Vol 10, Issue 1 - Utah Poison Control Center

Official Newsletter of the Utah Poison Control Center
2008 • Volume 10 • Issue 1
The University of Utah
Utah Poison Control Center
I n t h i s i s s ue
Hydrogen Peroxide
by Stacie Rabe, PharmD
Hydrogen Peroxide
Introduction
In July 2006, the FDA
warned consumers not to
ingest high concentration
(35%) or ‘Food Grade’
hydrogen peroxide because
it can cause ill health effects
and even death.1 This
warning was in response
to health claims that
promoted the use of ‘Food
Grade’ hydrogen peroxide
to cure diseases such as
cancer, AIDS, and multiple
sclerosis. The use of ‘Food
Grade’ hydrogen peroxide
to cure diseases has also been
called ‘hyperoxygenation
therapy’.2 ‘Food Grade’
hydrogen peroxide is
available for purchase at
health food stores and
online retailers. Various
routes of administration are
recommended by retailers
and include ingestion,
topical application, IV
infusion and enemas.3
Pharmacology
Hydrogen peroxide
is a topical antiseptic
and disinfectant in
concentrations less than 6%.
It can be applied to the skin
or used as an oral rinse. It
should not be used in the
Sympathomimetics
M44 Sodium Cyanide
Outreach Education
Meet the UPCC Staff: Barbara Crouch
eye, or on large areas of the
body, puncture wounds, or
burned skin.4 It is also an
oxidizing agent and releases
oxygen when it comes
into contact with tissue.
The amount of oxygen
released depends on the
concentration of hydrogen
peroxide. One ml of 3%
solution releases 10 ml
oxygen, whereas one ml of
35% solution releases 100
mL of oxygen.5
Adverse Effects &
Toxicology
Concentrated solutions
(> 10%) are used for
bleaching paper and textiles,
manufacturing other
chemicals, as a food
preservative and for the
production of rocket fuel. Toxicity can occur following
ingestion, skin or mucous
membrane exposure,
inhalation and
wound irrigation. The
severity of toxicity is
dependent on the route and
duration of exposure, and
the concentration of the
solution.
The concentration of
hydrogen peroxide used
in “hyperoxygenation”
therapy varies depending
on the route of
administration. Topical
application is typically
3%, IV administration
is usually 0.075%,
and the concentration
recommended for ingestion
is 35%.3 Proponents of
hyperoxygenation therapy
recommend diluting the
peroxide in drinks, such
as juice and water.2 They
also recommend storing a
small bottle of the hydrogen
peroxide in the refrigerator,3 a contributing factor to
unintentional exposures.6
A study performed by the
Utah Poison Control (cont. on pg. 2)
Sympathomimetics
by Andrea Chan,
PharmD Candidate
Introduction
Nasal decongestants
belong to the
pharmacological class
of sympathomimetic
amines, which are
structurally similar to
adrenaline and include:
phenylpropanolamine,
pseudoephedrine, and
phenylephrine. These
agents have historically
been marketed in both
single and combination
products primarily for the
relief of symptoms related
to colds and allergies.
Availability
Phenylpropanolamine was
marketed orally in nasal
decongestants and weight loss
products. In 2000, the final
report of the Hemorrhagic
Stroke Project identified
phenylpropanolamine as
an independent risk factor
for hemorrhagic stroke
in women.1 In November
2000, the FDA requested
manufacturers to voluntarily
remove phenylpropanolamine
from all drug products. Subsequently, the FDA
advisory panel on nonprescription medications
reviewed the data from the
Hemorrhagic Stroke Project
and recommended that
phenylpropanolamine be
reclassified as not safe for
over-the-counter (OTC) use.2 The proposed rule for public
comment was published in
December 2005. Pseudoephedrine is available
orally as a nasal decongestant. It has been used illicitly as a
precursor in the production of
methamphetamine. In efforts
to try to control
(cont. on pg. 3) A program of the University of Utah College of Pharmacy
TOXICOLOGY TODAY 1
O ut r eac h e d ucatio n
Education Material Highlight
The UPCC worked collaboratively with a
pediatric resident to develop a new brochure. The
brochure title, “In Your Hands or Out Of Reach,”
is a reminder that potential poisons should be put
away when not in use. This brochure includes a
list of common potential poisons from around the
home, helpful hints to prevent poisonings, and a
household checklist, and is available in English and
Spanish. It was reviewed by pediatric healthcare
providers and
parents. We are
excited to share
the new product
with you. If you
would like copies
to distribute, you
may order it using
the order form on
our website: www.
utahpoisoncontrol.
org under Education and Prevention > Education
Materials link or call 1-800-222-1222.
