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CASE REPORTS 17 Quetiapine interaction \*jisj First report of an interaction with concomitant oxcarbazepine leading to extrapyramidal disorders in an elderly patient: case report A 77-year-old man was hospitalised with symptoms of Lewy body dementia and started treatment with quetiapine and oxcarbazepine [dosages not stated]. One week later, he developed extrapyramidal disorders, with dramatic worsening of the Webster scale and an inability to walk. Quetiapine and oxcarbazepine were discontinued and his symptoms resolved. Author comment: "The speed of increasing dose of the antipsychotic drug . . . might be a possible influencing factor as well as a (pharmacokinetic) interaction of quetiapine and oxcarbazepine." Schuhmann T. Lewy body dementia, pharmacotherapeutic security and differential indication of antipsychotics according to adverse effects - a case report. Pharmacopsychiatry 38: 62-63, No. I, Jan 2005 [abstract] - Switzerland 801005254 >• Editorial comment: A search of AdisBase and Medline did not reveal any previous case reports of an interaction between quetiapine and oxcarbazepine. The WHO Adverse Drug Reactions database contained 228 reports involving the concomitant use of quetiapine and oxcarbazepine. Reteplase l^ First report of choiesterol emboiisation leading to renal failure and gastric ulcers in an elderly patient: case report A 68-year-old woman developed renal failure and gastric ulcers associated with cholesterol emboiisation following treatment with reteplase and for a myocardial infarction. The woman was hospitalised and received reteplase [dosage not stated] followed by a heparin infusion; she experienced an episode of hypotension (BP 70/38mm Hg) after administration of reteplase and was treated with IV fluids. Her creatinine level increased from 2 mg/dL on admission to 3.2 mg/dL by hospital day 8, and laboratory investigations revealed persistent peripheral eosinophilia from day 2. She also experienced epigastric disconifort and, on day 9, developed melaena. Oesophagoduodenoscopy revealed erosive gastritis with multiple shallow gastric ulcers, and a mucosal biopsy showed cholesterol crystal clefts in the lumen of arterioles. The woman received prednisone for 2 weeks, but her renal function did not improve and haemodialysis was subsequently initiated. At follow-up 10 months later, she remained dependent on haemodialysis. Hitti WA, Anderson J. Cholesterol emboU-induced renal failure and gastric ulcer after thrombolytic therapy. Southeni Medical Journal 98: 235-237, No. 2, Feb 2005 - USA 801003307 >• Editorial comment: A search of AdisBase, Medline and the WHO Adverse Drug Reactions database did not reveal any previous case reports of cholesterol crystal emboli associated with reteplase. Risperidone Morning pseudoneutropenia: case report A 33-year-old woman developed morning pseudoneutropenia during treatment withrisperidonefor paranoid schizophrenia. The woman began receiving risperidone 1 mg/day, titrated to 4 mg/day within 4 weeks. After 6 weeks of outpatient treatment she was hospitalised. On admission, at 8:00am, she had a WBC count of 3240/mm3, and an absolute neutrophil count (ANC) of 1560/mm'. The next morning, at 8:00am, both counts had further decreased, indicating neutropenia and leucopenia. Six hours later, a repeat blood sample revealed her WBC count and ANC had normalised. During the next 8 weeks,risperidonewas titrated to 12 mg/day; blood tests taken at 8:00am and 2:00pm twice weekly revealed consistently that, at 8:00am, her WBC count was 2910-3620/mm3, and her ANC was 1310-1850/nmi', and at 2:00pm, these levels were within the normal range. As her ANCs were within normal range at 2:00pm, efficacious risperidone treatment was not interrupted. Esposito D, Corruble E. Hardy P, Chouinard G. Risperidone-induced moming pseudoneutropenia. American Journal of Psychiatry 162: 397, No. 2, Feb 2005 - France 8010O7M4 Sildenafil see Nitric oxide/sildenafil Tacrolimus 12^ Interaction with voriconazole leading to renal impairment in a renal transplant recipient: case report A 55-year-old male renal transplant recipient receiving immunosuppressive therapy with tacrolimus developed increased tacrolimus serum concentrations leading to renal impairment, during treatment with voriconazole for a Pseudallescheria boydii skin infection. The man, who had a history of cholestasis, was switched from itraconazole to oral voriconazole [V-Fend] 4 mg/kg twice daily, with concomitant tacrolimus 2 mg/day, after 1 month of itraconazole treatment; his tacrolimus dosage had been reduced by 50% when itraconazole was initiated 1 month prior to admission. After 7 days, his previously stable tacrolimus trough concentration (< 12 ng/mL) increased markedly. After 10 and 17 days, his tacrolimus trough concentration increased to 20 ng/mL and 25 ng/mL, respectively, and was associated with renal graft fiincdon impairment; his serum creatinine levels increased from 1.2 to 1.9 mg/dL after 10 days, and 3.9 mg/dL after 17 days. The man's tacrolimus dosage was reduced over 3 days, ending with 0.5mg every other day, and then slowly recovered. Author comment: "Because voriconazole is metabolized by the hepatic CYP-450 systems, drug interaction with calcineurin inhibitors occurs, resulting in increased serum concentration and sometimes leading to renal toxicity. . . Perhaps, in this case, the interaction might have been aggravated by the chronic cholestasis our patient was suffering from." Tintillier M, Kirch L, Goffin B, Cuvelier C, Pochet J-M. Interaction between voriconazole and tacrolimus in a kidney-transplanted patient. Nephrology Dialysis Transplantation 20: 664-665, No. 3, Mar 2005 - Belgium 801005301 0114-9954/05/1048-00017/$11.00 © 2005 Adis Data Information BV. All rights reserved Reactions 23 Apr 2005 No. 1046

