Pharmacology - Toxicities and side effects

Atropine > pralidoxime

Physostigmine, control hyperthermia

Atropine, glucagon

Penicillamine, trientine

Nitrate + thiosulfate, hydroxocobalamin

Clinical features:- Initially hemorrhagic gastroenteritis, shock symptoms- In case patient survives: symptom-free interval afer 6 hours- Causes dark-colored stools- 1-2 days later: Risk of renal and liver failure, unconsciousness, and respiratory depression Diagnostics: - Anion gap metabolic acidosis- Radiopaque pills on abdominal x-ray Treatment:- Antidote: Deferoxamine- Whole bowel irrigation

Sources of exposure:- Battery manufacturing, metallurgy, corrosion inhibition- Gun range- Tableware containing lead Risk factors:- Home built before 1978- Pica or mouthing behaviors (eg, infants, developmental delay)- Sibling with lead poisoning- Low socioeconomic status- Immigrant or international adoptee Clinical features:- May be asymptomatic- Abdominal pain/constipation- Cognitive impairment/behavioral problems- Encephalopathy- Paralysis of the radial or peroneal nerve (wrist/foot drop)- Symptoms of anemia- Kidneys: Nephropathy, renal cell carcinoma- Purple-bluish line on the gums (lead line or Burton line) Management:- Obtain a venous sample (if screening performed by capillary sample)- Environmental surveillance (identify & remove lead sources)- Notify public health department- Nutritional counseling- Chelation therapy if lead level ≥ 45 µg/dL (children) or ≥ 50/80 µg/dL (symptomatic/asymptomatic adults)→ Oral succimer with/without IV/IM EDTA

Dimercaprol, succimer

Fomepizole > ethanol, dialysis Methanol ingestion:- Visual blurring, central scotomata- Afferent pupillary defect- Altered mentation- High osmolar gap, increased anion gap metabolic acidosis Ethylene glycol ingestion:- Flank pain- Hematuria, oliguria- Cranial nerve palsies, tetany- Calcium oxalate crystals in urine

Methylene blue, vitamine C (reducing agent)

NaHCO3 (alkalinize urine), dialysis

NaHCO3 (stabilizes cardiac cell membrane)

- Cocaine- Amphetamines- Sumatriptan- Ergot alkaloids

- Nitrates- Vancomycin- Adenosine- Niacin- Ca2+ channel blockers- Echinocandins Red man syndrome – rate-dependent infusion reaction to vancomycin causing widespread pruritic erythema. Manage with diphenhydramine, slower infusion rate.

- Anthracyclins (eg, doxorubicin, daunorubicin) - Prevent with dexrazoxane

Agents that prolong QT interval:- Antiarrhythmics class Ia, III- Antibiotics (eg, macrolides)- Antipsychotics (eg, haloperidol)- Antidepressants (eg, TCAs)- Antiemetics (eg, ondansetron)

- Lithium- Demeclocycline (semisynthetic tetracycline derivative)

- Tacrolimus- Protease inhibitors- Niacin- HCTZ- Corticosteroids

- Lithium- Amiodarone

- Lithium- Amiodarone- Sulfonamides

- Carbamazepine- Cyclophosphamie- SSRIs

- Macrolides (eg, erythromycin)

- Acamprosate (to treat alcohol dependence)- Antidiabetic agents (acarbose, metformin, pramlintide)- Colchicine- Cholinesterase inhibitors - Lipid-lowering agents (eg, ezetimibe, orlistat)- Macrolides (eg, erythromycin)- Quinidine- SSRIs

- Acetaminophen- Valproic acid- Halothane- Amanita phalloides (death cap mushroom)

- Rifampin- Isoniazid- Pyrazinamide- Statins- Fibrates

- Didanosine (NRTI)- Corticosteroids- Alcohol- Valproic acid- Azathioprine- Diuretics (furosemide, HCTZ)

- Bisphosphonates- Ferrous sulfate- NSAIDs- Potassium chloride- Tetracyclines

- Ampicillin- Cephalosporins- Clindamycin- Fluoroquinolones

- Clozapine- Carbamazepine- Propylthiouracil- Methimazole- Colchicine- Ganciclovir

- Carbamazepine- Methimazole- Propylthiouracil- NSAIDs- Benzene- Chloramphenicol

- Penicillin- Methyldopa- Cephalosporins

- Allopurinol- Anticonvulsants- Antibiotics- Sulfa drugs DRESS is a potentially fatal delayed hypersensitivity reaction. Latency period (2-8 weeks) followed by fever, morbilliform skin rash, and frequent multiorgan involvement.- Treatment: withdrawal of offending drug, corticosteroids

- Isoniazid- Sulfonamides- Dapsone- Primaquine- Aspirin- Ibuprofen- Nitrofurantoin

- Hydroxyurea- Phenytoin- Methotrexate- Sulfa drugs

- Heparin- Vancomycin- Linezolid

- Combined oral contraceptives- Hormone replacement therapy- SERMs (eg, tamoxifen, raloxifene, clomiphene)

- Phenytoin- Hydralazine- α-methyldopa- Isoniazid- Sulfa drugs- Procainamide- Etanercept

- Protease inhibitors- Glucocorticoids

- Cyclosporine- Phenytoin- Ca2+ channel blockers

- Pyrazinamide- Thiazides- Furosemide- Niacin- Cyclosporine

- Statins- Fibrates- Niacin- Colchicine- Daptomycin- Hydroxychloroquine- Interferon-α- Penicillamine- Glucocorticoids

- Corticosteroids- Depot medroxyprogesterone acetate- GnRH agonists- Aromatase inhibitors- Anticonvulsants- Heparin- PPIs

- Anti-epileptic drugs (especially lamotrigine)- Allopurinol- Sulfa drugs- Penicillin

Tetracyclines

Quinidine, quinine - Can present with tinnitus, hearing/vision loss, psychosis, and cognitive impairment

- Antipsychotics- Metoclopramide- Reserpine (VMAT inhibitor)

- Phenytoin - Vincristine

- Vitamin A- Tetracyclines- Growth hormones

- Buproprion- Isoniazid (vitamin B6 deficiency)- Imipenem/cilastatin- Tramadol- Enflurane

- Topiramate (blurred vision/diplopia, haloes)- Digoxin (yellow-tinged vision)- Isoniazid (optic neuropathy/color vision changes)- Vigabatrin (bilateral visual field defects)- PDE-5 inhibitors (blue-tinged vision)- Ethambutol (color vision changes)