(cont. from pg. 1)
of hydrogen peroxide.3 Inhalation of concentrated
solutions has resulted in pulmonary edema, coma
and seizures.4
Hydrogen Peroxide
Center reviewed 325 hydrogen peroxide exposures
reported over a 36 month period. Most of the
exposures were from ingestion (85%), less severe
outcomes were associated with concentrations <
10% (compared to > 10%) and the only severe
outcomes (or death) were from ingestion of 35%
hydrogen peroxide.6 Common symptoms from
ingestion of 3% hydrogen peroxide are vomiting,
mild abdominal pain and bloating.4 As a strong
oxidizer, it is corrosive and can cause severe burns
to the GI mucosa, mucus membranes, skin and
eyes.4 Systemic effects after ingestion are due to the
oxygen gas that is released, which can cause massive
gastric distention, perforation and gas embolism
to various organs causing life-threatening tissue
ischemia.4 Following oral ingestion a patient
may present with white discoloration of the skin
around the mouth, vomiting blood or foam,
abdominal pain and bloating, seizures, gastric
mucosal hemorrhage and edema.7 Symptoms of a
gas embolism include rapidly deteriorating mental
status, cyanosis, respiratory failure, seizures, and
ischemic EKG changes.7 A MRI of the brain can
be used to assess for anoxic brain injury.8
Skin exposure to 35% can result in blistering
and necrosis. Embolic complications have
resulted from bowel and wound irrigation.4 Acute
hemolytic anemia, air embolism, hemorrhage and
death have been reported following IV infusions
In Your Hands or
Out of Reach
Preventing Accidents
Poison Control Update Conference
May 29th, 2008 and june 5th, 2008
The Utah Poison Control Center is offering
regional update conferences in Salt Lake on
May 29th and Richfield on June 5th. The goal
is to provide a forum for health professionals
and other public health advocates to improve
their knowledge and understanding of
current poisoning issues, including: Trends
in prescription and OTC drug abuse, recent
poisonings in the news, and education tools
for high risk populations. ACPE, CHES, and
UNA continuing education credits will be
available. Registration is due by April 18th.
Visit our website for the Update
Conference Registration Brochure
www.utahpoisoncontrol.org
Treatment
Topical exposures should be thoroughly irrigated
with water. Decontamination with activated
charcoal is not recommended. There is a high risk
of aspiration, charcoal does not bind hydrogen
peroxide and administration will make endoscopic
evaluation more difficult. Nasogastric aspiration
can potentially remove large volumes of hydrogen
peroxide if the patient presents immediately after
exposure. Patients with abdominal distention
from oxygen liberation should be treated with
nasogastric suctioning. A chest or abdominal
x-ray can be used to look for gas emboli. There
are case reports that hyperbaric oxygen therapy is
helpful in treating hydrogen peroxide associated
gas emboli.5 Patients who are asymptomatic can
be released after 6 hours. Patients who experienced
any cardiac or pulmonary symptoms should be
admitted and observed for 24 to 72 hours.
TOXICOLOGY TODAY References
1.
http://www.fda.gov/bbs/topics/
NEWS/2006/NEW01420.html. Last
accessed August 2006.
2.
http://educate-yourself.org/cancer/
benefitsofhydrogenperozide17jul03.html.
3.
Green S. Oxygentation Therapy:
Unproven treatments for cancer
and AIDS. http://www.quackwatch.
org/01QuackeryRelatedTopics/Cancer/
oxygen. Last accessed August 2006.
4.
Micromedex® Healthcare Series,
Thomson Micromedex, Greenwood
Village, Colorado (Edition expires
[9/2006]).
5.
Flomenbaum N, Goldfrank L.
Goldfrank’s Toxicologic Emergencies
8th edition, New York: McGraw-Hill
Publishing, 2006:1386-1387.
6.
Dickson KF, Caravati EM: Hydrogen
peroxide exposure- 325 exposures
reported to a regional poison control
center. 1994 Clin Tox;32(6)705-714.
7.
Giberson TP, Kern JD: Near-fatal
hydrogen peroxide ingestion. Ann Emerg
Med 1989;18:778-779.
8.
Cannon G, Caravati EM. Hydrogen
peroxide neurotoxicity in childhood:
case report with unique magnetic
resonance image. J of Child Neurology
2003;18:805-808.
A publication for Health Professionals.
2
(cont. from pg. 1)
Sympathomimetics
methamphetamine manufacturing, the Combat
Methamphetamine Epidemic Act of 2005 restricts
pseudoephedrine, as well as phenylpropanolamine
and ephedrine, to be sold “behind the counter” in
limited amounts (3.6 grams per day or 9 grams
per 30 days) requiring photo identification with
each purchase.3 As a result, manufacturers have
reformulated many pseudoephedrine containing
products with phenylephrine, which cannot be
converted to methamphetamine. Phenylephrine has replaced pseudoephedrine as
the most commonly available nasal decongestant
in a variety of non-prescription cough and cold
preparations. The safety and effectiveness of
phenylephrine was the subject of a recent FDA nonprescription drug advisory committee meeting.
