Serotonin syndrome due to duloxetine and tramadol use in an older patient

This case report describes a 92-year old woman presenting with acute confusion and agitation. She was initially diagnosed as having a hyperactive delirium. However, based on the presence of additional and evolving features of twitchiness, reduced coordination, palpitations and headaches, the diagnosis was re-evaluated. The clinical presentation was subsequently recognised as being that of the serotonin syndrome. In this instance, the serotonin syndrome was judged to have arisen from the concurrent use of duloxetine and tramadol. Duloxetine is an antidepressant with serotonergic properties. Tramadol is an analgesic agent with weak opiate agonist receptor effects, and also exerts reuptake inhibition of noradrenaline and serotonin. The patient’s polypharmacy was reviewed, and alongside other general supportive care measures, her symptoms and signs resolved within 48 hours. This report serves as a clinical reminder on the potential pitfalls of polypharmacy in older patients. Delirium is a common presentation in older patients, and on occasions, clearly establishing the underlying causes or risk factors may prove challenging or even elusive. The report prompts clinicians to bear in mind that the presentation and diagnosis of the serotonin syndrome requires a high index of suspicion, and that patients may present atypically. In support of pharmacovigilance reporting, two scales of causality assessment are employed in this case review. The application of these systems exemplifies their potential in promoting and enhancing objectivity when clinicians report suspected adverse drug reactions (ADRs) noted in routine clinical practice.

Capillary Electrophoresis Methods for the Determination of Tramadol: A Review

Tramadol is a widely used opioid analgesic frequently prescribed for treatment of moderate to severe, acute and chronic pain. It has a complex mechanism of action, acting both as a central opiate agonist and as a norepinephrine and serotonin reuptake inhibitor. It is a chiral substance, having two chiral centers in its structure and it is used in therapy as a racemic mixture of two of its enantiomers, (S,S)-tramadol and (R,R)-tramadol. In the last 25 years, several analytical procedures have been published in the literature for the achiral and chiral determination of tramadol from pharmaceutical formulations and biological matrices. Among these methods, capillary electrophoresis techniques have proved to be an efficient, reliable and cost-effective solution. The purpose of the present review is to provide a systematic survey to present and discuss the electrodriven methods available in the literature for the achiral and chiral analysis of tramadol.

Opiate addiction and overdose: experiences, attitudes, and appetite for community naloxone provision

BackgroundMore than 200 opiate overdose deaths occur annually in Ireland. Overdose prevention and management, including naloxone prescription, should be a priority for healthcare services. Naloxone is an effective overdose treatment and is now being considered for wider lay use.Aim To establish GPs’ views and experiences of opiate addiction, overdose care, and naloxone provision.Design and setting An anonymous postal survey to GPs affiliated with the Department of Academic General Practice, University College Dublin, Ireland.MethodA total of 714 GPs were invited to complete an anonymous postal survey. Results were compared with a parallel GP trainee survey.ResultsA total of 448/714 (62.7%) GPs responded. Approximately one-third of GPs were based in urban, rural, and mixed areas. Over 75% of GPs who responded had patients who used illicit opiates, and 25% prescribed methadone. Two-thirds of GPs were in favour of increased naloxone availability in the community; almost one-third would take part in such a scheme. A higher proportion of GP trainees had used naloxone to treat opiate overdose than qualified GPs. In addition, a higher proportion of GP trainees were willing to be involved in naloxone distribution than qualified GPs. Intranasal naloxone was much preferred to single (P<0.001) or multiple dose (P<0.001) intramuscular naloxone. Few GPs objected to wider naloxone availability, with 66.1% (n = 292) being in favour.ConclusionGPs report extensive contact with people who have opiate use disorders but provide limited opiate agonist treatment. They support wider availability of naloxone and would participate in its expansion. Development and evaluation of an implementation strategy to support GP-based distribution is urgently needed.