Not your regular high: cardiac dysrhythmias caused by loperamide

Wightman, Rachel; Hoffman, Robert S.; Howland, Mary Ann; Rice, Brian; Biary, Rana; Lugassy, Daniel

doi:10.3109/15563650.2016.1159310

Cited by 41 publications

(30 citation statements)

References 6 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Because of this, the FDA released a warning in 2016 regarding its potential for negative cardiac side effects . Since the earliest case reports in 2014, several case reports have since described the various cardiac manifestations induced by loperamide abuse . While the exact mechanisms are not completely understood, the various cardiac manifestations are suspected to be due to lopermide's effects primarily on hERG/Ikr potassium channel and cardiac sodium channels, which mimic the effect of Vaughan–Williams Class III and Class IA antiarrhythmic agents, respectively .…”

Section: Discussionmentioning

confidence: 99%

“…3 Since the earliest case reports in 2014, 1 several case reports have since described the various cardiac manifestations induced by loperamide abuse. [4][5][6][7][8][9][10] While the exact mechanisms are not completely understood, the various cardiac manifestations are suspected to be due to lopermide's effects primarily on hERG/Ikr potassium channel and cardiac sodium channels, which mimic the effect of Vaughan-Williams Class III and Class IA antiarrhythmic agents, respectively. 11,12 Patients with predominantly Class III manifestations exhibit the expected QT prolongation and torsades de pointes VT, whereas predominantly Class IA manifestations exhibit QRS widening due to delayed sodium channel upstroke and monomorphic ventricular tachycardia.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Wide complex tachycardia and cardiomyopathy: What would you do?

Ahmed

Freeland

Steinberg

et al. 2018

Cardiovasc electrophysiol

View full text Add to dashboard Cite

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Wide complex tachycardia and cardiomyopathy: What would you do?

Ahmed

Freeland

Steinberg

et al. 2018

Cardiovasc electrophysiol

View full text Add to dashboard Cite

“…Loperamide overdose was not suspected initially in many cases, so a level was not sent, a barrier added to the need for sending to a reference laboratory. When obtained, the serum loperamide level was significantly above the upper therapeutic range of 3.1 ng/mL in most cases …”

Section: Methodsmentioning

confidence: 91%

“…Given the outliers in values, averages for loperamide dose, QRS duration, QTc interval, and days to clinical stability or resolution of ECG changes are presented as median (interquartile range). When the dose of loperamide ingested was a range in a given case, the median for that case was entered into the calculation for overall median dosage; for example, if the dose of loperamide was 40 to 160 mg per day, then 100 mg was the contributed value from that case to the sample median loperamide dose. If the dose or QTc duration was published as “greater than” or “at least” a given value, the given value was used; for example, Eggleston in 2015 presented a patient who ingested at least 400 mg of loperamide per day .…”

Section: Methodsmentioning

confidence: 99%

Electrocardiographic changes in loperamide toxicity: Case report and review of literature

Teigeler

Stahura

Alimohammad

et al. 2019

Cardiovasc electrophysiol

View full text Add to dashboard Cite

Introduction Loperamide, an antidiarrheal agent, is a µ‐opioid receptor agonist increasingly abused to prevent opioid withdrawal or to produce euphoric effects. At supra‐therapeutic doses, loperamide can cause cardiac toxicity due to blockade of Na and IKr channels, resulting in wide QRS rhythms, severe bradycardia, prolonged QTc, polymorphic ventricular tachycardia, cardiac arrest, and death. There are limited data on the cardiotoxic effects of high dose loperamide. Methods and Results A case report of loperamide toxicity is presented and then added to a contemporary review of the literature. In total, the presentation and management of 36 cases of loperamide cardiotoxicity are summarized. The overall median daily dose (interquartile range) of loperamide was 200 (134‐400) mg. The median QRS duration was 160 (125‐170) ms. The median QTc duration was 620 (565‐701) ms. Ventricular tachycardia was experienced by 24/36 (67%) of patients, 20 of which were specified to be polymorphic. Treatment was supportive, providing advanced cardiopulmonary life support and aggressive electrolyte repletion. Isoproterenol infusion or overdrive pacing was employed in 19/36 (53%) of cases. The median time to electrocardiogram normalization or hospital discharge, whichever came first, was 5 (3.5‐10) days. Conclusion Loperamide overdose is a toxidrome that remains underrecognized, and in patients with unexplained cardiac arrhythmias, loperamide toxicity should be suspected. Prompt recognition is critical due to the delayed recovery and high risk for life‐threatening arrhythmias.

