hundred seventy-six cases were reviewed while 826 were excluded. Of 650 included cases, 562 developed no clinical effects. Mild effects were noted in 77. There were no deaths. Moderate/major effect cases were investigated: two medication-naive nondiabetic individuals with accidental exposures developed clinically significant hypoglycemia requiring treatment. One diabetic patient on a DPP-4 inhibitor developed prolonged hypoglycemia requiring admission and continuous exogenous dextrose. Of 650 included exposures to DPP-4 inhibitors, 639 (98.3%) had either no or minor clinical effects. Three resulted in clinically significant hypoglycemia requiring intervention. None of the moderate or major clinical outcomes were the result of intentional overdoses for the purpose of self-injury. No exploratory ingestions resulted in moderate or major effects. Based on this data, exposure to DPP-4 inhibitors may rarely result in clinically significant hypoglycemia.     

Clinical Marine Toxicology: A European Perspective for Clinical Toxicologists and Poison Centers

Clinical marine toxicology is a rapidly changing area. Many of the new discoveries reported every year in Europe involve ecological disturbances—including global warming—that have induced modifications in the chorology, behavior, and toxicity of many species of venomous or poisonous aquatic life including algae, ascidians, fish and shellfish. These changes have raised a number of public issues associated, e.g., poisoning after ingestion of contaminated seafood, envenomation by fish stings, and exposure to harmful microorganism blooms. The purpose of this review of medical and scientific literature in marine toxicology is to highlight the growing challenges induced by ecological disturbances that confront clinical toxicologists during the everyday job in the European Poison Centers.     

Overdoses with Aripiprazole: Signs,Symptoms and Outcome in 239 Exposures Reported to the Danish Poison Information Centre

The aim of this study was to characterize the clinical signs and symptoms of exposures to aripiprazole overdoses. We retrospectively identified all aripiprazole exposures reported to the Danish Poison Information Centre (DPIC) from June 2007 to May 2015. Information concerning demographics, ingested dose and symptoms was extracted from the DPIC database and medical records. Information on death and admission to hospital was obtained from Danish national registers. We analysed 239 cases, 86 concerning single‐drug exposures to aripiprazole, and 153 cases where aripiprazole had been taken with at least one other substance (mixed‐drug). The median ingested aripiprazole dose was 105 mg (IQR: 50‐1680 mg) in the single‐drug exposure group and 120 mg (IQR: 60‐225 mg) in the mixed‐drug exposure group . The most commonly reported symptom was light sedation, reported in 63% of the single‐drug group and 50% of the mixed‐drug exposure group. There were no malignant arrhythmias or ECG abnormalities after single‐drug exposures. No deaths were recorded in relation to the intake. We found a long‐term mortality rate of 13 deaths per 1000 person‐years (95% CI: 7; 23 per 1000 person‐years), which is significantly higher than in an age‐ and gender‐matched background population. In conclusion, we found that aripiprazole overdoses had few and mild symptoms predominantly related to the sedative properties. We detected a benign cardiovascular safety profile and no new safety concerns. Our findings may support an increased threshold of 300 mg for hospital admission after a single‐drug exposure with aripiprazole and symptoms not worse than light sedation.     

The role of Poison Control Centers in radiation accidents

In the days after the nuclear reactor accident at Chernobyl (USSR) in April 1986, the Dutch Poison Control Center had to answer questions concerning possible health effects caused by (over)exposure to ionizing radiation. These questions were similar to questions asked regarding exposure to toxic agents after chemical accidents. It is obvious that the experience and practical approach of a Poison Control Center in handling toxicological problems can be used in problems concerning ionizing radiation.     

Characterization of US poison centers: a 1998 survey conducted by the American Association of Poison Control Centers

A 1998 survey of all 73 US poison centers, including 52 certified centers and 21 noncertified centers, is presented. Despite a continued decline of the number of poison centers operating in the US, the volume of calls has steadily increased. In 1997 these centers handled 3.65 million telephone consultations, including 2,475,010 human poison exposure cases, 134,646 animal poison exposures, and 1,036,148 information calls. Nearly the entire US population had access to a poison center (99.9%), although only 78.5% of the US population was served by a certified center. Certified poison centers handled 83.6% of human poison exposure cases reported to US poison centers. Calls to certified centers were twice as likely to be handled by staff who were certified as specialists in poison information. On average, poison center utilization was 9.2 human exposure consultations/1,000 population. Total national poison center expenses approached $81 million. The average cost/human exposure case was $33.30 in certified centers, a substantial savings when compared with the alternative of emergency department management. State governments provided the single largest source of funding. Poison center funding remains unstable, with 41% of centers reporting a possible or definite budget reduction anticipated in the next budget year. In the past 5 y, 47.9% of centers faced threat of closure. Center certification and increased public education activity, especially the distribution of poison prevention materials and number of media contacts, were associated with greater utilization of the poison center in the region served.     

