<i>Notes from the Field:</i> Outbreak of Severe Illness Linked to the Vitamin K Antagonist Brodifacoum and Use of Synthetic Cannabinoids — Illinois, March–April 2018

Moritz, Erin D.; Austin, Connie; Wahl, Michael; DesLauriers, Carol; Navon, Livia; Walblay, Kelly; Hendrickson, Monica; Phillips, Angie; Kerins, Janna L.; Pennington, Audrey F.; Lavery, Amy M.; Zahran, Tharwat El; Kauerauf, Judy; Yip, Luke; Thomas, Jerry; Layden, Jennifer E.

doi:10.15585/mmwr.mm6721a4

Cited by 51 publications

(49 citation statements)

References 3 publications

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“…In March 2018, the Illinois Department of Public Health (IDPH) was informed by the state poison center of 4 patients presenting to local emergency departments over a 2-week period with unexplained bleeding and markedly elevated international normalized ratios (INRs; 5 to .20; normal INR, ,1.1). 1 None of the patients reported accidental exposure to rodenticides or receipt of anticoagulants. Further investigation by the IDPH revealed that all patients reported synthetic cannabinoid use in the previous 3 days.…”

Section: Introductionmentioning

confidence: 94%

“…The demographics and clinical features of patients with cannabinoidassociated coagulopathy have recently been described. 1,26 The case series by Moritz et al 1 describes 155 patients (76 confirmed and 79 probable) evaluated by the IDPH; Kelkar et al 26 describe a subset of this larger cohort (n 5 34), who presented to 1 medical center and underwent additional evaluation. In the IDPH series, patients presenting with coagulopathy were young (median age, 32 years; range, 18-65 years) and predominantly men (74%) and white (52%).…”

Section: Clinical Features Of Cannabinoidassociated Coagulopathymentioning

confidence: 99%

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Bad weed: synthetic cannabinoid–associated coagulopathy

Arepally

Ortel

2019

Blood

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Recent multistate outbreaks of coagulopathy caused by brodifacoum-tainted synthetic cannabinoids or “fake weed” highlight the public health impact of long-acting anticoagulant rodenticides (LAARs). Patients presenting with this syndrome have had recent exposure to synthetic cannabinoids, evidence of isolated vitamin K antagonism with or without bleeding, and detectable levels of brodifacoum and other LAARs in circulation. This article will provide information on synthetic cannabinoids, LAARs, and coagulopathic manifestations arising from use of adulterated synthetic cannabinoids and their management.

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Section: Introductionmentioning

confidence: 94%

Section: Clinical Features Of Cannabinoidassociated Coagulopathymentioning

confidence: 99%

Bad weed: synthetic cannabinoid–associated coagulopathy

Arepally

Ortel

2019

Blood

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“…A recent outbreak of life-threatening coagulopathy and bleeding in Illinois [ 7 , 8 ] and other States was determined to be due to inhalation of synthetic cannibinoids (SCs). Several case reports have described the occurrence of intracranial bleeding following SC use.…”

Section: Should Cytochrome P450 Inducers Be Used To Increase Long-actmentioning

confidence: 99%

Should Cytochrome P450 Inducers be Used to Accelerate Clearance of Brodifacoum from Poisoned Patients?

et al. 2019

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A recent multi-state outbreak of life-threatening bleeding following inhalation of synthetic cannabinoids has been attributed to contamination with the long-acting anticoagulant rodenticide (LAAR) brodifacoum, a second-generation, highly potent, long-acting derivative of the commonly used blood thinner warfarin. While long-term treatment with high-dose vitamin K1 restores coagulation, it does not affect brodifacoum metabolism or clearance, and, consequently, brodifacoum remains in the human body for several months, thereby predisposing to risk of bleeding recurrence and development of coagulation-independent injury in extrahepatic tissues and fetuses. This has prompted the evaluation of pharmacological measures that accelerate brodifacoum clearance from poisoned patients. Since the induction of certain cytochrome P450 (CYP) enzymes accelerates warfarin metabolism, using CYP inducers, such as phenobarbital, to accelerate brodifacoum clearance seems plausible. However, unlike warfarin, brodifacoum does not undergo significant metabolism in the liver, nor have the effects of phenobarbital on vitamin K1 metabolism been previously determined. In addition, the safety of phenobarbital in brodifacoum-poisoned patients has not been established. Therefore, we propose that CYP inducers should not be used to accelerate the clearance of brodifacoum from poisoned patients, but that alternative approaches such as reducing enterohepatic recirculation of brodifacoum, or using lipid emulsions to scavenge brodifacoum throughout the body, be considered.

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“…First, a clear case definition needs to be specified by the investigators. Often an unexpected event-such as the recent US outbreak of synthetic cannabinoids containing long-acting anticoagulant rodenticides [11] or implementation of extra-corporeal membrane oxygenation as a novel treatment modality for severe multi-organ poisoning [12]-warrants deliberate study and dissemination of findings. Investigators must start with an easily understandable case definition.…”

mentioning

confidence: 99%