show abstract

“…Although laboratory confirmation was only available in four cases, clinical features were consistent with previously reported cases (2-4). Optimal management of loperamide-associated cardiac toxicity is not yet clear; multiple interventions have been reported (2,4). Health care providers and public health officials should remain vigilant for loperamide abuse and report adverse events to the U.S. Food and Drug Administration's MedWatch reporting system (http://www.fda.gov/Safety/MedWatch).…”

Section: Notes From the Fieldmentioning

confidence: 99%

Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008–2016

Eggleston¹,

Marraffa²,

Stork³

et al. 2016

MMWR Morb. Mortal. Wkly. Rep.

View full text Add to dashboard Cite

Loperamide is an over-the-counter antidiarrheal with opioidreceptor agonist properties. Recommended over-the-counter doses (range = 2-8 mg daily) do not produce opioid effects in the central nervous system because of poor oral bioavailability and P-glycoprotein efflux* of the medication (1); recent reports suggest that large doses (50-300 mg) of loperamide produce euphoria, central nervous system depression, and cardiotoxicity (2-4). Abuse of loperamide for its euphoric effect or for selftreatment of opioid withdrawal is increasing (5). Cases of loperamide abuse reported to the Upstate New York Poison Center and New York City Poison Control Center were analyzed for demographic, exposure, clinical, and laboratory characteristics. Cases of intentional loperamide abuse reported to the National Poison Database System (NPDS) also were analyzed for demographic, dose, formulation, and outcome information.A New York case of loperamide abuse was defined as any call to the Upstate New York Poison Center or New York City Poison Control Center reporting intentional loperamide abuse during January 1, 2008-March 31, 2016. An NPDS loperamide abuse case was defined as any exposure reported to NPDS citing intentional loperamide abuse during January 1, 2008-March 31, 2016.Among the 22 New York loperamide abuse cases identified, 18 patients were male. Median patient age was 30 years (range = 19-48 years). Electrocardiogram abnormalities included QTc prolongation in 15 (68%) patients, QRS prolongation in nine (41%) patients, and ventricular dysrhythmia in eight (36%) patients. The average reported daily dose was 358 mg (range = 34-1,200 mg). Previous opioid abuse was reported by 15 patients, previous treatment with methadone or buprenorphine (a partial opioid agonist used to treat opioid addiction) by eight patients, and chronic abuse by 13 patients. Opioid withdrawal symptoms after cessation of loperamide were reported by nine patients. Serum loperamide concentrations were obtained from four patients and ranged from 77-210 ng/mL, representing 25-875 times the therapeutic range of 0.24-3.1 ng/mL (6).A total of 179 NPDS cases were identified, approximately half of which were reported after January 1, 2014 (Figure). Notes from the FieldAmong the 179 cases, 137 (77%) of the patients were male, the median patient age was 26 years (range = 7-87 years), and 154 (86%) were admitted to or treated in a health care facility. The average loperamide dose was 196.5 mg (range = 2-1,200 mg), and nearly all cases (95%) involved tablets or capsules. Cardiac conduction disturbances were reported in 24 (13%) patients, ventricular tachycardia or fibrillation in 16 (9%) patients, other dysrhythmias in 10 (6%) patients, and other electrocardiogram changes in five (3%) patients. Outcome was reported for 132 patients and was coded as moderate (pronounced or prolonged systemic symptoms, non-life threatening) or major (life-threatening symptoms or residual disability) for 66 patients (50%). Four (3%) deaths were reported.These cases support the reported ass...

show abstract

Not your regular high: cardiac dysrhythmias caused by loperamide

Cited by 41 publications

References 6 publications

Wide complex tachycardia and cardiomyopathy: What would you do?

Wide complex tachycardia and cardiomyopathy: What would you do?

Electrocardiographic changes in loperamide toxicity: Case report and review of literature

Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008–2016

Contact Info

Product

Resources

About