It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Disclosures It's Over the Counter So It • Nancy Denke DNP, ACNP-BC, FNP-BC, Must Be Safe FAEN has no financial relationships with commercial interests to disclose • Any unlabeled/unapproved uses of drugs or products referenced will be disclosed Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Objectives Introduction • Discuss the general approach to the "poisoned" OTC analgesic overexposure is common in patient the U.S. due to ease of availability and lack of • Evaluate the risks, benefits, and safe use of provider oversight common analgesics • Explain reasons for patient-related medication errors, strategies to prevent overdose, symptoms of overdose, and strategies to treat acute toxicity Prompt recognition & tx may prevent morbidity/mortality R/T analgesic OD The Approach to the Ingestion Patient • Patients with substance abuse problems are common in general medical practices • No age or socioeconomic group is not touched • Initial dx & tx of addiction problems are often done by the PCP before referral • You can be a powerful influence for getting a patient to accept tx, especially when you Gummin D.D., et. al. (2018). 2017 Annual report of the American association of are empathic without being judgmental poison control centers’ National Poison data system (NPDS): 35th annual report. Clinical Toxicology, 56(12), 1-200. 1 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Sedative Intoxication Clinical PEARLS Physical Symptoms Psychiatric Symptoms Slurred speech Inappropriate Behavior Incoordination Mood Liability Unsteady Gait Impaired Judgement Nystagmus Impaired Social Functioning Decreased Reflexes Impaired Occupational Functioning Impaired Attention or Memory Stupor or Coma Symptom Intoxication Withdrawal Stimulants Cardiac- Heart Rate Tachy, CP, arrhythmias Normal BP Normal or increased Normal Temp Chills/hot flashes Normal GI/Wt N & V, weight loss Increased appetite Psychomotor Agitation Decreased Muscular Weakness Normal Neurological Seizure Vivid dreams, hypersomnia Affect Euphoric to blunted Fatigued Vigilance Hyper Normal Emotion Irritable, angry Dysphoric Reaction to others Sensitive, paranoid Normal Judgement Impaired Normal for the patient Social Impaired Normal for the patient Now Lets Talk About What Can You Can By at Your Local Pharmacy or “Drugstore” 2 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Why Buy Alcohol When You It Affects the CNS Can Get This!!! • Might stagger when they walk, speak The vanilla extract without making sense, or seem sleepy is usually 35 • They might vomit because alcohol can percent or 70 proof. irritate the stomach • Breathing and HR might decrease, along Vodka is usually 70 with BP or 80 percent proof It’s Everywhere!! Tylenol Extended Release = Tylenol Emergency Room APAP Fun Facts! Pharmacokinetics • #1 drug for overdoses in the world! Absorption • Found in >600 different Rx and OTC med, • Rapidly absorbed from the GI tract including: • Peak concentration occurs between 60 -120 min – pain relievers, fever reducers, sleep aids • Peak plasma levels occur within 4 hours cough, cold, and allergy medicines Metabolism • Listed in ingredients as acetaminophen, • Occurs via several pathways in the liver APAP or actem! Excreted by the kidneys • Max dose 4000 mg/day Half Life • Acetaminophen Awareness Coalition- •2 hr https://www.knowyourdose.org/common- • With liver dysfunction, may ↑to 17 hr medicines/ 3 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN How Do I Know If My Patient Rumack-Matthew Nomogram Took a Toxic Dose? Factors involved in predicting hepatotoxicity • total quantity ingested • time from ingestion to treatment 150 mg/dl at • age of the patient hihours is • alcoholism 4 possibly toxic • enzyme inducing medications Serum concentration related to Rumack nomogram • Adult threshold for liver damage is 150 mg/kg • Children under 10 appear to be more resistant When to Treat? Why NAC (Acetadote)? 90% to 95% of acetaminophen metabolism takes place in the liver Acetaminophen Case Study The Labs • MR is a 21 yo female with chronic abdominal pain due to gastroparesis. • Recently she began having increases pain dtthldue to the placemen tfGtb5t of a G tube 5 week s ago • To deal with the pain she has taken 120 tabs of Percocet • 4 infusions of NAC 4 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Treatment Treatment 4 hour post-ingestion level- one time only! 4 hour post ingestion APAP level • levels drawn earlier may be erroneous • levels may be accurate out to 18 hours • levels drawn earlier may be • Labs erroneou s – Baseline CBC • levels may be accurate out to 18 – Creatinine, BUN, blood sugar, electrolytes hours – PT/INR, AST, ALT • elevations typically seen 24-36 hrs post ingestion N-acetylcysteine APAP Summary Lovingly known as NAC • APAP may overwhelm the livers stores of • If APAP level plots above the possible risk