I had the opportunity to attend the North American Congress of Clinical Toxicology (NACCT), the annual meeting of the American Academy of Clinical Toxicology (AACT) held in Boston, Massachusetts September 12-16, 2016. Besides attending some awesome educational sessions related to clinical toxicology, I also had the chance to meet and connect with friends and acquaintances, old and new, from within the #FOAMtox community, which always proves to be a great experience.
I served as “ghost” tweeter behind the @ALiEMconf Twitter account, and shared clinical pearls from the meeting that are worth knowing and/or further exploration for the #FOAMed community. Among those that I shared from the account as well as my own personal Twitter account, listed below are my top 10 favorite pearls that I gained from the conference:
- Stimulant-induced hyperthermia is a combination of both heat production through the action of uncoupling proteins and decreased heat dissipation through vasoconstriction. For those interested in learning more about the effects of temperature on toxicological emergencies, the journal Temperature dedicated a whole issue on this topic a few years ago. Bonus: It’s open access (#FOAMtox for the win).
- As an acute phase reactant, low serum iron concentrations may be a risk factor for neuroleptic malignant syndrome. There are have been a number of publications on the topic, including this recent article, and this manifestation may lead to a reduction in the overall number of available dopamine receptors, predisposing patients to this toxicological emergency. This theory may warrant further exploration, but the hypothesis is somewhat compelling.
- Opioid-induced hyperalgesia may be more important than opioid tolerance in those patients on chronic maintenance therapy with opioid analgesics. Lewis Nelson (@LNelsonMD) busted the myth of the association between opioid tolerance and exacerbation of pain, and this eye-opener of an article authored by the folks from @UMassTox provides a great overview of this concept (ditto #FOAMtox).
- Ciraparantag is yet another agent that may be on the horizon for the reversal of anticoagulants. Also known by code name PER977, this is yet another agent currently under preliminary investigation for the reversal of coagulopathy secondary to unfractionated heparin, low molecular weight heparin, direct thrombin inhibitors, and factor Xa inhibitors – essentially the mother of all antidotes for anticoagulant-induced bleeding. It will be interesting to observe what happens in the landscape of reversal agents for life-threatening bleeding in the coming years should it be approved, as idarucizumab is currently available on the market for dabigatran-induced bleeding and andexanet alfa was recently denied approval by the Food and Drug Administration pending further evaluation. This article provides a good overview on what we know thus far about ciraparantag as well as these other reversal agents.
- Ketamine may be administered intranasally for analgesia and procedural sedation. Yes, for those of you who have a special place in your heart for the many uses of ketamine for patients in the emergency department, this may be a new route of administration to explore in such patient populations. As presented by Dr. Renee Petzel Gimbar (@theereneepetzel), doses of ketamine as high as 9 mg/kg administered intranasally have been evaluated in pediatric patients for procedural sedation. For analgesia, doses ranging between 0.5 and 1 mg/kg of ketamine given via the intranasal route may be an option.
*BONUS* Trick of the Trade: Bear in mind that with the different concentrations of ketamine that exist, it may be reasonable to utilize the 100 mg/mL concentration to minimize the volume necessary for intranasal use. This article provides some other practical considerations of intranasal administration of medications in both the pre-hospital and emergency department settings.
- Dynorphin plays an essential role in the development of neuroaddiction. Dynorphin is a molecule that serves as a ligand for the kappa opioid receptor and upon binding, it decreases the release of dopamine. In patients who chronically abuse alcohol, opioids, and stimulants, the expression of dynorphin increases, leading to subsequent drug withdrawal and a negative affect state. As our understanding of the activities of this ligand continues to develop, kappa opioid receptors may prove to be a future target in managing neuroaddiction.
- Abuse-deterrent formulations are not all that desirable in mitigating the opioid abuse epidemic. As much as this seems to be an ideal mechanism in reducing the potential for abuse, abuse-deterrent formulations of opioid analgesics may be associated with more harm than good. The FDA has issued guidance to the pharmaceutical industry as to what should be constituted within the manufacturing and labeling of such agents, but recent studies as this one have demonstrated that despite these agents being on the market, the abuse of opioid analgesics is still rampant. Post-marketing studies and assessment of patients who are on these analgesics is somewhat problematic, but some suggest that heroin use has become increasingly popular since introduction of these formulations, and the rate of opioid overdose continues to be on the rise.
- (Almost) any medication that can be administered intravenously can be administered via the intraosseous route. When in a bind for access in critical situations, the intraosseous route may be reasonable and feasible. This post from Emergency Medicine PharmD reviews several classes of medications that may be given via the intraosseous route.
- We do not know much about the implications of toxicological complications and dosing of antidotes in the setting of obesity. This point was raised in the discussion of antidotes in both of the cases presented at the AACT acute and intensive care symposium. This article provides a solid start to those who are interested in learning more about this topic, and may even serve as a stepping stone for future research in this area.
- The pharmaceutical industry is wrong about the reality of addiction to opioids, and it is all because of a five-sentence editorial published a long time ago. In both of their presentations on the various nuances of the opioid abuse epidemic, Drs. David Juurlink (@DavidJuurlink) and Lewis Nelson highlighted this editorial published by the New England Journal of Medicine in 1980 that has been cited repeatedly in industry-sponsored medical literature, providing a false sense of security about the safety of opioid analgesics among prescribers. As Dr. Juurlink highlighted in his discussion of the opioid abuse epidemic in North America, in order to undo years of perpetuation of this myth, “de-education” is required; perhaps it will even take a new generation of prescribers to be educated on the realities of opioid analgesics as early on as during the graduate medical education curriculum.
For those readers who desire more clinical pearls from the conference, search #NACCT16 on Twitter for other pearls shared by live and remote attendees alike.
Nadia Awad (@Nadia_EMPharmD) blogs at Emergency Medicine PharmD
The PharmERToxGuy 
@point 8: with regard to the ‘almost’ what cannot be given i.o.?
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Thank you for your comment. Here is Nadia’s reply:
Nearly all medications can be administered intravenously can theoretically be effectively administered via the intraosseous (IO) route. One medication where IO administration is somewhat problematic is adenosine. There is some literature demonstrating the effectiveness of adenosine via the IO route in conversion of supraventricular tachycardia to normal sinus rhythm (PMID: 8193689 and 8780485), but one recently published case series in pediatric patients suggests that IO may not be the most efficient route for administration of adenosine as a means to achieve therapeutic response (PMID: 22217885).
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Thanks for the reply. It’s my understanding that tibial i.o.’s were used in the cases reported in that last article. Theoretically humeral i.o.’s might get adenosine fast enough in the central circulation. Do you know if there’s any experience in adenosine via humeral i.o.?
René
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I’m not aware of any published experience with humeral adenosine administration. This is the one drug where I think IV access would be more likely to be effective, even if the IO access is close to the heart. If IV access is not attainable right away, electricity for unstable SVT or a CCB or BB for stable SVT would probably be better. That being said, it may be worth spending the time getting the IV for stable SVT so as not to discomfort a responsive patient.
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