AromaticNitrogen
Bluelighter
- Joined
- Oct 31, 2013
- Messages
- 67
A good friend of mine in another part of the state was taken to the emergency room this morning. His fiance and brother reported progressively deteriorating speech organization and ultimately, around 3 am, intense hallucinations. He is around 5'9 220 lbs.
He began on Abilify 5 mg QHS and Bupropion SR 150 mg BID for treatment resistant anxiety and depression. He has taken Alprazolam 1 mg BID prn for years now. About two weeks ago his Abilify was increased to 10 mg QHS. Since initiation of the Abilify, he had reported extrapyramidal symptoms of increasing intensity, most notably some similar to restless leg syndrome. For this, Benztropine 2 mg QHS was initiated four days prior to this episode. He had also abruptly discontinued Abilify at the same time to change to another neuroleptic which he ended up not being able to afford and thus did not initiate.
Upon arrival at the ER this morning he exhibited xerostomia, confusion, slurred speech, and disorganized sentences with leaps from one topic to another in mid-sentence. From what I was able to gather from his fiance, BP was 170/95 and resting pulse ~100 bpm. He was actively hallucinating, describing his ER room as being full of people including the mailman and numerous professional football players. Toxicology came back negative according to the hospital. He was given Haloperidol 5 mg PO shortly after arrival and the dose repeated around 90 minutes later. His fiance had brought his medications to the hospital for the staff to review. His condition was attributed to discontinuation of Abilify resulting in refractory psychosis. No psychiatric consult occurred. He has no history of psychotic episodes. He was sent home around 8 am due to not being a suicide risk and told to call his psychiatrist on Monday.
At around 9 am I received a phone call from his brother, and subsequently his fiance, and was given all of this information. A few questions later I learned that he had been talking to unseen people, having trouble urinating, and "trying to drink the TV remote." He had also been "spitting his dip" into a cup despite not having a dip in his mouth. I recognized these as tell-tale signs of anticholinergic toxicity, asked about any new meds he had begun, and found out about the Benztropine 2 mg. A count of the bottle, filled on 1/14, revealed 21 of 30 tablets remaining as of 9am 1/18. A total of 18 mg had been consumed between the night of 1/14 and 1/17. This appeared to confirm the suspicion of anticholinergic toxicity. His fiance called the hospital about this, and they were dismissive of it and suggested he be taken to a psychiatric hospital for further evaluation. Being stable, she opted against this and is keeping tabs on his vitals. He is drinking plenty of water and taking Alprazolam 1 mg Q6-8 H. It seems as though the severity of intoxication is finally beginning to lessen. Pupils are moderately reactive to light and he is able to urinate a bit better.
My question is with regards to the presentation of the syndrome and the dose involved. From what I have available to me at home, there does not appear to be much literature available with respect to the toxicity of Benztropine. A few abstracts that I have been able to find have described patients safely managed on daily doses of up to 6 or 8 mg.
My friend who is currently experiencing the throws of delerium is not a drug user, It is our belief that he mistakenly took 2 tablets instead of 1 nightly either by mistaking the directions or thinking that more would help alleviate his symptoms. We won't know until the effects have subsided.
Benztropine has a relatively long half life, but at the same time it seems difficult to imagine that four doses, spaced around 20-24 hours apart, would result in a clinical toxidrome. The people on this forum are pretty fucking sharp, from what I have seen. Does anyone know the acute toxic threshold of this drug, because it's not well established from what I can tell? And if not, could a congenital hypersensitivity to anticholinergics have resulted in his symptoms?
He's going to be alright, but the fact that this occurred has really pushed my "why the fuck did it happen" button. Any input or discussion is appreciated.
He began on Abilify 5 mg QHS and Bupropion SR 150 mg BID for treatment resistant anxiety and depression. He has taken Alprazolam 1 mg BID prn for years now. About two weeks ago his Abilify was increased to 10 mg QHS. Since initiation of the Abilify, he had reported extrapyramidal symptoms of increasing intensity, most notably some similar to restless leg syndrome. For this, Benztropine 2 mg QHS was initiated four days prior to this episode. He had also abruptly discontinued Abilify at the same time to change to another neuroleptic which he ended up not being able to afford and thus did not initiate.
Upon arrival at the ER this morning he exhibited xerostomia, confusion, slurred speech, and disorganized sentences with leaps from one topic to another in mid-sentence. From what I was able to gather from his fiance, BP was 170/95 and resting pulse ~100 bpm. He was actively hallucinating, describing his ER room as being full of people including the mailman and numerous professional football players. Toxicology came back negative according to the hospital. He was given Haloperidol 5 mg PO shortly after arrival and the dose repeated around 90 minutes later. His fiance had brought his medications to the hospital for the staff to review. His condition was attributed to discontinuation of Abilify resulting in refractory psychosis. No psychiatric consult occurred. He has no history of psychotic episodes. He was sent home around 8 am due to not being a suicide risk and told to call his psychiatrist on Monday.
At around 9 am I received a phone call from his brother, and subsequently his fiance, and was given all of this information. A few questions later I learned that he had been talking to unseen people, having trouble urinating, and "trying to drink the TV remote." He had also been "spitting his dip" into a cup despite not having a dip in his mouth. I recognized these as tell-tale signs of anticholinergic toxicity, asked about any new meds he had begun, and found out about the Benztropine 2 mg. A count of the bottle, filled on 1/14, revealed 21 of 30 tablets remaining as of 9am 1/18. A total of 18 mg had been consumed between the night of 1/14 and 1/17. This appeared to confirm the suspicion of anticholinergic toxicity. His fiance called the hospital about this, and they were dismissive of it and suggested he be taken to a psychiatric hospital for further evaluation. Being stable, she opted against this and is keeping tabs on his vitals. He is drinking plenty of water and taking Alprazolam 1 mg Q6-8 H. It seems as though the severity of intoxication is finally beginning to lessen. Pupils are moderately reactive to light and he is able to urinate a bit better.
My question is with regards to the presentation of the syndrome and the dose involved. From what I have available to me at home, there does not appear to be much literature available with respect to the toxicity of Benztropine. A few abstracts that I have been able to find have described patients safely managed on daily doses of up to 6 or 8 mg.
My friend who is currently experiencing the throws of delerium is not a drug user, It is our belief that he mistakenly took 2 tablets instead of 1 nightly either by mistaking the directions or thinking that more would help alleviate his symptoms. We won't know until the effects have subsided.
Benztropine has a relatively long half life, but at the same time it seems difficult to imagine that four doses, spaced around 20-24 hours apart, would result in a clinical toxidrome. The people on this forum are pretty fucking sharp, from what I have seen. Does anyone know the acute toxic threshold of this drug, because it's not well established from what I can tell? And if not, could a congenital hypersensitivity to anticholinergics have resulted in his symptoms?
He's going to be alright, but the fact that this occurred has really pushed my "why the fuck did it happen" button. Any input or discussion is appreciated.
