Two Cases of Statin-Induced Myopathy Caused By Induced Hypothyroidism

ObjectiveTo present information regarding the potential danger of performing levothyroxine withdrawal radioiodine scans and treatment in patients with thyroid cancer who are concurrently taking lipid-lowering agents.MethodsWe review the clinical history, serial laboratory data, and radiologic findings in 2 patients with multifocal papillary carcinoma of the thyroid.ResultsBoth study patients had substantial elevations of muscle enzymes or myopathies (or both) when they were withdrawn from levothyroxine therapy, during treatment with lipid-lowering agents, in preparation for radioiodine scanning and treatment.ConclusionExtreme caution should be exercised when levothyroxine therapy is withdrawn from patients taking lipid-lowering agents. Such patients should be monitored very closely or, when appropriate, recombinant human thyroid-stimulating hormone injections should be used rather than levothyroxine withdrawal in this setting. (Endocr Pract. 2008;14:726-731)     

Staphylococcal bacteraemia,fusidic acid,and jaundice.

Fusidic acid was used to treat 131 out of 250 patients with staphylococcal bacteraemia over 10 years. Other antimicrobial agents were given to the 119 remaining patients. Thirty-seven patients were already jaundiced before antibiotic treatment was started. Jaundice developed during treatment in 38 out of 112 patients given fusidic acid (34%) and in two out of 101 patients given other antimicrobials. The incidence of jaundice was higher in patients given fusidic acid intravenously (48%) rather than by mouth (13%). Jaundice appeared within 48 hours after the administration of fusidic acid in 93% of these cases. When the drug was stopped serum bilirubin concentrations fell to normal values within four days in those patients in whom they had been previously normal and who survived the bacteraemic episode. Fusidic acid was associated with increasing jaundice in 13 of 19 patients (68%) already jaundiced before it was given. In six out of 32 patients who developed jaundice while receiving intravenous fusidic acid serum alkaline phosphatase activity was raised suggestive of cholestatic jaundice. The mechanism in the remaining patients was unknown. Fusidic acid, particularly the intravenous preparation, in invaluable in treating severe staphylococcal infection but should be used with caution in patients with abnormal liver function. Patients receiving intravenous fusidic acid should be given the oral form of the drug as soon as their clinical condition permits.     

Minor tranquillizers in somatic disorders.

Conclusive evidence of improved outcome due to adjunctive anxiolytic therapy in some somatic conditions is lacking. However, such therapy may facilitate patient management without being "curative". The resulting improved feeling of well-being may be of value in the management of gastrointestinal disorders, migraine and myocardial infarction. Negative effects may be observed in acute respiratory conditions, especially during acute exacerbations of chronic conditions, with the administration of benzodiazepines; hence they should be used with caution. The use of these agents in treating persons with hypertension seems to be of no value and may even be detrimental. Careful evaluation of each case is desirable, and treatment should be planned with its termination in mind.     

Alterations of lithium clearance in rats by different modes of lithium administration

This study examines the effects of acute versus dietary lithium administration on proximal tubular fluid output (Vprox) and sodium clearance in 6 groups of unrestrained, conscious rats. Vprox was estimated on the basis of the renal lithium clearance. The aim was to find the mode of lithium administration which least influences the proximal and distal reabsorption of sodium. The lithium doses used resulted in serum lithium concentrations between 0.2 and 0.3 mmol/l with no difference between the groups. Acute intravenous lithium administration increased lithium clearance by 40% and sodium clearance by 109%. Administration by gastric tube increased lithium clearance by 22% and sodium clearance by 78% in comparison to dietary administration of lithium. Potassium excretion did not change by acute lithium administration. The data presented indicate that prior to measurements of lithium clearance, lithium should be administered in the diet for 2 days, since acute lithium administration, intravenously or by gastric tube, causes great changes in renal tubular reabsorption.     

Particularité des traitements anticoagulants et de leur surveillance en gériatrie

Frail elderly patients are at high risk of both thromboembolic disease and bleeding, especially those older than 80 years of age. Anticoagulants have narrow therapeutic ranges and are difficult to use to older patients because polymedication and multiple comordities are frequent in this population. To minimize the risk of haemorrhage, caution should be used when administering anti-coagulant treatment in these frail patients.     