Pharmacology
Phenylpropanolamine and phenylephrine
are sympathomimetic amines that work by
direct stimulation of alpa1-adrenergic receptors. Pseudoephedrine has both direct and indirect alpha
and beta (greater affinity) adrenergic activity. These
agents are used as nasal decongestants and work by
acting directly on alpha-adrenergic receptors in the
mucosa of swollen nasal membranes resulting in
vasoconstriction and decreased nasal congestion. In general, sympathomimetic amines have both
cardiac and central nervous system stimulatory
properties. Common adverse effects include
excitability, restlessness, anxiety, dizziness, tremor
and hypertension. Tachycardia is common with
pseudoephedrine, whereas reflex bradycardia may
occur with phenylpropanolamine and phenylephrine. Safety
There has been much attention to the risk for
serious and life-threatening cardiac and CNS events
associated with sympathomimetic agents beginning
with phenylpropanolamine. In 2004, the FDA
banned ephedra alkaloids in dietary supplements
due to unreasonable cardiac and CNS risks. Pseudoephedrine, a stereoisomer, of ephedrine, has
also been associated with myocardial infarction.4 A recent FDA nonprescription drug advisory
committee meeting focused on the safety and efficacy
of phenylephrine. A report of the outcome of that
committee meeting has not yet been published. Along with concerns about individual
decongestants, the FDA has been evaluating
information about the safety and efficacy of OTC
cough and cold preparations in general in the
pediatric population. On January 17, 2008 the
FDA issued a public health advisory recommending
avoiding use of OTC cough and cold preparations
in children under 2 years of age.5 The FDA is
currently evaluating the safety of OTC cough and
cold preparations in children 2-11 years of age. Many manufacturers have voluntarily withdrawn
OTC cough and cold preparations marketed for
children under the age of 2 years. The public health
advisory followed review of serious side effects
reported in children and the recommendations of
the FDA nonprescription advisory board. OTC medications that were marketed prior to
1962 are approved under a monograph approved
by therapeutic class. Medications included in
OTC monographs are generally considered safe
and effective although they do not undergo the
same rigorous evaluation as a prescription or OTC
product approved through a new drug application. Rigorous evaluation of safety and efficacy of
individual drugs in all age groups is not generally
available.
Summary
Sympathomimetic nasal decongestants are
available to consumers in many different OTC cold
remedies as single and combination products. They
may be perceived as safe to the public because of
their OTC status. While the risk of serious and lifethreatening adverse events with OTC decongestants
is rare, no drug is completely safe. Clinicians
should be aware of the risks and benefits of OTC
nasal decongestants and report any serious adverse
reactions or toxicity to the poison control center
and/or through the FDA MedWatch program.
M - 4 4 S odi u m
C Y a n id e
The United States Department of
Agriculture, Animal and Plant Health
Inspection Service, Bureau of Wildlife
Services would like us to remind you that
the M-44 sodium cyanide device is used in
Utah. The device is tubular and is placed
in the ground with 1.5 inches sticking
out of the ground baited with meat. This
device is used in specific situations to
control coyotes, redfox, gray fox and wild
dogs. The purpose of the device is to
protect livestock, poultry, and endangered
species and to prevent the spread of disease. Although this device is primarily used on
private lands, it may also be used on federal
land in any county in the state. Areas
where it is used are marked with signs.
While human exposure to this device
would be extremely unlikely, it is important
to know that this device contains 91%
sodium cyanide. Please report any exposure
to this device to the Utah Poison Control
Center at (800) 222-1222. We thank you
in advance for your assistance.
telecommunications And the upcc All “emergency” calls to the UPCC are
recorded. The digital recording becomes
part of the patient’s medical record. Digital
recordings are valuable in training new
employees and are an integral part of our
continuous quality improvement program.
References
1.
Kernan WN, Viscoli CM, Brass LM, et al. Phenylpropanolamine and the risk of
hemorrhagic stroke. N Eng J Med. 2000; 343:1826-1832.
2.
U.S. Food and Drug Administration. Phenylpropanolamine (PPA) Information Page.
Available at: http://www.fda.gov/cder/drug/infopage/ppa/default.htm. Accessed August
27, 2007.
3.
US Department of Justice Office of Diversion Control. Combat Methamphetamine
Epidemic Act 2005. Available at: http:///www.deadiversion.usdoj.gov/meth. Accessed
April 3, 2008
4.
