Podcasts about loperamide

In this episode, we review the high-yield topic of ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Loperamide⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠from the Gastrointestinal section. Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets Linkedin: https://www.linkedin.com/company/medbullets

Disclaimer - The information provided is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Consult your doctor before taking any of these medications. leukotape P - https://amzn.to/4a6bNo9Tylenol - https://amzn.to/3vgMS2pAdvil - https://amzn.to/3PDcOfjAntihistamines Desloratadine 5mg - (prescription)Cetirizine 10mg - https://amzn.to/43zxgU1Motion sickness Meclizine 25mg - https://amzn.to/3x45Ut4Cough & ColdDextromethorphan capsules 15mg - https://amzn.to/3IPCYIbGuaifenesin tablets 200mg - https://amzn.to/3vrOyGc Throat lozenges that contain benzocaine - https://amzn.to/43yOQYvHydrocortisone Cream 1% - https://amzn.to/3VQ93r5Topical Antibiotic ointment - https://amzn.to/3x9qnwNScopolamine (prescription) patches for motion sickness. Azithromycin 250mg tabletsAzithromycin is the antibiotic that can be used for travellers diarrhea. Also for travellers diarrhea. Loperamide 2mg tabs. (Imodium)Quick dissolve tabs are most convenient.Tools:Thermometer - https://amzn.to/3TPReFJScissors - https://amzn.to/3J6O6AuTweezers - https://amzn.to/4cGmgbIFirst Aid Kit - https://amzn.to/4aOmY59Sunscreen - https://amzn.to/3J93TP5Lip Balm w/ sunscreen - https://amzn.to/3VRzVH8Buff Coolnet UV - https://ghfly.shop/BuffBuff Elite Sun Glove - https://ghfly.shop/SunGlove

Join Drs. Galandiuk, Bolshinsky, Kavalukas, and Simon as they discuss Management of Advanced and Malignant Polyps.  Come with us as we navigate through sessile serrated lesions, pathology reports, and rectal polyp nuances.  Hosts:  - Susan Galandiuk, University of Louisville, Louisville, Kentucky, @DCREdInChief - Vladimir Bolshinsky, Peninsula Health, Victoria, Australia, @bolshinskyv - Sandy Kavalukas, University of Louisville, Louisville, Kentucky, @sandykava - Hillary Simon, University of Louisville, Louisville, Kentucky, @HillaryLSimon Producer:  - Manasa Sunkara MS3, University of Louisville, Louisville, Kentucky, @manasasunkara12 Learning objectives:  - Review colorectal cancer screening for the average risk patient. - Understand what a malignant polyp is defined as and management strategies.  - Discuss the pathology review and re-review processes.  References:  - Church J, et al. Keeping the Cecum Clean: A Randomized, Prospective, Placebo-Controlled Trial of Loperamide as Part of Preparation for Colonoscopy. Diseases of the Colon & Rectum 56(1):p 120-125, January 2013. https://pubmed.ncbi.nlm.nih.gov/23222289/ - Fan C, et al. Management of Serrated Polyps of the Colon. Curr Treat Options Gastroenterol 16(1):182-202, March 2018. https://pubmed.ncbi.nlm.nih.gov/29445907/ - Gupta S, et al. Recommendations for Follow-Up After Colonoscopy and Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer. The American Journal of Gastroenterology 115(3): 415-434, March 2020. https://pubmed.ncbi.nlm.nih.gov/32039982/ - Hyman N, Waye JD. Endoscopic four quadrant tattoo for the identification of colonic lesions at surgery. Gastrointest Endosc 37:56–58, 1991. https://pubmed.ncbi.nlm.nih.gov/1706283/ - Kaltenbach T, et al. Endoscopic Removal of Colorectal Lesions—Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointestinal Endoscopy 91(3): 486-519, March 2020. https://pubmed.ncbi.nlm.nih.gov/32067745/ - Keswani R, et al. AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review. Gastroenterology, 161(2): 701 – 711, Aug 2021. https://pubmed.ncbi.nlm.nih.gov/34334168/ - Shaukat A, et al. Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommendations of the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology, 159(5): 1916 - 1934.e2, Nov 2020. https://pubmed.ncbi.nlm.nih.gov/33159840/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent epispdes here: https://app.behindtheknife.org/listen