Evidence that Phosphoinositide Metabolism in Rat Cerebral Cortex Stimulated by Pilocarpine, Physostigmine, and Pargyline In Vivo Is Not Changed by Chronic Lithium Treatment

The effect of chronic versus acute administration of lithium on receptor-linked phosphoinositide metabolism was assessed by comparing the change in the cerebral cortex levels of myo-inositol 1-phosphate in response to pilocarpine, physostigmine, or pargyline in rats. Rats were exposed to either 29 consecutive days of LiCl injections or 27 and 39 days of dietary Li2CO3, followed by injected LiCl at the end of the diet to insure a constant level of exposure to the drug. In each experiment, an acute group received a single injection of LiCl 20-24 h before they were killed. One hour before being killed, some of the animals acutely exposed to lithium and some of the animals chronically exposed to lithium each received pilocarpine, physostigmine, or pargyline. At the conclusion of the experiment, the rats were killed and brain levels of myo-inositol 1-phosphate and lithium were determined. A differential production of myo-inositol 1-phosphate in groups receiving acute versus chronic lithium would provide evidence of a change in receptor-linked phosphoinositide metabolism due to the chronic administration of lithium. Brain levels of myo-inositol 1-phosphate are dependent on tissue lithium concentrations; consequently, significant differences observed in brain lithium levels between the groups receiving acute versus chronic lithium prevented a meaningful assessment of the effect of the mode of lithium administration on the production of myo-inositol 1-phosphate in those groups. Stepwise multiple regression analysis and the measured brain lithium levels were used to assess the response of myo-inositol 1-phosphate levels to stimulation in animals receiving acute or chronic lithium treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

双膦酸盐类药物致不良反应回顾性分析

目的:分析双膦酸盐类药物所致不良反应情况。方法:检索中国期刊全文数据库(CNKI)、万方数据库(Wan Fang)、中文科技期刊数据库(VIP)2004年1月至2013年8月国内有关双膦酸盐致不良反应的个案报道,按年龄、性别、原发病、药物名称、给药途径、不良反应发生时间、临床表现症状、治疗与转归等进行分类统计分析。结果:48例不良反应包括运动系统、消化系统、感官系统、循环系统、神经系统及全身性损害,高年龄段与女性发生率较高。结论:临床上应重视双膦酸盐类药物所致不良反应,坚持合理用药。     

Effect of long-term administration of antidepressants on the lipid composition of brain plasma membranes

The connection between changes in lipid pattern in brain plasma membranes and long-term administration of therapeutically effective doses of antidepressants has not been sufficiently demonstrated so far. Therefore, we analyzed effect of antidepressants that differ in pharmacological selectivity on membrane lipid composition in the rat brain tissue. Laboratory rats were given desipramine, maprotiline, citalopram, moclobemide or lithium for a 4-week period. We observed a significant decrease in phosphatidylethanolamine representation after administration of maprotiline, citalopram and moclobemide when compared with controls. Membrane cholesterol content was decreased after desipramine administration and increased after citalopram or lithium treatment. Electroneutral phospholipids were decreased after the administration of all tested antidepressants except for desipramine. Decrease in phosphatidylserine was found following long-term administration of maprotiline or desipramine; relative representation of phosphatidylinositol was reduced after lithium treatment. Statistically significant negative correlation between cholesterol and electroneutral phospholipids was discovered. Membrane microviscosity evaluated by fluorescence anisotropy of membrane probes was only slightly decreased after desipramine and increased after citalopram administration. Hypothesis was supported that changes in brain neurotransmission produced by antidepressants could be, at least partially, associated with adaptive changes in membrane cholesterol and phospholipids.     

Glycogen synthase kinase 3beta as a likely target for the action of lithium on circadian clocks

Although lithium is one of the most commonly used drugs in the prophylaxis and treatment of bipolar disorder, the mechanisms underlying its therapeutic action are still unclear. Together with its mood-stabilizing effects, lithium is also known to influence the circadian clocks of several organisms including man. Circadian rhythms are altered in patients with bipolar disorder, and it is believed that these rhythms may play an important role in disease mechanisms. It is therefore possible that some of the therapeutic actions of lithium may be related to its effect on circadian clocks. Identifying the targets for lithium's action on circadian clocks would therefore be important both for understanding the mechanisms of its therapeutic effect and also in further understanding disease mechanisms in bipolar disorders. Using Drosophila melanogaster as a model system, we show that long-term administration of lithium results in lengthening of the free-running period (τ) of circadian locomotor activity rhythm of flies in constant darkness (DD). This effect occurs at concentrations similar to the plasma levels of lithium used in the treatment of bipolar disorder. The lithium-treated flies also show reduced activity of one of the previously reported targets of lithium action, Glycogen Synthase Kinase 3β (GSK 3β). GSK 3β has been shown to be involved in the regulation of circadian clocks as the down regulation of this protein results in an elongation of τ. The τ elongation resembles the effect seen with lithium administration in a number of organisms including man, and taken together with the earlier observations our results suggest that lithium inhibits the activity of GSK 3β to produce its effect on circadian clocks.     