Manini AF, Kabrhel C, Thomsen TW. Acute myocardial infarction after over-the-counter
use of pseudoephedrine. Ann Emerg Med 2005;45:213-6.
5.
US Food and Drug Administration. Public Health Advisory Nonprescrption Cough and
Cold Medicine Use in Children. Available at: http://www.fda.gov/cder/drug/advisory/
cough_cold_2008.htm. Accessed January 25, 2008.
www.utahpoisoncontrol.org
TOXICOLOGY TODAY 3
M eet t h e upcc s ta f f
Toxins in the news
Fentanyl Patch Deaths: Deaths and life-threatening events
have occurred in opioid-naive patients and when opioid-tolerant
patients have applied more patches than prescribed, changed the
patch too frequently, and exposed the patch to a heat source.
Barbara Insley Crouch, Pharmd,
msph joined the UPCC in 1990. Since 1992 she has served as the
UPCC director. She received her BS
in Pharmacy from the Philadelphia
College of Pharmacy and Science, her
PharmD jointly administered by the University of Texas Health
Science Center at San Antonio and The University of Texas at
Austin College of Pharmacy. She completed a Clinical Toxicology
Fellowship at the Maryland Poison Center, University of
Sudden Hearing Loss from Erectile Dysfunction Drugs:
Maryland School of Pharmacy. She received a masters of science
Acute hearing loss with occasional tinnitus, vertigo, or dizziness
in public health from the University of Utah. Prior to moving
has been reported in patients taking erectile dysfunction drugs
to Utah she worked at the Delaware Valley Regional Poison
(PDE5 inhibitors: Viagra (sildenafil), Cialis (tadalafil) and
Control Center and the San Francisco Bay Area Regional Poison
Levitra (vardenafil). In most cases the hearing loss involved one
ear, and about a third of the time it was temporary.
Control Center. She is also a faculty member in the Department
http://www.fda.gov/medwatch/safety/2007/safety07.htm#PDE5
of Pharmacotherapy, University of Utah College of Pharmacy
where she also serves as vice-chair. When not working she enjoys
Biphosphonates Associated Pain: Severe bone, joint, or muscle
pain has occurred in patients taking bisphosphonates. The pain cooking, exercise, reading, snowshoeing, skiing, hiking and
may occur within days, months, or years after starting the drug. camping. Favorite poisoning topics: inhalants, non-prescription
drugs of abuse, salicylates and dietary supplements.
http://www.fda.gov/medwatch/safety/2008/safety08.htm#Bisphosphonates
Fentanyl Buccal Tablets (Fentora): Life-threatening
respiratory depression can occur in patients who are not opioidtolerant. It should not be prescribed for acute or postoperative
pain, headaches, or post-traumatic pain. Patients should never
take more than two doses to treat an episode of breakthrough
pain. Fentora cannot be substituted for Actiq on a mcg-for-mcg
basis. http://www.fda.gov/medwatch/safety/2007/safety07.htm#Fentora
Utah Poison
Control Center Staff
Director
Barbara Insley Crouch, PharmD, MSPH
Medical Director
E. Martin Caravati, MD, MPH
Associate Medical Director
Douglas E. Rollins, MD, PhD
Assistant Directors
Heather Bennett, MPA
Scott Marshall, PharmD, CSPI*
Administrative Assistant
Julie Gerstner
Specialists in Poison Information
Kathleen T. Anderson, PharmD, CSPI*
Michael Andrus, PharmD
Bradley D. Dahl, PharmD,CSPI*
Michael L. Donnelly, RN, BSN, CSPI*
Craig Graham, RN, BSN
Mo Mulligan, RN, BSN, JD
Ed Moltz, RN, BSN, CSPI*
Sandee Oliver, RN, BSN, CSPI*
Micah Redmond, RN, BSN
Cathie Smith, RN, BSN
John Stromness, BS Pharm, RPh, CSPI*
Poison Information Providers
Megan Glanville
Monique Hall
Christine Holman
Karen Thomas
Outreach Education Provider
Marty C. Malheiro, MS, CHES
Assistant Education Provider
Sherri Pace, BS, CHES
Editors
E. Martin Caravati, MD, MPH
Barbara Insley Crouch, PharmD, MSPH
Please send comments and
suggestions for future articles to
the editor of Toxicology Today at:
Thank You
The Utah Poison Control Center expresses its sincere thanks to
the health care professionals, public health officials and toxicology
colleagues that work together to treat and prevent poisonings.
585 Komas Dr., Suite 200
Salt Lake City, Utah 84108
Or send e-mail to
poison@hsc.utah.edu
*CSPI denotes Certified Specialist in Poison Information.
Administrative: (801) 587-0600
TOXICOLOGY TODAY 4