In this episode, we review the high-yield topic of ⁠⁠⁠⁠⁠⁠⁠⁠⁠Loperamide⁠ from the Gastrointestinal section. Follow ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠Medbullets⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠ on social media: Facebook: www.facebook.com/medbullets Instagram: www.instagram.com/medbulletsofficial Twitter: www.twitter.com/medbullets --- Send in a voice message: https://podcasters.spotify.com/pod/show/medbulletsstep1/message

In this episode, I discuss loperamide (Imodium) pharmacology, adverse effects, and drug interactions. Loperamide has opioid-type activity in the gut but has extremely low oral bioavailability. This allows it to be used for diarrhea but at lower doses won't cause systemic opioid-like effects. Loperamide abuse has been reported. Excessive dosages can increase the risk of cardiac arrest and other cardiovascular concerns. Medication causes of diarrhea should be ruled out prior to starting a medication like loperamide. I discuss numerous medications that can cause diarrhea in this podcast.

Download the cheat: https://bit.ly/50-meds  View the lesson: https://bit.ly/LoperamideImodiumNursingConsiderations      Generic Name loperamide Trade Name Imodium Indication acute diarrhea, decrease drainage post ileostomy Action inhibits peristalsis, reduces the volume of feces while increasing the bulk and viscosity Therapeutic Class antidiarrheal Nursing Considerations • may lead to constipation – insure proper use • assess bowel function • assess fluid and electrolyte levels

Thank you David "Batman" Brown OMS IV for developing this podcast. Thank you Joshua Hansen, OMS III for joining us! This podcast reviews the problem of Loperamide misuse as an alternative to other opioids. This was a way of looking at how metabolism, excretion and transporter pumps might affect the medications we use. We enjoyed our discussion and hope you find it as interesting as we did! Thank you Jordan Turner for creating the perfect bumper music!

Guest: Tyler S. Oesterle, M.D., M.P.H. (@OesterleMD) Host: Darryl S. Chutka, M.D. (@ChutkaMD) Opioid abuse remains a significant problem, and as law enforcement and regulatory agencies tighten access to prescription analgesics, individuals are seeking alternatives. It's been discovered that when taken at very high doses, loperamide can produce similar effects to the opioid analgesics and the drug is inexpensive when compared to the price of both illicit and prescription opioids. As a result, loperamide abuse has become a significant problem. In this episode we discuss loperamide abuse with Tyler Oesterle, M.D., M.P.H., a psychiatrist at Mayo Clinic's Rochester campus. We'll review the typical central nervous system effects of high dose loperamide and the associated safety issues. Specific topics: Current status of the opioid crisis in the U.S. Effects of loperamide in both therapeutic and excessive doses Reasons behind taking high dose loperamide in excessive doses Safety issues associated with high dose loperamide Potential of high dose loperamide leading to drug dependence Connect with the Mayo Clinic's School of Continuous Professional Development online at https://ce.mayo.edu/ or on Twitter @MayoMedEd.