Functional genetic variation in the Rev-Erbα pathway and lithium response in the treatment of bipolar disorder

Bipolar disorder (BD) is characterized by disruptions in circadian rhythms such as sleep and daily activity that often normalize after lithium treatment in responsive patients. As lithium is known to interact with the circadian clock, we hypothesized that variation in circadian 'clock genes' would be associated with lithium response in BD. We determined genotype for 16 variants in seven circadian clock genes and conducted a candidate gene association study of these in 282 Caucasian patients with BD who were previously treated with lithium. We found that a variant in the promoter of NR1D1 encoding Rev-Erbα (rs2071427) and a second variant in CRY1 (rs8192440) were nominally associated with good treatment response. Previous studies have shown that lithium regulates Rev-Erbα protein stability by inhibiting glycogen synthase kinase 3β (GSK3β). We found that GSK3β genotype was also suggestive of a lithium response association, but not statistically significant. However, when GSK3β and NR1D1 genotypes were considered together, they predicted lithium response robustly and additively in proportion to the number of response-associated alleles. Using lymphoblastoid cell lines from patients with BD, we found that both the NR1D1 and GSK3β variants are associated with functional differences in gene expression. Our findings support a role for Rev-Erbα in the therapeutic mechanism of lithium and suggest that the interaction between Rev-Erbα and GSK3β may warrant further study.     

Regional Alterations in Rat Brain Neurotransmitter Systems Following Chronic Lithium Treatment

Abstract: Chronic, but not acute, consumption of lithium leads to a significant decrease in serotonin and GABA receptor binding in selected regions of the rat brain, with no changes noted in P-adrenergic or cholinergic muscarinic receptor binding. In addition, the concentration of β-methoxytyramine, a dopamine metabolite, in the corpus striatum was increased in the animals treated chronically with lithium, suggesting a possible enhancement in dopamine release, or inhibition of uptake, in this brain area. In contrast, chronic consumption of rubidium had no effect on any of the parameters studied. The results suggest that lithium administration causes selective changes in brain neurotransmitter receptor systems and that the net result of these changes may be a decrease in GABAergic and serotoninergic activity. The fact that these alterktions are noted only after chronic administration suggests that they may be related to the therapeutic action of lithium in the prophylactic treatment of recurrent manic- depressive psychosis.     

Effects of lithium on the pituitary-gonadal axis in the rat: evidence for dose-dependent changes in plasma gonadotropin and testosterone levels

The purpose of the present study was to examine the effects of lithium, a drug which is now used rather widely in the treatment of acute mania and the prophylaxis of manic-depressive bipolar disorders, on the pituitary-gonadal function in the laboratory rat. Sexually adult male rats, maintained under standardized laboratory conditions (LD 14: 10; lights on at 06:00 h, CST), were injected (ip) with lithium chloride both acutely for 1 day and chronically for 5 days, and by utilizing a low and high dose. For the low dose, lithium was injected twice daily (at 10:00 and 15:00 h) at 2.5 meg/Kg for 1 and 5 days, whereas in the high dose groups, also receiving lithium twice daily and at the same hours, the dosages were 5 meq/Kg for 1 day and 3.5 meq/Kg for 5 days. Animals were sacrificed 4 hours after the last lithium (or saline) injections. Plasma and pituitary levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH), and plasma levels of testosterone (T) were measured by radioimmunoassay (RIA). The administration of the low dose led to a significantly higher (P less than 0.001) plasma FSH, but unaltered plasma LH, levels after 5 days. In contrast, the high dose lithium led to significant suppressions of plasma LH (P less than 0.02; on day 5) and FSH (P less than 0.001; on both day 1 and 5) levels. The levels of plasma T also showed a significant reduction following the low dose (P less than 0.02; on day 5), as well as the high dose lithium treatment, as evident after both 1 (P less than 0.02) and 5 (P less than 0.02) days. Regardless of the dosage, or the duration of treatment, pituitary gonadotropin levels remained unaltered following lithium. The results of our present experiments suggest that lithium administration, either acutely or on a chronic basis, might be associated with significant adverse effects on the pituitary-testicular axis. Furthermore, since some of the hormonal changes were evident when plasma lithium concentration was within the therapeutic range, our data may have potential clinical implications.     

