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The case of a 58 year old woman on maintenance lithium therapy who developed an acute organic brain syndrome is reported. The patient subsequently showed evidence of persistent brain damage. It is suggested that lithium toxicity was precipitated by electrolyte disturbances possibly caused by self medication with a diuretic, where serum levels of lithium were an unreliable measure of impending toxicity.
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The main actions of benzodiazepines (hypnotic, anxiolytic, anticonvulsant, myorelaxant and amnesic) confer a therapeutic value in a wide range of conditions. Rational use requires consideration of the large differences in potency and elimination rates between different benzodiazepines, as well as the requirements of individual patients. As hypnotics, benzodiazepines are mainly indicated for transient or short term insomnia, for which prescriptions should if possible be limited to a few days, occasional or intermittent use, or courses not exceeding 2 weeks. Temazepam, loprazolam and lormetazepam, which have a medium duration of action are suitable. Diazepam is also effective in single or intermittent dosage. Potent, short-acting benzodiazepines such as triazolam appear to carry greater risks of adverse effects. As anxiolytics, benzodiazepines should generally be used in conjunction with other measures (psychological treatments, antidepressants, other drugs) although such measures have a slower onset of action. Indications for benzodiazepines include acute stress reactions, episodic anxiety, fluctuations in generalised anxiety, and as initial treatment for severe panic and agoraphobia. Diazepam is usually the drug of choice, given in single doses, very short (1 to 7 days) or short (2 to 4 weeks) courses, and only rarely for longer term treatment. Alprazolam has been widely used, particularly in the US, but is not recommended in the UK, especially for long term use. Benzodiazepines also have uses in epilepsy (diazepam, clonazepam, clobazam), anaesthesia (midazolam), some motor disorders and occasionally in acute psychoses. The major clinical advantages of benzodiazepines are high efficacy, rapid onset of action and low toxicity. Adverse effects include psychomotor impairment, especially in the elderly, and occasionally paradoxical excitement. With long term use, tolerance, dependence and withdrawal effects can become major disadvantages. Unwanted effects can largely be prevented by keeping dosages minimal and courses short (ideally 4 weeks maximum), and by careful patient selection. Long term prescription is occasionally required for certain patients.
The clinical and laboratory toxic findings of ninety-four patients receiving systemic isotretinoin therapy for cystic acne are listed. A comparison of the toxicity for two different dosage schedules is made. Coexistent diseases such as ulcerative colitis, manic depression psychoses, Gilbert's disease and cluster headaches are unaffected by this systemic medication.
Major causes of drug-induced psychoses include cocaine, amphetamines, phencyclidine, cannabinoids, LSD, mescaline, the so-called designer drugs, anticholinergic compounds, and steroids. Most drug-induced psychoses are managed with general supportive measures, reassurance, minimizing patient stimulation, and benzodiazepines as needed; however, specific antidotes such as physostigmine for anticholinergic poisoning or urinary acidification to enhance excretion of amphetamines or phencyclidine may be indicated in some patients. Any patient with a drug-induced psychosis must be evaluated carefully for evidence of other toxic effects of the drug in question.
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Substance abuse and hypertension are an important health concern, especially in adolescent and young adults presenting with elevated blood pressure and associated cardiovascular conditions. Illicit drugs including cocaine, marijuana, amphetamines, and methylenedioxymethamphetamine remain potential sources of acute or newly diagnosed hypertension. Cocaine is a powerful vasoconstrictor clearly related to hypertensive crises, myocardial infarction, arrhythmias, sudden death, strokes, and seizures, although not a definite cause of chronic hypertension. Potential therapies for cocaine induced hypertension and vasoconstriction include nitroglycerin, alpha-blockade combined alpha-à -blockade, and calcium channel blockers. The use of à -blockers alone should be avoided because of possible paradoxical rise in blood pressure including slight increases in systolic and diastolic blood pressure. Amphetamines and the newly abused 3,4-methylenedioxymethamphetamine are powerful sympathetic stimulants which may mimic the action of cocaine. Ecstasy, or 3,4-methylenedioxymethamphetamine, has additional severe psychiatric effects and should be considered in psychoses, panic disorders, and attempted suicide with new onset hypertension. The treatment approaches to 3,4-methylenedioxymethamphetamine toxicity needs further investigation. (c)2000 by Le Jacq Communications, Inc.
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