DOCSLIB.ORG

Drug-Induced Hyperpigmentation: Review and Case Series

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text

Load more

J Am Board Fam Med: first published as 10.3122/jabfm.2019.04.180212 on 12 July 2019. Downloaded from CLINICAL REVIEW Drug-Induced Hyperpigmentation: Review and Case Series Rosa M. Gime´nez García, MD, and Sergio Carrasco Molina, MIR Background: Hyperpigmentation is a common dermatologic problem that may have substantial impact on the patient, since it affects the appearance and quality of life, and may influence treatment adher- ence. There are few studies of drug-induced hyperpigmentation. Methods: We studied drug-induced hyperpigmentation in patients attending an outpatient dermatol- ogy clinic in the Western Area of Valladolid (Spain) from August 1, 2017 to April 20, 2018. Results: The incidence of drug-induced hyperpigmentation was 1.31% in patients attending a first dermatology consultation in the study period. Of the 16 patients, 8 were taking more than 1 drug. The most frequent drugs identified were nonsteroidal anti-inflammatory agents (25%), antihypertensive agents (18.75%), antimalarials (12.5%), antibiotics, antineoplastic agents, psychoactive agents, simva- statin, allopurinol, amiodarone and mucolytic (6.25% each). Hyperpigmentation was found in the mu- cosa in 25% of patients and in photograph-exposed areas in 37.5%. Discussion: Diagnosing drug-induced hyperpigmentation is a dermatologic challenge. A differential diagnosis with hyperpigmentation caused by endocrine and metabolic disorders, the most closely-re- lated disorders to drug-induced hyperpigmentation, and with hyperpigmentation of idiopathic origin, should be conducted. Drug-induced hyperpigmentation is a relatively frequent reason for consultation, especially in polypharmacy patients. The sample may have been biased as many patients receiving treat- ments frequently associated with drug-induced hyperpigmentation, such as antineoplastic drugs, are copyright. diagnosed and treated by other specialties, such as oncologists. Conclusion: Family physicians and specialists should consider drugs as a cause of hyperpigmenta- tion to facilitate the correct diagnosis and treatment. (J Am Board Fam Med 2019;32:628–638.) Keywords: Dermatology, Hyperpigmentation, Pharmacology, Practice Management, Spain Hyperpigmentation is a common dermatologic to dermal deposition of endogenous or exogenous http://www.jabfm.org/ problem that may have substantial impact on the pigments such as hemosiderin, iron or heavy met- patient, since it affects the appearance and quality als. Hyperpigmentation is a frequent reason for of life. Hyperpigmentation is defined as the dark- consultation, particularly in patients with darker ening of the skin’s natural color, usually due to an skin.1 increase in melanin deposition (hypermelanosis) in The color of human skin is mainly determined the epidermis or dermis, an increase in chro- by 2 types of melanin; eumelanin and pheomelanin. on 24 September 2021 by guest. Protected mophores of nonmelanic origin (hyperchromia), or Other important determinants of skin color are the number of blood capillaries it contains, the chro- mophores it may possess, such as carotenoids or lycopenes, and the collagen content of the dermis.2 This article was externally peer reviewed. Submitted 26 July 2018; revised 24 February 2019; ac- The melanocytes, located in the epidermal basal cepted 26 February 2019. layer, produce melanin by biosynthesis in the or- From the Department of Medicine, Dermatology and Tox- icology, Faculty of Medicine, Valladolid, Spain (RMGG); De- ganelles called melanosomes, which are transported partment of Dermatology, Hospital Universitario Rio to the periphery and transferred, thanks to their Hortega, Valladolid, Spain (SCM). Funding: none. dendritic extensions, from the melanocytes to the Conflict of interest: none declared. surrounding keratinocytes. Each melanocyte inter- Corresponding author: Rosa Gimenez Garcia, MD, Calle Carabela 115, Boecillo, 47151 Valladolid, Spain (E-Mail: acts with more or less 36 keratinocytes, in what is [email protected]͒. known as the melano-epidermal unit.2 628 JABFM July–August 2019 Vol. 32 No. 4 http://www.jabfm.org J Am Board Fam Med: first published as 10.3122/jabfm.2019.04.180212 on 12 July 2019. Downloaded from Hypermelanosis in the epidermis is caused by an especially when the chronology between taking the increase in melanin in the basal and suprabasal drug and the onset of hyperpigmentation is un- layer of the skin associated with a normal or ele- known. The true incidence of drug-induced hyper- vated amount of melanocytes. Dermal hypermela- pigmentation is very difficult to estimate because nosis may be due to various mechanisms, such as not all cases are recorded or reported for pharma- the transfer of melanin from the epidermis to the cological study, and there are no