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Ephedrine Withdrawal Causes Severe Psychiatric Symptoms: A Case Report

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Ephedrine Withdrawal Causes Severe Psychiatric Symptoms: A Case Report Gene Makela, Pharm.D., BCPP Kelly Slear Marcella Hoyland Kelly Slear Marcella Hoyland ... – PowerPoint PPT presentation

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Title: Ephedrine Withdrawal Causes Severe Psychiatric Symptoms: A Case Report


1
Ephedrine Withdrawal Causes Severe Psychiatric
SymptomsA Case Report
  • Gene Makela, Pharm.D., BCPP
  • Kelly Slear
  • Marcella Hoyland

2
Kelly SlearMarcella Hoyland
  • Pharmaceutical Investigations course, West
    Virginia University
  • School of Pharmacy

3
The Case
  • 64-year-old woman
  • long history of depression
  • abruptly increased symptoms of depression and
    suicidal ideation with a plan to shoot herself
    with a gun
  • difficulty sleeping
  • very low energy
  • decreased appetite, energy, and concentration
  • language and memory intact

4
The Case
  • judgment and insight poor
  • some signs of paranoia during the interview she
    reported my family wants to get rid of me
  • auditory hallucinations had returned recently
    she heard voices of her great aunt and uncle
    telling her she was worthless, no good, and she
    should have died when she was born
  • major depressive disorder with psychotic features
    was diagnosed
  • Beck Depression Inventory (BDI) 63

5
Medications on Admission
  • mirtazepine 30mg daily
  • olanzapine 20mg daily
  • levothyroxine 0.88mg daily
  • conjugated estrogen 0.625mg daily
  • calcium carbonate 600mg twice daily
  • compliant with therapy, had been stable

6
Pharmacist Intervention
  • pharmacist faculty member with student conducted
    detailed medication history with following
    findings
  • patient was taking eight Xenadrine capsules daily
    as a weight loss product for the past three to
    four months
  • she reported that she took this product until two
    days before admission to the hospital
  • at that time, on the advice of her daughter, she
    abruptly discontinued the Xenadrine

7
Components of Xenedrine
  • Pantothenic acid 20mg
  • Bitter orange - standardized to 2.5mg synephrine
    (similar to phenylephrine)
  • Ma Huang (ephedra) - standardized to 10mg
    ephedrine
  • Guarana extract (100mg caffeine)
  • Ginger root 25mg
  • White willow bark (15mg salicin)
  • L-tyrosine, L-carnitine, Magnesium phosphate,
    Deanol (choline precursor).
  • Note normal dose is 2 capsules daily

8
Bitter Orange
  • Citrus aurantium
  • Adrenergic amines
  • Synephrine and octopamine (structurally similar
    to epinephrine)
  • Hordenine
  • Tyramine
  • Methyltyramine

9
Background
  • Common adverse effects of ephedrine reported to
    FDA by consumers included elevated blood
    pressure, tachycardia, muscle injury, psychosis,
    and memory loss
  • FDA mandates rule in 1997 requiring manufactures
    of supplements containing ephedrine that products
    be labeled with information about risks and
    dangers
  • FDA requires stronger labeling cautions in 2003
    ephedrine has a significant risk of illness or
    injury to the consumer
  • FDA creates new Adverse Event Reporting System
    (CAERS) in 2003 to enable both health care
    providers and consumers to more easily report
    adverse events from dietary supplements
  • In February, 2004, the FDA acts to ban
    ephedra-containing products

10
Resolution
  • mirtazepine dosage increased to 45mg at bedtime
  • over the next several days depression symptoms
    and psychosis cleared without further
    intervention
  • BDI 54 after 2 days
  • on the day of discharge, seven days after
    admission, the patient reported feeling much
    better
  • no suicidal thoughts or auditory hallucinations
  • hopeful about the future
  • discharge diagnoses included major depressive
    disorder, recurrent, improving, Xenadrine abuse,
    and Xenadrine withdrawal, resolving

11
Whatever happened toEphedrine Products?
  • 2008 internet search
  • Ephedra products still available
  • many new products marketed using bitter orange
    as a substitute for MaHuang

12
Advertisement for ephBURN25
  • this product is made from the old ephedra like
    the old lipodrene smell the pills youll agree
  • one capsule
  • MaHuang extract 8 Dark (25mg)
  • Caffeine 200mg
  • Other ingredients
  • Dose 1 capsule twice daily

13
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14
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15
Considerations
  • abrupt discontinuation of a stimulant taken for a
    long period of time may lead to depressive
    symptomatology
  • In this unique case, however, a depressed patient
    stable on medications was thrown into severe
    depression with psychosis and suicidality as a
    result of the abrupt withdrawal of a
    non-prescription dietary supplement used for
    weight loss
  • despite combined antidepressant (mirtazepine) and
    antipsychotic (olanzapine) treatment,
    discontinuation of a non-prescription weight loss
    product was sufficient to acutely de-stabilize
    this patients condition

16
Results / Conclusions
  • abrupt discontinuation of non-prescription
    stimulant medication may cause severe depressive
    symptomatology, even in a patient whose
    depression had been adequately controlled with
    prescription medication
  • detailed medication history important in
    clarifying cause of hospitalization, helpful in
    defining the appropriate course of treatment.

17
What Would Have Happened if
  • There was no pharmacist intervention? possible
  • delayed or incorrect diagnosis
  • higher doses of prescribed medication potential
    adverse effects
  • addition of other medication to stabilize patient
    potential drug interactions
  • prolonged hospitalization

18
To Take Home
  • Psychiatric pharmacists can facilitate accurate
    diagnoses by conducting medication histories
  • Resultant pharmacotherapeutic approaches may
    minimize length of stay for patients
  • Current availability of ephedrineneed for
    awareness

19
Questions ???
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