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  • CASE REPORTS 17

    Quetiapine interaction \*jisjFirst report of an interaction with concomitantoxcarbazepine leading to extrapyramidal disorders inan elderly patient: case report

    A 77-year-old man was hospitalised with symptoms ofLewy body dementia and started treatment withquetiapine and oxcarbazepine [dosages not stated]. Oneweek later, he developed extrapyramidal disorders, withdramatic worsening of the Webster scale and an inabilityto walk. Quetiapine and oxcarbazepine were discontinuedand his symptoms resolved.

    Author comment: "The speed of increasing dose of theantipsychotic drug . . . might be a possible influencingfactor as well as a (pharmacokinetic) interaction ofquetiapine and oxcarbazepine."Schuhmann T. Lewy body dementia, pharmacotherapeutic security and differentialindication of antipsychotics according to adverse effects - a case report.Pharmacopsychiatry 38: 62-63, No. I, Jan 2005 [abstract] -Switzerland 801005254

    > Editorial comment: A search of AdisBase andMedline did not reveal any previous case reports of aninteraction between quetiapine and oxcarbazepine. TheWHO Adverse Drug Reactions database contained228 reports involving the concomitant use of quetiapineand oxcarbazepine.

    Reteplase l ^First report of choiesterol emboiisation leading torenal failure and gastric ulcers in an elderly patient:case report

    A 68-year-old woman developed renal failure andgastric ulcers associated with cholesterol emboiisationfollowing treatment with reteplase and for a myocardialinfarction.

    The woman was hospitalised and received reteplase[dosage not stated] followed by a heparin infusion; sheexperienced an episode of hypotension (BP 70/38mm Hg)after administration of reteplase and was treated with IVfluids. Her creatinine level increased from 2 mg/dL onadmission to 3.2 mg/dL by hospital day 8, and laboratoryinvestigations revealed persistent peripheral eosinophiliafrom day 2. She also experienced epigastric disconifortand, on day 9, developed melaena.Oesophagoduodenoscopy revealed erosive gastritis withmultiple shallow gastric ulcers, and a mucosal biopsyshowed cholesterol crystal clefts in the lumen ofarterioles.

