opana induced ttp like illness (1)(1)
TRANSCRIPT
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YETANOTHERREASONTO
STAYAWAYFROMDRUGS
Dr. Heather Tarantino
Dr. Srikanth Nimmagadda
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Introduction
Thrombotic thrombocytopenic purpura (TTP)
like illness is a rare but serious blood disorder
characterized by microangiopathic hemolytic
anemia and thrombocytopenia, in the
absence of certain known causes of TTP.
TTP has not been associated previously with
abuse of any opiate.
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Inroduction:
This is the first report outside of Tennessee, TTP-like illness associated with abuse of an opioidpain reliever by injection.
Our case meets the current case definition byCDC for IV drug abuse-related TTP, a diagnosis ofTTP since February 1, 2012 in a person who hadused drugs intravenously for nonmedicalreasons.
This case also supports the findings previouslypublished in the one and only case control studyby Tennessee Department of Health.
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Case Report
Patient is a 35 yr Old, Caucasian female,
CC: I have burning epigastric pain
Burning epigastric pain, 15/10 in intensity, since last 3 months,gradually getting worse, radiating to back, propping up and opanahelps to relieve pain.
Associated with nausea and decreased appetite, PMH: Hepatitis C, Chronic low back pain
Home Medication: Diclofenac Sodium 50 mg two times a day
PSH: C-Section X 4, D & C X 3,
FH: DM, CVA
Social History: 1 PPD X 24 years, Quit alcohol 7 years ago, IV drugabuse: Opana ER 20 mg per day, last abuse was 2 days ago, THCoccasional abuse, last time 1-2 months ago
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Case Report
Clinical Examination:
Vitals: BP: 130/81, T: 36.6 C, PR: 88, RR: 18, 100%
saturation on RA,
Constitutional: Significant distress with severe pain,well nourished,
Abdomen: Epigastric and RUQ tenderness, Liver
palpable 2 inches below costal margin, No
splenomegaly, Bowel sounds , soft and present all 4quadrants
Skin: Multiple needle marks and tracks on fore arm
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Case Report
Labs: CBC: WBC 11.9, Hb 7.4, MCV
100, Platelet count : 41,000
Cr: 1.1(Baseline 0.7-0.8),GFR:56
Direct coombs: Negative
UDS: Positive for opiates
LDH: 729, Haptoglobin:
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Case Report
The diagnosis of TTP-AHUS(Atypical
hemolytic uremic syndrome)/TTP like illness
is made on basis of 3
Microangiopathic hemolytic anemia
Thrombocytopenia
Acute renal insufficiency
Ruling out other causes
case definition given by CDC
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Hospital course
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
ClinicalProgress
Time Line
LDH
Hemoglobin
Platelets
Plasmapheresis
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Discussion
New formulation of Opana ER was released in Feb,2012, with the intent to inhibit crushing anddissolving the tablets.
Ingredients: polyethylene oxide (PEO) and polyethylene glycol.
Unclear what component or components of reformulated Opana ER might trigger TTP-like illness
In one study in rats, intravenously injected PEO caused thrombocytopenia.
Onaugust13,2012,a Nephrologist reported to the Tennessee Department of Health(TDH)threecases of unexplained thrombotic thrombocytopenic purpura (TTP),
By the end of October, a total of 15 such cases had been reported. Fourteen of the 15 patientsreported injecting reformulated Opana ER.
Seven of the 15 were treated for sepsis in addition to TTP-like illness. Twelve patients reportedchronic hepatitis C or had positive test results for anti-HCV antibody.
To test for an association between TTP like illness and injection of reformulated Opana ER, TDHconducted a case control study.
This study identified a strong association (odds ratio=35.0; 95% confidence interval=3.9-312.1)between TTP-like illness and injection of reformulated Opana ER.
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Clinical implications
The extent of this problem is not clear because there is no requirement to report such cases andbecause IV drug use might not be suspected or reported among patients with TTP.
Recommendations from CDC for physicians prescribing Opana ER,2 A. Clinicians treating patients with TTP of unknown etiology should:
1. Ask patients about intravenous drug use. a. Patients who report IV drug use should be asked about the specific drugs injected.
2. Perform a urine drug test. a. A negative drug test is not definitive because the interval between the critical drug use and diagnosis might be
greater than the time during which a drug can be detected in the urine, which is probably not more than 4 days in thecase of opioids.
3. Request a copy of the patients prescriptions for controlled substances from the state prescription drugmonitoring program to determine if any doctor has prescribed the patient Opana ER. This informationmight be more accurate than the patients report of drug sources.
B. Clinicians treating patients with TTP who report IV use of Opana ER should: 1. Counsel patients regarding the risks of continued IV drug use, including blood-borne infections, fatal
overdose, and TTP.
2. Refer them to substance abuse treatment programs in their community. A list of substance abuse
treatment facilities is located at: http://www.samhsa.gov/treatment/index.aspx 3. Notify other clinicians who have prescribed the patient Opana ER of the diagnosis of TTP and the
reported association with that drug.
Prompt initiation of treatment on suspicion of diagnosis with plasmapheresis was also advised.
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References
1. Morbidity and Mortality Weekly Report (MMWR) January
11, 2013 / 62(01);1-4
2. CDC Health Advisory CDCHAN-00331-2012-26-10-UPD-N
3. Uptodate, Diagnosis of thrombotic thrombocytopenic
purpura-hemolytic uremic syndrome in adults
4. Peripheral smear image: Cleveland Clinic Center for
Continuing Education, Disorders of Platelet Function and
Number