glutathione. line administer N-acetylcysteine (NAC) • Rise in liver enzymes may occur, which reflects • If NAC is indicated, full regimen should be the hepatic toxicity followed • Timely administration of NAC may protect the – 2 or 3 bag infusion patient from hepatic damage • NAC loading dose is 140 mg/kg • Therapy should be initiated as soon as possible, but NAC is beneficial at any time • NAC maintenance doses are 70 mg/kg • If APAP levels can not be obtained, assume a toxic dose has been ingested, initiate NAC, and continue until regimen complete What Should I Remember? Diphenhydramine • APAP present in polypharmacy ingestions – OTC meds to treat insomnia, allergic disease, & cold symptoms. – Consequential risk of unintended dip hen hy dram ine OD in c hildren • No symptoms may be present…screen • 150 mcg/ml at 4 hours is a “treat” level • Metoclopramide (Reglan) 0.1-1.0 mg/kg is very effective in controlling nausea/vomiting associated with APAP toxicity 5 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Hooked on Benadryl Can Diphenhydramine be Abused? • More than a harmless dependency • Usually not, BUT if you quit you may have – Some use as an OTC sleep aid, while others some adverse symptoms if enjoy the sedative & euphoric effects it diphenhydramine has not been taken at provides as a result of dopamine release the usual recommended dose • It’s lin ke d to s hor t-tlterm memory loss. • If ta ken fldidftitfor a prolonged period of time at a • It’s an anticholinergic larger than usual dose, there may be some symptoms of withdrawal including insomnia, irritability, picking even severe confusion Symptoms of Benadryl Diphenhydramine Case Study Withdrawal • 17 yo guy • May not be as bad as ETOH or heroin, but • Ingested entire bottle (40 tabs) Benadryl™ they are very real and need to be monitored (diphenhydramine) 50 mg • Symptoms of withdrawal include: • Mom found him acting strangely (agitated, – IidtlInsomnia and restlessness confused, with jerking and picking – Nausea and diarrhea movements) ≈ 2 hrs later & called EMS – Hot and cold sweats • No co-ingestants – Cold-like symptoms • Displaying typical anticholinergic S & S • ECG shows wide-complex tachycardia & just had a Sz Anticholinergic Initial Symptoms • Use of anticholinergics has a long hx which includes ritual, recreational & therapeutic use of Blind as a bat (dilated pupils) plants containing atropine, and scopolamine Dry as a bone • Antagonist of the histamine H1 receptor with Full as a flask (can’t urinate) anticholinergic properties Hot as a hare (or hell, or Hades) • Classic anticholinergic syndrome is a Red as a beet manifestation of competitive antagonism of Mad as a hatter (easily describable, hallucinations) acetylcholine at peripheral and central muscarinic receptors Tacky (tachycardic) as a leisure suit – Systems affected Phantom behaviors (“woolgathering”- “picking”) • CNS, & the Autonomic Nervous System (parasympathetic portion) 6 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Diphenhydramine-Induced Progression of Symptoms Symptoms & Treatment Initial peripheral parasympathetic signs and • Rhabdomyolysis symptoms (“blind as a bat, . .”) Then confusion with hallucinations and agitated •Sz delirium – benzodiazepines • MtbliMetabolic ac idiidosis – Sodium bicarb • Toxic Psychosis – ID can be difficult since its presents as delirium Eventually stupor and coma • Physostigmine Finally recovery of consciousness with paranoia Dextromethorphan (DXM) Things to Do! Popular Street Names • Obtain an ECG (to rule out prolonged • Purple drank QTc) • Lean • Administer benzodiazepines (for sz or • Sizzurp agitation) • DblDouble cup • Consider physostigmine (for altered • Skittles mental status) • Orange crush • Obtain APAP level •Dex • Consult toxicologist • Red devils •Velvet DXM • 1/10 teens has used DXM to get high – also known as “robotripping” • Dissociative effects prompt some teens to use it for anxiety- get a powerful buzz – dose for dissociative effect is around 1000mg or about 500mL of cough syrup • Many mix with ETOH or weed or opioids to intensify the effect https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3977765/?report=printable 7 It’s Over the Counter So It Must Be Safe Pre 7 Nancy Denke DNP, ACNP-BC, FNP-BC, FAEN Serotonin Syndrome • Dextromethorphan can act as a non- selective serotonin reuptake inhibitor • Important to recognize serotonin syndrome so you avoid adding another serotoninergic agent such as ondt(Zf)!dansetron (Zofran)! • Hallmark of serotonin syndrome is clonus • Treatment – Cool them – IV fluids and benzodiazepines Triple C One Teens Thoughts • Coricidin® products have high prevalence of abuse in the adolescents “After the first time I did it I just really loved – Dextromethorphan & chlorpheniramine maleate it. I would take them when I got up in the morning, before school, during school, after • Poor man’s PCP school, before I went to bed.