large-scale pro- dermis and its accumulation within the mel- spective studies. The aims of this study were to anophages (pigmentary incontinence), and is com- review drug-induced hyperpigmentation, to carry monly observed in inflammatory skin diseases af- out a study of patients with drug-induced hyper- fecting the basal layer and/or the dermal-epidermal pigmentation attending a dermatology clinic for junction. Another cause is dermal deposition of the first time, and to summarize the drugs known to endogenous and exogenous pigments, such as he- cause hyperpigmentation.4,11 mosiderin or iron, or a local or systemic exposure to heavy metals (silver, gold, mercury). Metals such Review as iron can stimulate melanogenesis, as observed in Antibiotics patients with hemochromatosis.3 Tetracycline-induced hyperpigmentation is mainly Drug-induced hyperpigmentation is estimated due to minocycline and, less frequently, doxycy- to account for 10% to 20% of cases of acquired cline or other first-generation tetracyclines. Mino- hyperpigmentation,4 although these figures are cycline-induced hyperpigmentation may occur in probably highly speculative, as most cases are idio- up to 15% of patients, especially those receiving pathic, especially in elderly patients. The incidence prolonged treatment. Three types of hyperpigmen- of drug-induced hyperpigmentation varies accord- tation induced by minocycline have been described: ing to the drug involved, ranging from isolated hyperpigmentation type 1 (blue-black hyperpig- cases to 25% of patients receiving a treatment.5 mentation in the site of previous inflammation or Some drugs are associated with the development of scarring) produced by pigment granules, probably copyright. hyperpigmentation of the skin or mucous mem- iron chelates of minocycline; type 2 hyperpigmen- branes.4–6 tation (gray-blue hyperpigmentation that affects Clinically, the discoloration that appears on the normal skin, especially the legs) is probably due to skin is acquired and usually grows slowly and minocycline metabolites in the skin; type 3 hyper- spreads insidiously, worsening over months or pigmentation (dirty skin syndrome in areas exposed years after treatment initiation. Some topograph- to the sun) in which microscopic studies finds ical distributions are more characteristic of drug- higher amounts of melanin in the macrophages of http://www.jabfm.org/ induced hyperpigmentation, such as areas ex- the epidermis and dermis (Figure 1). This probably posed to the sun, and may include the mucous also applies to type-4 hyperpigmentation (hyper- membranes, especially the oral and conjunctive pigmentation of scars).11,12 membranes. Some characteristics of the distribu- Isolated cases of hyperpigmentation due to levo- tion are very suggestive of specific drugs, such as floxacin have been described, although in isolated the flagellated hyperpigmentation found when cases and long-term treatment regimens, or due to cytostatic treatments containing bleomycin are polymyxin, an antibiotic used primarily for resis- on 24 September 2021 by guest. Protected used.7 The color acquired due to hyperpigmen- tance against Gram-negative germs, or to tigecy- tation is not specific for drug-induced hyperpig- cline, a new glycylcycline antibiotic.13–16. mentation. However, drug-induced hyperpig- Overdoses of rifampicin may induce reddish hy- mentation frequently presents as an unusual perpigmentation,17 whereas isoniazid may some- purple, with color tones such as red-yellow (clo- times produce purplish hyperpigmentation associ- fazimine),8 or slate or blue-gray (psychotropic ated with pellagra.18 Dapsone may also trigger drugs, amiodarone, or metals).9,10 hyperpigmentation aggravated by the sun.19 The diagnosis of hyperpigmentation is compli- cated due to the lack of direct evidence or inade- Antihypertensives quate information. Many elderly patients are re- Despite their widespread use, very few cases of ceiving polypharmacy, making it more difficult to hyperpigmentation induced by antihypertensive associate a pigment change with a specific drug, drugs have been reported. doi: 10.3122/jabfm.2019.04.180212 Drug-Induced Hyperpigmentation 629 J Am Board Fam Med: first published as 10.3122/jabfm.2019.04.180212 on 12 July 2019. Downloaded from Figure 1. Minocycline induced facial Figure 2. Hyperpigmentation due to lercanidipine. hyperpygmentation. ropathic pain. Changes in hair color and curly hair Angiotensin II receptor antagonists block the have been described after use as have changes in binding of angiotensin II to its receptor subtype 1. nail pigmentation30,31 and 1 case of labial hyper- Increased use of these antihypertensive agents has pigmentation.32 led to more visits to pharmacovigilance centers, but Ten percent of patients taking phenytoin de- copyright.
Recommended publications
  • The Pharmacology of Amiodarone and Digoxin As Antiarrhythmic Agents

