Loperamide-Induced Torsades de Pointes: A Case Series

Katz, Kenneth D.; Cannon, Robert D.; Cook, Matthew D.; Amaducci, Alexandra; Day, Ryan; Enyart, Joshua; Burket, Glenn A.; Porter, Lauren; Roach, Timothy; Janssen, Jennifer K.; Williams, Kelly

doi:10.1016/j.jemermed.2017.04.027

Cited by 28 publications

(16 citation statements)

References 17 publications

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“…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%

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

Teigeler

Stahura

Alimohammad

et al. 2019

Cardiovasc electrophysiol

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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.

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Section: Methodsmentioning

confidence: 91%

“…| 2621 loperamide level was significantly above the upper therapeutic range of 3.1 ng/mL in most cases. 1,2,[4][5][6][7]12,17,19,23,25,31 The median QRS duration on presentation was 160 (125-170) ms.…”

Section: Review Of Literaturementioning

confidence: 99%

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

Teigeler

Stahura

Alimohammad

et al. 2019

Cardiovasc electrophysiol

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“…For respiratory depression, data suggest naloxone should be effective . In the setting of ventricular dysrhythmias, intravenous magnesium sulfate and sodium bicarbonate have been used for successful treatment, while intravenous isoproterenol and transcutaneous or transvenous pacing have been used to manage QTc prolongation.…”

Section: Discussionmentioning

confidence: 99%

Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina

Powell

Presnell

2019

Journal of Forensic Sciences

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Loperamide is an over‐the‐counter, μ‐opioid receptor agonist commonly used as an antidiarrheal agent. Loperamide was thought to have minimal abuse potential due to its low bioavailability and limited central nervous system activity; however, there have been increasing reports of loperamide misuse in supratherapeutic doses to achieve euphoria and/or avoid opioid withdrawal. A literature review suggests a rise in loperamide abuse was inevitable, with substantial increases in reported cases over the last decade. Five fatal cases of toxic medication use where loperamide was listed as a primary or contributory cause of death were identified at the Medical University of South Carolina. The characteristic autopsy demographics and findings are described, and the mechanisms of abuse and toxicity of loperamide are reviewed. Loperamide overdoses are a growing concern from both a forensic and clinical standpoint, and the frequency of reported cases will likely increase as awareness grows within the medical and toxicological communities.

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“…There is a lack of primary literature to guide the management of TdP and ventricular arrhythmias. An extensive literature search revealed only a few case reports of lidocaine and isoproterenol being used together for patients experiencing TdP, and a single case report on the use of isoproterenol for TdP in a pregnant female [3][4][5]. Takaya, et al reported a case of donepezil-induced TdP in an 81-year-old female, refractory to magnesium and lidocaine, that was successfully treated with isoproterenol [3].…”

Section: Introductionmentioning

confidence: 99%

“…The first, a 28-year-old man, was initially responsive to IV magnesium, sodium bicarbonate, lidocaine and isoproterenol (2-10 mcg/min) but developed persistent TdP when isoproterenol was discontinued for tachyphylaxis and ultimately required a pacemaker. The second, a 39-year-old woman with TdP refractory to IV magnesium and sodium bicarbonate, was successfully treated for 4 days with IV isoproterenol titrated to HR above 100 beats per minute (bpm) [4]. Mittadodla, et al reported a case of idiopathic VF in a 32-year-old 6-week pregnant woman, refractory to IV lidocaine, metoprolol and amiodarone, that was successfully treated with isoproterenol titrated to a heart rate above 120 bpm [5].…”

Section: Introductionmentioning

confidence: 99%

Isoproterenol and Lidocaine for Recurrent Torsades de Pointes in a 32-year-old Pregnant Woman

Reachi¹,

Jenna²,

Abby³

et al. 2019

Int J Crit Care Emerg Med

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Loperamide-Induced Torsades de Pointes: A Case Series

Cited by 28 publications

References 17 publications

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

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

Loperamide as a Potential Drug of Abuse and Misuse: Fatal Overdoses at the Medical University of South Carolina

Isoproterenol and Lidocaine for Recurrent Torsades de Pointes in a 32-year-old Pregnant Woman

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