Treatment Advice on the Internet Leads to a Life-Threatening Adverse Reaction: Hypotension Associated with Niacin Overdose

Abstract

We describe a case of massive oral niacin overdose that resulted in severe persistent hypotension without the manifestation of cutaneous flushing. This case is the highest overdose of niacin reported in the literature to date and the first time severe persistent hypotension has been attributed to niacin. A 56-year-old male with a history of schizophrenia presented to the emergency department after orally ingesting 11,000 mg of niacin. The patient cited an Internet resource that recommended high-dose niacin for therapy of schizophrenia as the reason for his ingestion. He stopped his psychiatric medications several weeks prior to his niacin overdose. At presentation, the patient was alert and normothermic. His pulse was 68 beats per minute and his blood pressure was initially 92/41 mmHg. Hypotension with a blood pressure of 58/40 developed over the next few hours and persisted despite intravenous infusion of over 4 liters of normal saline. The physical exam was otherwise unremarkable, specifically without signs of an allergic reaction or cutaneous flushing. He required intravenous dopamine infusion for 12 hours to support a mean arterial blood pressure greater than 60 mmHg. Evaluation for other etiologies of hypotension was unrevealing. Serum niacin levels were 8.2 ug/ mL and 5.6 ug/mL at 48 and 96 hours post ingestion, respectively, giving an apparent T1/2 of 87 hours. Massive overdose of niacin appears to be capable of causing severe, persistent hypotension in the absence of cutaneous flushing. In this case, the ingestion of a dietary supplement based on Internet advice led to a severe adverse reaction.

Educating patients to evaluate web‐based health care information: the GATOR approach to healthy surfing

“…Adverse events related to substandard or misinterpreted web‐based health information have been well‐documented, reinforcing the premise that most patients lack the necessary tools to appropriately search, interpret and comprehend web‐based information (Hainer et al. 2000b , Ernst & Schmidt 2002, 2004 , Schmidt & Ernst 2004 , Mularski et al. 2006 , See et al.…”

Investigation of niacin on parameters of metabolism in a physiologic dose: randomized, double-blind clinical trial with three different dosages

“…There are few case reports with nicotinic acid in excessive doses up to 11 g where patients developed hypotension (Pasternak and Kolman 1991;Stephenson and Kolka 1994;Mularski et al 2006). In contrast to this, we assessed no nicotinic acid-induced effects on blood pressure and pulse in a physiological dose range.…”

Availability of prescription drugs for bipolar disorder at online pharmacies

“…Notably, 7% of the 96 online purchasers of tramadol experienced serious adverse events (life-threatening seizures) versus no seizures in the 349 who purchased tramadol with a prescription at a local pharmacy. Other examples of serious adverse reactions in patients who took self-prescribed medications from the Internet include lithium toxicity from a dietary supplement (Pauzé and Brooks, 2007), severe hypotension from high-dose niacin by a patient with schizophrenia (Mularski et al, 2006), and panic attacks from selegiline and phenylethylamine by a patient with depression (McKean et al, 2015).…”