- Written by Ethan Abbott
Toxicology Literature of Note
This Canadian study looks at 6455 treatment courses with NAC and the incidence of anaphylactoid reactions. 8.2% experienced a reaction, where 75.4% were cutaneous and treated with antihistamines. Over 50% of courses were stopped before the 21 hour completion. Although not a safety study, this paper does highlight that NAC is safe to use, and its small risks are not outweighed by the benefit of preventing hepatotoxicity.
Of note, although antihistamines can be given, the real intervention would be to temporarily pause or slow down the rate of the NAC. It should not be stopped entirely and should not be withheld if the patient has another APAP overdose and requires treatment again.
Anaphylactoid reactions with NAC administration
Social media is now being recognized as an interesting means to investigate public health issues. The follow study uses Twitter to estimate prescription opioid misuse from tweets in different geographical locations. It is difficult to collect epidemiological metrics from social media, but this is a new and interesting means of research on public health.
Tox on Twitter (sorry, this one is too large to upload here)
Occasionally non-human exposures are published, and although not specifically relevant to our clinical practice, they can be interesting and add to our knowledge. The following case report describes the death of an adult Boxer (dog) after ingestion of holiday tinsel garland, due to zinc. I did a quick literature search and could not find a human study with the same exposure, but it is not that much of a stretch to consider a child munching on the Christmas tree decorations.
Toxicology in the News
Kratom, an “herbal supplement” which is being used by the public to treat opioid withdrawal has been linked to Salmonella infections. This short article discusses the use of Kratom and the new concern over bacterial contamination, highlighting the fact that the supplement industry is not regulated and is without any quality checks.
Salmonella contamination in Kratom
Before the opioid crisis, our country was plagued by methamphetamine. It is the reason we need to show ID at CVS in order to buy Sudafed. It appears that crystal meth has made a significant reappearance, and is now killing more people in Oregon than opioids. Although, in our population, always confirm what the patient means when they say that they took “meth”. At SBH, its more likely methadone, rather than methamphetamine.
Although not Tox, February 3rd was National Woman Physician Day! The following article is a history of the first woman in American to obtain a medical degree.
“It’s not easy to be a pioneer — but oh, is it fascinating!”
Elizabeth Blackwell
Toxicology Drug of the Month
Caffeine
Caffeine (1, 3, 7- trimethylxanthine) is a methylxanthine and causes the release of endogenous catecholamines, resulting in stimulation of beta 1 and 2 receptors. It is also a structural analog of adenosine and acts as an adenosine antagonist.
In overdose methylxanthines can cause nausea, and most significant acute overdoses result in severe and protracted vomiting. They are cardiac stimulants and will produce tachycardia and hypertension, even in therapeutically.
Electrolyte disturbances, particularly hypokalemia can result in dysrhythmias. Seizures are a major complication of methylxanthine toxicity.
Management includes administration of activated charcoal, which can not only decrease absorption, but also may help eliminate the toxin via “gut dialysis”. If the patient is with a normal mental status and without vomiting, a dose of 1 GRAM/kg can be offered.
Benzodiazepines can be provided for anxiety, and also help to treat the tachycardia and SVT. Adenosine is unlikely to be helpful due to the adenosine antagonism.
Significant tachycardia and hypertension, unresponsive to BZD can be treated with beta blockers, as long as the patient does not also use cocaine.