    The woman received prednisone for 2 weeks, but herrenal function did not improve and haemodialysis wassubsequently initiated. At follow-up 10 months later, sheremained dependent on haemodialysis.Hitti WA, Anderson J. Cholesterol emboU-induced renal failure and gastric ulcerafter thrombolytic therapy. Southeni Medical Journal 98: 235-237, No. 2, Feb 2005- U S A 801003307

    > Editorial comment: A search of AdisBase, Medlineand the WHO Adverse Drug Reactions database did notreveal any previous case reports of cholesterol crystalemboli associated with reteplase.

    RisperidoneMorning pseudoneutropenia: case report

    A 33-year-old woman developed morningpseudoneutropenia during treatment with risperidone forparanoid schizophrenia.

    The woman began receiving risperidone 1 mg/day,titrated to 4 mg/day within 4 weeks. After 6 weeks ofoutpatient treatment she was hospitalised. On admission,at 8:00am, she had a WBC count of 3240/mm3, and anabsolute neutrophil count (ANC) of 1560/mm'. The nextmorning, at 8:00am, both counts had further decreased,indicating neutropenia and leucopenia. Six hours later, arepeat blood sample revealed her WBC count and ANChad normalised. During the next 8 weeks, risperidone wastitrated to 12 mg/day; blood tests taken at 8:00am and2:00pm twice weekly revealed consistently that, at8:00am, her WBC count was 2910-3620/mm3, and herANC was 1310-1850/nmi', and at 2:00pm, these levelswere within the normal range. As her ANCs were withinnormal range at 2:00pm, efficacious risperidone treatmentwas not interrupted.

    Esposito D, Corruble E. Hardy P, Chouinard G. Risperidone-induced momingpseudoneutropenia. American Journal of Psychiatry 162: 397, No. 2, Feb 2005 -France 8010O7M4

    Sildenafilsee Nitric oxide/sildenafil

    Tacrolimus 12^Interaction with voriconazole leading to renalimpairment in a renal transplant recipient: case report

    A 55-year-old male renal transplant recipient receivingimmunosuppressive therapy with tacrolimus developedincreased tacrolimus serum concentrations leading to renalimpairment, during treatment with voriconazole for aPseudallescheria boydii skin infection.

    The man, who had a history of cholestasis, wasswitched from itraconazole to oral voriconazole [V-Fend]4 mg/kg twice daily, with concomitant tacrolimus2 mg/day, after 1 month of itraconazole treatment; histacrolimus dosage had been reduced by 50% whenitraconazole was initiated 1 month prior to admission.After 7 days, his previously stable tacrolimus troughconcentration (< 12 ng/mL) increased markedly. After 10and 17 days, his tacrolimus trough concentrationincreased to 20 ng/mL and 25 ng/mL, respectively, andwas associated with renal graft fiincdon impairment; hisserum creatinine levels increased from 1.2 to 1.9 mg/dLafter 10 days, and 3.9 mg/dL after 17 days.

    The man's tacrolimus dosage was reduced over 3 days,ending with 0.5mg every other day, and then slowlyrecovered.

    Author comment: "Because voriconazole ismetabolized by the hepatic CYP-450 systems, druginteraction with calcineurin inhibitors occurs, resulting inincreased serum concentration and sometimes leading torenal toxicity. . . Perhaps, in this case, the interactionmight have been aggravated by the chronic cholestasisour patient was suffering from."Tintillier M, Kirch L, Goffin B, Cuvelier C, Pochet J-M. Interaction betweenvoriconazole and tacrolimus in a kidney-transplanted patient. Nephrology DialysisTransplantation 20: 664-665, No. 3, Mar 2005 - Belgium 801005301

    0114-9954/05/1048-00017/$11.00 2005 Adis Data Information BV. All rights reserved Reactions 23 Apr 2005 No. 1046