    The Pharmacology of Amiodarone and Digoxin As Antiarrhythmic Agents

    Part I Anaesthesia Refresher Course – 2017 University of Cape Town The Pharmacology of Amiodarone and Digoxin as Antiarrhythmic Agents Dr Adri Vorster UCT Department of Anaesthesia & Perioperative Medicine The heart contains pacemaker, conduction and contractile tissue. Cardiac arrhythmias are caused by either enhancement or depression of cardiac action potential generation by pacemaker cells, or by abnormal conduction of the action potential. The pharmacological treatment of arrhythmias aims to achieve restoration of a normal rhythm and rate. The resting membrane potential of myocytes is around -90 mV, with the inside of the membrane more negative than the outside. The main extracellular ions are Na+ and Cl−, with K+ the main intracellular ion. The cardiac action potential involves a change in voltage across the cell membrane of myocytes, caused by movement of charged ions across the membrane. This voltage change is triggered by pacemaker cells. The action potential is divided into 5 phases (figure 1). Phase 0: Rapid depolarisation Duration < 2ms Threshold potential must be reached (-70 mV) for propagation to occur Rapid positive charge achieved as a result of increased Na+ conductance through voltage-gated Na+ channels in the cell membrane Phase 1: Partial repolarisation Closure of Na+ channels K+ channels open and close, resulting in brief outflow of K+ and a more negative membrane potential Phase 2: Plateau Duration up to 150 ms Absolute refractory period – prevents further depolarisation and myocardial tetany Result of Ca++ influx
  • Dermatology Eponyms – Sign –Lexicon (P)

    Dermatology Eponyms – Sign –Lexicon (P)