Acute cardiac failure and hepatic ischemia induced by disopyramide phosphate.

Two patients abruptly developed congestive heart failure and elevation in serum transaminase levels when given disopyramide phosphate; enzyme abnormalities and hemodynamic status corrected upon withdrawal of the drug. Both patients had underlying ischemic cardiomyopathy. Myocardial infarction, pulmonary embolism, and viral hepatitis were ruled out in both patients. One patient had a liver biopsy documenting central hepatic necrosis with congestion, consistent with hepatic ischemia and not toxic hepatitis. In the other patient, cardiac decompensation and hepatocellular enzyme elevation were reproduced on rechallenge with the drug. Disopyramide should be used with caution in patients with heart failure.     

Lithium Treatment Aggregates the Adverse Effects on Erythrocytes Subjected to Arsenic Exposure

The present study was designed to investigate the effects of lithium treatment on red blood cells which were given arsenic exposure. Long-term lithium therapy is being extensively used for the treatment of bipolar disorders. Arsenic is a group I carcinogen and a major toxic pollutant in drinking water that affects millions of people worldwide. Male SD rats were segregated into four groups, viz. normal control, lithium treated, arsenic treated, and lithium + arsenic treated. Lithium was supplemented as lithium carbonate at a dose level of 1.1 g/kg diet for a period of 8 weeks. Arsenic was given in the form of sodium arsenite at a dose level of 100 ppm in drinking water, ad libitum, for the same period. Lysates of red blood cells were used to investigate the effects of lithium and arsenic treatments on anti-oxidant enzymes, reduced glutathione (GSH), and lipid peroxidation (LPO) levels. Various hematological parameters, activities of Na⁺ K⁺ ATPase and delta-aminolevulinic acid dehydratase (δ-ALAD) were also assessed. A significant reduction was observed in the activities of antioxidant enzymes, GSH levels, total erythrocyte counts, Na⁺ K⁺ ATPase, and ALAD enzyme activities in lysates of red blood cells when exposed either to lithium or arsenic. In addition, a significant increase in the levels of malondialdehyde (MDA), lymphocytes, neutrophils, and total leukocytes was also observed following lithium as well as arsenic treatments. However, when arsenic-treated rats were subjected to lithium treatment, a pronounced alteration was noticed in all the above parameters. Therefore, we conclude that lithium supplementation to the arsenic-treated rats enhances the adverse effects on red blood cells and therefore use of lithium may not be medicated to patients who are vulnerable to arsenic exposure through drinking water. It can also be inferred that adverse effects of lithium therapy may get aggravated in patients thriving in the arsenic-contaminated area.

     

Veratrum viride; hypotensive and cardiac effects of intravenous use

The hypotensive action of veratrum viride given intravenously was studied in 24 patients, 22 of them hypertensive and 2 normotensive. Vasodepression of considerable but variable degree was obtained in all patients. Maximum hypotension occurred 8 to 15 minutes after injection and relative hypotension usually lasted at least two hours. In four patients subnormal hypotension occurred but there were no clinical manifestations of shock. The blood pressure rose promptly when pressor drugs were administered.A dose of 0.3 to 0.5 mg. brought about a satisfactory decrease in blood pressure. The degree of decrease was affected by the speed of administration and in a few patients by idiosyncratic sensitivity to the drug. Veratrum has an extravagal action on the pulse rate, and in that and other respects resembles digitalis. Veratrum should be given with caution to digitalized patients. Atropine reduced but did not abolish the hypotensive effect of veratrum, and was more effective when given before veratrum. This indicates that the parasympathomimetic action of veratrum is important in the mechanism of blood pressure reduction.     

