Post on 28-Dec-2015
transcript
Ephedrine Withdrawal Causes Severe Psychiatric Symptoms:
A Case Report
Gene Makela, Pharm.D., BCPP
Kelly Slear
Marcella Hoyland
Kelly SlearMarcella Hoyland
Pharmaceutical Investigations course, West Virginia University
School of Pharmacy
The Case 64-year-old woman long history of depression abruptly increased symptoms of depression
and suicidal ideation with a plan to shoot herself with a gun
difficulty sleeping very low energy decreased appetite, energy, and concentration language and memory intact
The Case judgment and insight poor some signs of paranoia: during the interview she
reported “my family wants to get rid of me” auditory hallucinations had returned recently: she
heard voices of her great aunt and uncle telling her she was worthless, no good, and she should have died when she was born
major depressive disorder with psychotic features was diagnosed
Beck Depression Inventory (BDI) 63
Medications on Admission
mirtazepine 30mg daily olanzapine 20mg daily levothyroxine 0.88mg daily conjugated estrogen 0.625mg daily calcium carbonate 600mg twice daily compliant with therapy, had been stable
Pharmacist Intervention
pharmacist faculty member with student conducted detailed medication history with following findings: patient was taking eight Xenadrine capsules
daily as a weight loss product for the past three to four months
she reported that she took this product until two days before admission to the hospital
at that time, on the advice of her daughter, she abruptly discontinued the Xenadrine
Components of Xenedrine®
• Pantothenic acid 20mg
• Bitter orange - standardized to 2.5mg synephrine (similar to phenylephrine)
• Ma Huang (ephedra) - standardized to 10mg ephedrine
• Guarana extract (100mg caffeine)
• Ginger root 25mg
• White willow bark (15mg salicin)
• L-tyrosine, L-carnitine, Magnesium phosphate, Deanol (choline precursor).
• Note: normal dose is 2 capsules daily **
Bitter Orange
Citrus aurantium Adrenergic amines
Synephrine and octopamine (structurally similar to epinephrine)
Hordenine Tyramine Methyltyramine
Background Common adverse effects of ephedrine reported to FDA by
consumers included elevated blood pressure, tachycardia, muscle injury, psychosis, and memory loss
FDA mandates rule in 1997 requiring manufactures of supplements containing ephedrine that products be labeled with information about risks and dangers
FDA requires stronger labeling cautions in 2003: “ephedrine has a significant risk of illness or injury to the consumer”
FDA creates new Adverse Event Reporting System (CAERS) in 2003 to enable both health care providers and consumers to more easily report adverse events from dietary supplements
In February, 2004, the FDA acts to ban ephedra-containing products
Resolution mirtazepine dosage increased to 45mg at bedtime over the next several days depression symptoms
and psychosis cleared without further intervention BDI 54 after 2 days
on the day of discharge, seven days after admission, the patient reported feeling much better
no suicidal thoughts or auditory hallucinations hopeful about the future
discharge diagnoses included major depressive disorder, recurrent, improving, Xenadrine abuse, and Xenadrine withdrawal, resolving
Whatever happened toEphedrine Products?
2008 internet search… Ephedra products still available many new products marketed using
bitter orange as a substitute for MaHuang
Advertisement for ephBURN25
“this product is made from the old ephedra like the old lipodrene – smell the pills you’ll agree”
one capsule: MaHuang extract 8% Dark (25mg) Caffeine 200mg Other ingredients Dose: 1 capsule twice daily
http://www.worldclassnutrition.com/eph1.html
Is Ephedrine Legal?
May be you ask yourself how we are still selling ephedrine after the ephedra ban on A ugust 21,2006. The answer is very simple.
Ephedrine HCL is not Ephedra. Ephedra for weight loss has been banned. Ephedrine HCL is thedrug with ephedrine and it is used as a bronchodilator.
Although ephedra diet pills are banned, it is legal to sell remaining stocks of ephedra dietpills.
We bought remaining inventory from our d istributors. Ephedra Products are highly effectiveweight loss supplements and have helped millions slim down to achieve their goals with propernutrition plan and using recommended dosage. We have a select amount and they will be gon eshortly as they are heavily demanded.
http://www.buyvasoproephedrine.com/is-ephedrine-legal.html
Xenadrine RFA-1 is a registered trademark of Cytodyne Technologies Superdrine RX-10 is aregistered trademark of American Generic Labs, LLC
http://www.worldclassnutrition.com/superdrine.html
Considerations abrupt discontinuation of a stimulant taken for a long
period of time may lead to depressive symptomatology In this unique case, however, a depressed patient stable
on medications was thrown into severe depression with psychosis and suicidality as a result of the abrupt withdrawal of a non-prescription dietary supplement used for weight loss
despite combined antidepressant (mirtazepine) and antipsychotic (olanzapine) treatment, discontinuation of a non-prescription weight loss product was sufficient to acutely de-stabilize this patient’s condition
Results / Conclusions
abrupt discontinuation of non-prescription stimulant medication may cause severe depressive symptomatology, even in a patient whose depression had been adequately controlled with prescription medication
detailed medication history important in clarifying cause of hospitalization, helpful in defining the appropriate course of treatment.
What Would Have Happened if: There was no pharmacist intervention?…
possible: delayed or incorrect diagnosis higher doses of prescribed medication…
potential adverse effects addition of other medication to stabilize patient
…potential drug interactions prolonged hospitalization
To Take Home
Psychiatric pharmacists can facilitate accurate diagnoses by conducting medication histories… Resultant pharmacotherapeutic approaches may
minimize length of stay for patients**
Current availability of ephedrine…need for awareness
Questions ???