    2XU'HUPDWRORJ\2QOLQH Historical Article Dermatology Eponyms – sign –Lexicon (P)� Part 2 Piotr Brzezin´ ski1,2, Masaru Tanaka3, Husein Husein-ElAhmed4, Marco Castori5, Fatou Barro/Traoré6, Satish Kashiram Punshi7, Anca Chiriac8,9 1Department of Dermatology, 6th Military Support Unit, Ustka, Poland, 2Institute of Biology and Environmental Protection, Department of Cosmetology, Pomeranian Academy, Slupsk, Poland, 3Department of Dermatology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan, 4Department of Dermatology, San Cecilio University Hospital, Granada, Spain, 5Medical Genetics, Department of Experimental Medicine, Sapienza - University of Rome, San Camillo-Forlanini Hospital, Rome, Italy, 6Department of Dermatology-Venerology, Yalgado Ouédraogo Teaching Hospital Center (CHU-YO), Ouagadougou, Burkina Faso, 7Consultant in Skin Dieseases, VD, Leprosy & Leucoderma, Rajkamal Chowk, Amravati – 444 601, India, 8Department of Dermatology, Nicolina Medical Center, Iasi, Romania, 9Department of Dermato-Physiology, Apollonia University Iasi, Strada Muzicii nr 2, Iasi-700399, Romania Corresponding author: Piotr Brzezin′ski, MD PhD, E-mail: [email protected] ABSTRACT Eponyms are used almost daily in the clinical practice of dermatology. And yet, information about the person behind the eponyms is difficult to find. Indeed, who is? What is this person’s nationality? Is this person alive or dead? How can one find the paper in which this person first described the disease? Eponyms are used to describe not only disease, but also clinical signs, surgical procedures, staining techniques, pharmacological formulations, and even pieces of equipment. In this article we present the symptoms starting with (P) and other. The symptoms and their synonyms, and those who have described this symptom or phenomenon. Key words: Eponyms; Skin diseases; Sign; Phenomenon Port-Light Nose sign or tylosis palmoplantaris is widely related with the onset of squamous cell carcinoma of the esophagus.
  • An Approach to the Patient with a Dry Mouth

    An Approach to the Patient with a Dry Mouth

    MedicineToday 2014; 15(4): 30-37 PEER REVIEWED FEATURE 2 CPD POINTS An approach to the patient with a dry mouth Key points • The subjective complaint of ELHAM AFLAKI MD; TAHEREH ERFANI MD; NICHOLAS MANOLIOS MB BS(Hons), PhD, MD, FRACP, FRCPA; xerostomia needs to be MARK SCHIFTER FFD, RCSI(Oral Med), FRACDS(Oral Med) differentiated from true salivary hypofunction. Dry mouth is a common and disabling problem. After exclusion of treatable • Salivary hypofunction can significantly reduce quality causes, treatment is symptomatic to prevent the consequences of salivary of life through its adverse hypofunction, such as tooth decay and infection of the oral mucosa. effects on taste, mastication, swallowing, cleansing of the erostomia, or the subjective feeling of neuropathic-induced orofacial dysaesthesia) mouth, killing of microbes a dry mouth, is a common complaint. and psychological and psychiatric disorders, and speech. It is often a consequence of salivary such as anxiety and depression. • Salivary hypofunction is a hypofunction (hyposalivation), in substantive risk factor for X which there is objective evidence of reduced NORMAL SALIVA PRODUCTION dental caries, oral mucosal salivary output or qualitative changes in saliva. Under normal physiological conditions, the disease and infection, Typically, patients complain of oral dryness salivary glands produce 1000 to 1500 mL of particularly oral candidiasis. only when salivary secretion is reduced by more saliva daily as an ultrafiltrate from the circu- • Patients should be than half.1 As saliva has a crucial role in taste lating plasma. Therefore, simple dehydration investigated for contributory perception, mastication, swallowing, cleansing reduces saliva production. The parotid glands and underlying causes, of the mouth, killing of microbes and speech, are the major source of serous saliva (60 to 65% which include drugs and abnormalities in saliva production can signif- of total saliva volume), producing the stimu- rheumatological diseases.
  • PEMD-91-12BR Off-Label Drugs: Initial Results of a National Survey