Use of Metolazone in the Treatment of Ascites due to Liver Disease

In 8 out of 20 patients with chronic liver disease ascites was controlled with metolazone, 10 required additional amiloride or spironolactone to achieve control, and 2 were resistant to all diuretic therapy. An initial dose of 5 mg daily is suggested, though much higher doses may be required ultimately. When metolazone is used alone the high incidence of hypokalaemia (80%), hypochloraemia (35%), and encephalopathy (35%) compared with the results of other series is a major disadvantage and indicates that this drug should be used with caution in patients with liver disease. Hypokalaemia can usually be prevented by the simultaneous administration of amiloride or spironolactone. The low incidence of azotaemia (5%) suggests that this diuretic may be useful if renal function is particularly impaired.     

Sensitivity to Rifampicin: Incidence,Mechanism, and Prevention

Five out of 200 patients taking rifampicin 900 mg twice weekly and three out of 91 patients taking rifampicin who attended an immunology clinic developed intolerance to the drug. Antibodies to rifampicin, which were found in most cases, decreased steadily after the end of treatment but were detectable for up to 16 months. The dose of rifampicin and the blood levels are predominating factors in the occurrence of reactions. Thus the dose should be reduced in patients in whom rifampicin blood levels rise abnormally. When it is important to continue rifampicin treatment despite intolerance antibody titres within 24 hours after administration of the drug must be measured to find when they are lowest, which determines the “unreactive period,” and when a further dose may be safely given.     

Myelotoxicity of gold.

Of 55 patients who developed blood dyscrasias attributable to gold treatment 15 with bone marrow hypoplasia died. A few of the dyscrasias, occurring in patients who had taken a low total dose of sodium aurothiomalate, may have resulted from immune hypersensitivity, but most, occurring in patients who had taken a higher total dose, were due to cumulative toxicity. All patients receiving gold treatment should undergo frequent blood counts. Any pronounced or continuing fall in the counts is a warning of toxicity, and gold treatment should be stopped. Treatment should be resumed only with caution, and in some patients already in remission lower doses may be just as effective in controlling the disease.     

Potassium reduces lithium toxicity: Circadian rhythm actions are maintained

We tested whether a high potassium diet alters lithium's effects on locomotor activity rhythms to the same extent as it prevents lithium toxicity. Rats fed a standard diet containing 0.47% potassium lost weight after subcutaneous implantation of an osmotic pump delivering 1.35 mg of lithium chloride per hour, and most died or became sick within three weeks after implantation. In contrast, all rats fed a diet containing 4.1% potassium gained weight at the same rate regardless of whether they had received lithium infusions or placebo. In a second experiment, lithium administration by either diet or osmotic pump delayed wheel running rhythms, showing that lithium's central nervous system action did not depend on potassium intake or method of lithium administration. Dietary potassium supplementation may provide a useful strategy for improving the therapeutic index of lithium treatment.     

Study of the effect of lithium on lymphokine-activated killer cell activity and its antitumor growth.

The in vitro effect of lithium on lymphokine-activated killer cell (LAK) activity and its in vivo antitumor growth were observed. LAK activity was enhanced when LiCl was added during LAK cell induction, and this enhancement was observed both in human peripheral blood mononuclear cell and in mouse splenocytes used as LAK precursors. Cholera toxin, which can increase intracellular levels of cAMP, decreased LAK cell activity. However, lithium partially reversed this inhibitory effect, indicating that lithium increased LAK cell activity by decreasing cAMP levels. D-Sphingosine, an inhibitor of protein kinase C, and EGTA, a calcium chelator, both inhibited the LAK cell activity. However, their inhibitory effects could not be reversed by lithium because lithium was added in the culture in combination with one of these inhibitors during LAK cell induction. By using slot blot analysis, the effect of lithium on the expression of tumor necrosis factor-alpha mRNA of LAK cells was analyzed. Lithium increased the level of tumor necrosis factor-alpha mRNA when both lithium and interleukin 2 were added to induce LAK cells. The in vivo antitumor effect of lithium has also been studied. Using a mouse melanoma experimental model, the effect of lithium on tumor growth was also observed. Both lithium alone and interleukin 2/LAK had an antitumor effect, whereas the treatment of interleukin 2/LAK in combination with lithium had the strongest inhibitory effect on tumor growth, since this treatment resulted in reduction of tumor size and prolongation of survival in tumor-bearing mice. Therefore, it is hopeful that lithium can be used as a new immunomodulator for cancer immunotherapy and immune diseases.