A Retrospective Review of Supratherapeutic Modafinil Exposures

Modafinil is a non-amphetamine wakefulness-promoting agent used for the treatment of various sleep disorders characterized by excessive daytime sleepiness. There is little information in the medical literature with respect to supratherapeutic doses of this medication. We performed a retrospective review of the California Poison Control System database for all cases of single-substance ingestion of modafinil with follow-up to a known outcome for the time period 1998–2008. Data collected included age, gender, dose ingested, clinical effects, and medical outcome. There were a total of 87 patients, 53 (61%) of which were female. Patient ages ranged from 1.25 to 72 years with a mean of 30 years; 17 (20%) patients were aged 6 years or less. Thirty-three (38%) were intentional overdoses. Most commonly reported effects were tachycardia (n = 23), agitation (n = 14), anxiety (n = 11), headache (n = 8), hypertension (n = 6), dystonia/tremor (n = 6), and dizziness (n = 5). Forty-nine patients (56%) were managed at home, and 38 (44%) were managed in a healthcare setting. Therapies administered included activated charcoal (n = 8), benzodiazepines (n = 7), antihistamines (n = 2), intravenous fluids (n = 2), haloperidol (n = 2), and beta-blockers (n = 1). Effects were classified as none (n = 22), minor (n = 54), and moderate (n = 11). No major effects and no deaths occurred. Effects of modafinil overdose appear to be mild in most cases, with tachycardia and CNS symptoms predominating. Clinically significant effects requiring treatment occurred in a small number of patients.     

A Review of 29 Incidents Involving 4-Aminopyridine in Non-target Species Reported to the ASPCA Animal Poison Control Center

4-Aminopyridine (4-AP) is an avicide used in products that are approved by the Environmental Protection Agency (EPA) to control populations of various birds. Pharmaceutical 4-AP is also used in humans to treat neural and muscular dysfunctions associated with multiple sclerosis. Although strict restrictions for its use are in place, exposures to 4-AP bait by non-target species still occur. Twenty-nine exposures of 4-AP bait involving non-target species were identified and retrieved from the ASPCA Animal Poison Control Center medical record database. Canines were the most commonly exposed (86 %) species followed by felines (10 %). The highest frequency of exposures was reported from Colorado (22 %). Most commonly reported clinical signs in canines were tremors, hypersalivation, seizures, tachycardia, and ataxia. The onset time of signs ranged from 5 to 300 min with an average of 89 min. Clinical signs lasted from 15 to 84 h with an average of 37 h. Patient outcome was known in six cases; one dog died 4 h after the exposure and five made full recovery with supportive care. Treatment of five surviving patients included administration of activated charcoal, use of anticonvulsants and muscle relaxants like diazepam and methocarbamol, and intravenous fluids. Diagnosis of 4-AP toxicosis can be supported by testing the gastric contents of the exposed patient. Due to the rapid absorption, samples need to be collected and frozen/chilled promptly. For successful patient outcome, treatment must be implemented quickly after an exposure.     

Human exposure to banned pesticides reported to the French Poison Control Centers: 2012–2016

In 2008, 30 active substances from plant protection products were banned from marketing in France. Nevertheless, the French Poison Control Centers continue to see cases of poisoning caused by these active substances that are no longer approved. The aim of this study was to describe the characteristics of the reported cases in mainland France and in overseas French territories, over the period 2012–2016. A total of 408 cases of human exposure were reported during the study period. The most commonly reported substances were dichlorvos (24.8%, n = 108), paraquat (23.8%, n = 97), aldicarb (14.7%, n = 60), diuron (9.6%, n = 39), dinocap (5.1%, n = 21), methomyl (4.2%, n = 17), carbofuran (3.9%, n = 16), anthraquinone (2.9%, n = 12) and carbendazim (2.7%, n = 11). The number of cases of intoxication dropped sharply between 2012 (n = 119) and 2016 (n = 47), except in the overseas French territories. Among the 72 serious cases (severe or life-threatening or with a fatal outcome), the most common substances involved were paraquat (n = 34), aldicarb (n = 24) and carbofuran (n = 7). This study suggests persistent use of carbamate insecticides, the existence of illegal imports of dichlorvos or paraquat-based products, and the use of certain banned fungicides in the professional agricultural sector. Information and collection campaigns are therefore essential after the withdrawal of marketing authorization for the plant protection products.