    PEMD-91-12BR Off-Label Drugs: Initial Results of a National Survey

    11 1; -- __...._-----. ^.-- ______ -..._._ _.__ - _........ - t Ji Jo United States General Accounting Office Washington, D.C. 20648 Program Evaluation and Methodology Division B-242851 February 25,199l The Honorable Edward M. Kennedy Chairman, Committee on Labor and Human Resources United States Senate Dear Mr. Chairman: In September 1989, you asked us to conduct a study on reimbursement denials by health insurers for off-label drug use. As you know, the Food and Drug Administration designates the specific clinical indications for which a drug has been proven effective on a label insert for each approved drug, “Off-label” drug use occurs when physicians prescribe a drug for clinical indications other than those listed on the label. In response to your request, we surveyed a nationally representative sample of oncologists to determine: . the prevalence of off-label use of anticancer drugs by oncologists and how use varies by clinical, demographic, and geographic factors; l the extent to which third-party payers (for example, Medicare intermediaries, private health insurers) are denying payment for such use; and l whether the policies of third-party payers are influencing the treatment of cancer patients. We randomly selected 1,470 members of the American Society of Clinical Oncologists and sent them our survey in March 1990. The sam- pling was structured to ensure that our results would be generalizable both to the nation and to the 11 states with the largest number of oncologists. Our response rate was 56 percent, and a comparison of respondents to nonrespondents shows no noteworthy differences between the two groups.
  • WITHOUTUS010307409B2 (12 ) United States Patent ( 10 ) Patent No

    WITHOUTUS010307409B2 (12 ) United States Patent ( 10 ) Patent No

    WITHOUTUS010307409B2 (12 ) United States Patent ( 10 ) Patent No. : US 10 , 307 ,409 B2 Chase et al. (45 ) Date of Patent: Jun . 4 , 2019 ( 54 ) MUSCARINIC COMBINATIONS AND THEIR (52 ) U . S . CI. USE FOR COMBATING CPC . .. .. A61K 31/ 4439 (2013 . 01 ) ; A61K 9 /0056 HYPOCHOLINERGIC DISORDERS OF THE (2013 . 01 ) ; A61K 9 / 7023 ( 2013 . 01 ) ; A61K CENTRAL NERVOUS SYSTEM 31 / 166 ( 2013 . 01 ) ; A61K 31 / 216 ( 2013 . 01 ) ; A61K 31 /4178 ( 2013 .01 ) ; A61K 31/ 439 (71 ) Applicant: Chase Pharmaceuticals Corporation , ( 2013 .01 ) ; A61K 31 /44 (2013 . 01 ) ; A61K Washington , DC (US ) 31/ 454 (2013 .01 ) ; A61K 31/ 4725 ( 2013 .01 ) ; A61K 31 /517 (2013 .01 ) ; A61K 45 / 06 ( 72 ) Inventors : Thomas N . Chase , Washington , DC (2013 . 01 ) (US ) ; Kathleen E . Clarence -Smith , ( 58 ) Field of Classification Search Washington , DC (US ) CPC .. A61K 31/ 167 ; A61K 31/ 216 ; A61K 31/ 439 ; A61K 31 /454 ; A61K 31 /4439 ; A61K (73 ) Assignee : Chase Pharmaceuticals Corporation , 31 /4175 ; A61K 31 /4725 Washington , DC (US ) See application file for complete search history. ( * ) Notice : Subject to any disclaimer, the term of this (56 ) References Cited patent is extended or adjusted under 35 U . S . C . 154 (b ) by 0 days . U . S . PATENT DOCUMENTS 5 ,534 ,520 A 7 / 1996 Fisher et al. ( 21) Appl . No. : 15 /260 , 996 2008 /0306103 Al 12 /2008 Fisher et al. 2011/ 0021503 A1* 1/ 2011 Chase . .. A61K 31/ 27 ( 22 ) Filed : Sep . 9 , 2016 514 / 215 2011/ 0071135 A1 * 3 / 2011 Chase . .. .. .. A61K 31/ 166 (65 ) Prior Publication Data 514 / 215 2011 /0245294 Al 10 / 2011 Paborji et al.
  • Prescribing Trends of Antihistamines in the Outpatient Setting in Al-Kharj

    Prescribing Trends of Antihistamines in the Outpatient Setting in Al-Kharj

    Prescribing Trends of Antihistamines in the Outpatient Setting in Al-Kharj Nehad J. Ahmed1*, Menshawy A. Menshawy2 1Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia, 2Department of Medicinal chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia Abstract Aim: This study aims to illustrate the prescribing trends of antihistamines in the outpatient setting in Al-Kharj. Materials and Methods: This is a retrospective study that included the evaluation of antihistamines in the outpatient setting in a public hospital in Al-Kharj. The data were collected from the pharmacy-based computer system. Results: The total number of prescriptions that included antihistamines was 799. Most of the prescribed ORIGINAL ARTICLE ARTICLE ORIGINAL antihistamines were first-generation sedating antihistamines (chlorphenamine and diphenhydramine) (66.33%). About 63.20% of the prescribed antihistamines included chlorpheniramine followed by cetirizine (19.27%) and loratadine (14.39%). Conclusion: Antihistamines were prescribed commonly in the outpatient setting mainly first-generation sedating antihistamines. It is recommended to increase the awareness of health- care providers about the efficacy and the side effects of antihistamines and to encourage them to use these agents wisely. Key words: Antihistamines, outpatient, prescribing, trends INTRODUCTION In addition, antihistamines have been classified as sedating antihistamines (first-generation antihistamines) and non- ntihistamines are used in the sedating antihistamines (second-generation antihistamines).[4] management of allergic conditions. Sedating antihistamines include chlorphenamine, clemastine, They are useful for treating the itching hydroxyzine, alimemazine, cyproheptadine, promethazine, A [1] and ketotifen.[4] Non-sedating antihistamines include that results from the release of histamine.
  • Guide to Policy & Practice Questions

    Guide to Policy & Practice Questions

    OREGON BOARD OF CHIROPRACTIC EXAMINERS GUIDE TO POLICY & PRACTICE QUESTIONS 530 Center St NE, suite 620 Salem, OR 97301 (503) 378-5816 [email protected] Updated/Adopted: 9/17/2020 TABLE OF CONTENTS SECTION I ............................................................................................................................................................................................... 6 DEVICES, PROCEDURES, AND SUBSTANCES ............................................................................................................................... 6 DEVICES ................................................................................................................................................................ 6 BAX 3000 AND SIMILAR DEVICES................................................................................................................................................ 6 BIOPTRON LIGHT THERAPY ........................................................................................................................................................ 6 CPAP MACHINE, ORDERING ....................................................................................................................................................... 6 CTD MARK I MULTI-TORSION TRACTION DEVICE................................................................................................................... 6 DYNATRON 2000 ...........................................................................................................................................................................
  • Acebutolol Hydrochloride Eq 200 Mg Base, Capsule, Oral, 100 0.4612 B Eq 400 Mg Base, Capsule, Oral, 100 0.6713 B

    Acebutolol Hydrochloride Eq 200 Mg Base, Capsule, Oral, 100 0.4612 B Eq 400 Mg Base, Capsule, Oral, 100 0.6713 B

    TRANSMITTAL NO. 37 - FEDERAL UPPER LIMIT DRUG LIST NOVEMBER 20, 2001 The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and Section 1927(e) of the Social Security Act, as amended by OBRA 1993. Payment for multiple source drugs identified and listed below must not exceed, in the aggregate, payment levels determined by applying to each drug entity a reasonable dispensing fee (established by the State and specified in the State plan), plus an amount based on the limit per unit which CMS has determined to be equal to 150 percent applied to the lowest price listed (in package sizes of 100 units, unless otherwise noted) in any of the published compendia of cost information of drugs. The listing is based on data current as of April 2001 from First Data Bank (Blue Book), Medi- Span, and the Red Book. This list does not reference the commonly known brand names. However, the brand names are included in the electronic FUL listing provided to the state agencies. The FUL price list and electronic listing are available at http://www.cms.hhs.gov/Reimbursement/05_FederalUpperLimits.asp. In accordance with current policy, Federal financial participation will not be provided for any drug on the FUL listing for which the FDA has issued a notice of an opportunity for a hearing as a result of the Drug Efficacy Study and Implementation (DESI) program, and which has been found to be a less than effective or is identical, related or similar (IRS) to the DESI drug. The DESI drug is identified by the Food and Drug Administration or reported by the drug manufacturer for purposes of the Medicaid drug rebate program.
  • Tricyclic Antidepressant

    Tricyclic Antidepressant

    Princess Margaret Hospital for Children Emergency Department Guideline PAEDIATRIC ACUTE CARE GUIDELINE Poisoning – Tricyclic Antidepressant Scope (Staff): All Emergency Department Clinicians Scope (Area): Emergency Department This document should be read in conjunction with this DISCLAIMER http://kidshealthwa.com/about/disclaimer/ Poisoning – Tricyclic Antidepressant This guideline is a general approach to tricyclic antidepressant poisoning. For specific details please contact Poisons Information: 131126 or refer to the Toxicology Handbook. Agents: Amitriptyline Clomipramine Dothiepin Doxepin Imipramine Nortriptyline Trimipramine Background Tricyclic antidepressants (TCAs) act on a variety of receptors whose actions include: Noradrenaline reuptake inhibition Central and peripheral anticholinergic effect Fast sodium channel blockade in the myocardium Peripheral alpha1-adrenergic receptor blockade The life threatening effects of acute tricyclic antidepressant (TCA) overdose are: Rapid onset of coma Seizures Cardiac dysrhythmias Page 1 of 6 Emergency Department Guideline Poisoning – Tricyclic Antidepressant Hypotension and central and peripheral anticholinergic effects may also be seen Risk Assessment Most acute accidental paediatric exposures do not result in life threatening toxicity A 10kg child can develop life threatening poisoning with the ingestion of a single tablet (e.g. 150mg amitriptyline) Patients who ingest a large dose of TCA usually develop evidence of intoxication within 2-4 hours, and always within 6 hours If their is suspicion
  • Cetirizine) – New Drug Approval

    Cetirizine) – New Drug Approval

    Quzyttir™ (cetirizine) – New drug approval • On October 4, 2019, the FDA approved TerSera Therapeutics’ Quzyttir (cetirizine) injection, for the treatment of acute urticaria in adults and children 6 months of age and older. — Quzyttir is not recommended in pediatric patients less than 6 years of age with impaired renal or hepatic function. • Quzyttir is the first FDA approved intravenous (IV) formulation of cetirizine. Oral formulations of cetirizine are available generically as prescription as well as well over-the-counter (OTC) (eg, Zyrtec®). — Prescription oral cetirizine is approved for perennial allergic rhinitis and chronic urticaria. — Zyrtec and other OTC products are approved for use to temporarily relieve symptoms due to hay fever or other upper respiratory allergies: runny nose, sneezing, itchy and watery eyes, and itching of the nose or throat. • The efficacy of Quzyttir was established in a randomized, active-controlled, double-blind, single-dose study in 262 adult patients with acute urticaria. Patients were treated with Quzyttir or diphenhydramine injection. The primary efficacy endpoint was the change from baseline in patient-rated pruritus score assessed 2 hours post treatment. The study was non-inferiority design with the pre-specified non- inferiority margin of 0.50 for the difference between treatment groups. — The effectiveness of Quzyttir was demonstrated to be non-inferior to the effectiveness of diphenhydramine. The mean change from baseline in patient-rated pruritus score was -1.61 and -1.50 for Quzyttir and diphenhydramine, respectively (adjusted difference: 0.06; 95% CI: - 0.28, 0.40). • The efficacy of Quzyttir for the treatment of acute urticaria down to 6 months of age is based on extrapolation of the efficacy of Quzyttir in adults with acute urticaria and supported by pharmacokinetic data with oral cetirizine hydrochloride in patients 6 months to 17 years of age.
  • Potentially Harmful Drugs in the Elderly: Beers List

    Potentially Harmful Drugs in the Elderly: Beers List

    −This Clinical Resource gives subscribers additional insight related to the Recommendations published in− March 2019 ~ Resource #350301 Potentially Harmful Drugs in the Elderly: Beers List In 1991, Dr. Mark Beers and colleagues published a methods paper describing the development of a consensus list of medicines considered to be inappropriate for long-term care facility residents.12 The “Beers list” is now in its sixth permutation.1 It is intended for use by clinicians in outpatient as well as inpatient settings (but not hospice or palliative care) to improve the care of patients 65 years of age and older.1 It includes medications that should generally be avoided in all elderly, used with caution, or used with caution or avoided in certain elderly.1 There is also a list of potentially harmful drug-drug interactions in seniors, as well as a list of medications that may need to be avoided or have their dosage reduced based on renal function.1 This information is not comprehensive; medications and interactions were chosen for inclusion based on potential harm in relation to benefit in the elderly, and availability of alternatives with a more favorable risk/benefit ratio.1 The criteria no longer address drugs to avoid in patients with seizures or insomnia because these concerns are not unique to the elderly.1 Another notable deletion is H2 blockers as a concern in dementia; evidence of cognitive impairment is weak, and long-term PPIs pose risks.1 Glimepiride has been added as a drug to avoid. Some drugs have been added with cautions (dextromethorphan/quinidine, trimethoprim/sulfamethoxazole), and some have had cautions added (rivaroxaban, tramadol, SNRIs).
  • Nurse-Led Drug Monitoring Clinic Protocol for the Use of Systemic Therapies in Dermatology for Patients

    Nurse-Led Drug Monitoring Clinic Protocol for the Use of Systemic Therapies in Dermatology for Patients

    Group arrangements: Salford Royal NHS Foundation Trust (SRFT) Pennine Acute Hospitals NHS Trust (PAT) Nurse-led drug monitoring clinic protocol for the use of systemic therapies in dermatology for patients with inflammatory dermatoses Lead Author: Dawn Lavery Dermatology Advanced Nurse Practitioner Additional author(s) N/A Division/ Department:: Dermatology, Clinical Support and Tertiary Medicine Applies to: (Please delete) Salford Royal Care Organisation Approving Committee Dermatology clinical governance committee Salford Royal Date approved: 13 February 2019 Expiry date: February 2022 Contents Contents Section Page Document summary sheet 1 Overview 2 2 Scope & Associated Documents 2 3 Background 3 4 What is new in this version? 3 5 Policy 4 Drugs monitored by nurses 4 Acitretin 7 Alitretinoin Toctino 11 Apremilast 22 Azathioprine 26 Ciclosporin 29 Dapsone 34 Fumaric Acid Esters – Fumaderm and Skilarence 36 Hydroxycarbamide 39 Hydroxychloroquine 43 Methotrexate 50 Mycophenolate moefetil 57 Nurse-led drug monitoring clinic protocol for the use of systemic therapies in dermatology for patients with inflammatory dermatoses Reference Number GSCDerm01(13) Version 3 Issue Date: 11/06/2019 Page 1 of 77 It is your responsibility to check on the intranet that this printed copy is the latest version Standards 67 6 Roles and responsibilities 67 7 Monitoring document effectiveness 67 8 Abbreviations and definitions 68 9 References 68 10 Appendices N/A 11 Document Control Information 71 12 Equality Impact Assessment (EqIA) screening tool 73 Group arrangements: Salford Royal NHS Foundation Trust (SRFT) Pennine Acute Hospitals NHS Trust (PAT) 1. Overview (What is this policy about?) The dermatology directorate specialist nurses are responsible for ensuring prescribing and monitoring for patients under their care, is in accordance with this protocol.