In this podcast, Dr. Cole Pueringer, a toxicology fellow with the Minnesota Poison Control System (Hennepin Healthcare), discusses various over-the-counter medications and their toxicological potential. Enjoy the podcast! Objectives:     Upon completion of this podcast, participants should be able to: List at least 3 potentially dangerous over-the-counter (OTC) medications. Discuss the basic clinical presentation and management of the following over-the-counter (OTC) medications: acetaminophen, diphenhydramine loperamide, ibuprofen, and dextromethorphan. CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org. Click on the following link for your CME credit: CME Evaluation: "The Dose Makes the Poison: Over-the-Counter (OTC) Medication" (**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.)  DISCLOSURE ANNOUNCEMENT  The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws.  It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented. Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.    SHOW NOTES: Antihistamines:  Like so many other over-the-counter medications, the dose of antihistamines makes the poison. Sedation is the most common side effect in antihistamine overdose. Some, like diphenhydramine, are more toxic and have profound anticholinergic effects. Sinus tachycardia is one of the first presentations, but remember the phrases: Tachy as a tie, dry as a bone, mad as a hatter, red as a beet, hot as a hare and blind as a bat. Excitatory toxidromes can be confusing, but urinary retention, impaired bowel motility and the absence of diaphoresis will differentiate anticholinergic toxicity from the other excitatory toxidromes. the higher the dose, the more side effects seen, leading to seizures and cardiac toxicity. Physostigmine is an antidote for anticholinergic toxicity. Delirium is the main indication for physostigmine, but it can also be given to prevent intubation and at times to get a more accurate history from the patient. Physostigmine lowers the seizure threshold, so benzodiazepines are usually given prior administration. Most likely they have already been given to treat undifferentiated delirium and excitation. Of note, physostigmine is not the cure all for the toxidrome because it has a very short half life. In the setting of seizures in overdose, very few anticonvulsants are safe. Benzodiazepines are some of the safer GABAergic agents. GABA is our main CNS inhibitory neurotransmitter, it essentially "tones down the nerves". Propofol and some other GABAergic agents can also help with tachycardia and hyperthermia. In these settings, benzodiazepines are given in very high doses. Diphenhydramine causes sodium channel blockade, subsequently decreasing action potential. lowering calcium in the cells, and causing life threatening myocardial depression. Calcium is given in this circumstance, but the mainstay of treatment is sodium bicarbonate. It works by increasing overall sodium availability and the pH. The more acidotic the patient, the more of the drug becomes unbound and available. At higher pH levels, the sodium channel blockade weakens, and more of the drug becomes protein bound. What about other antihistamines? While overdose of other antihistamines will be uncomfortable, the life threatening seizures and cardiac toxicity is unique to diphenhydramine.  Acetaminophen:  Acetaminophen is the highest nationally in morbidity and mortality of all drug overdoses. Most often taken on it's own, it's also mixed into many over-the-counter remedies. In the first 24-hours post-ingestion, the symptoms can be minimal. It's metabolized in the liver, and a small portion is metabolized by CIP 2E1, resulting in the toxic metabolite NAPQI. Normally, glutathione will detoxify NAPQI, but in acetaminophen overdose, glutathione stores are depleted and the excess NAPQI creates havoc in the liver. In a reliable historian with an acute ingestion, the Rumack-Matthew nomogram is employed, and will help guide antidote therapy. Serum acetaminophen levels will not be helpful until 4 hours post-ingestion, unless something that slows GI transit time and absorption has been taken as well. N-acetylcysteine or "NAC", is the antidote for Tylenol. If given within eight hours of ingestion it can prevent any liver toxicity. It can also be started any time a serious ingestion is suspected. Keep in mind, delayed-release Tylenol, certain populations, and conditions can obscure the diagnosis and in those settings the Rumack-Matthew nomogram can no longer be used. Chronic alcoholics who have just stopped drinking and malnourished patients are at higher risk of toxicity. Subacute and chronic ingestion is also very common. Essential lab tests include serum acetaminophen levels, ALT and AST, and INR. One would expect any or all of these to be elevated in significant toxicity. If they are, NAC is given intravenously for nearly 24 hours. NAC won't reverse hepatotoxicity that has already occurred, but will prevent more from happening. Dextromethorphan:  Dextromethorphan, referred to sometimes as "robotripping" or "robo-frying". Taken in excess causes an individual to become disassociated. It is an NMDA antagonist, like ketamine, LSD and PCP. Expect to see the same clinical signs of serotonin excess, as well as dystonia. Patients can alternate dramatically between vacant blank stares, to incredibly violent outbursts. Patient and staff safety is a crucial element in treating this toxidrome. Rotatory nystagmus, a distinctive rapid "clock ticking" of the eyes is diagnostic of this type of ingestion. Loperamide:  When Loperamide, an over-the-counter antidiarrheal, is used in abuse it can lead to death. It acts similar to opioids, slowing down the GI tract but without the central effects, because it is actively expelled from the CNS. In large doses, however, it delivers an opioid-like high. Loperamide can cause respiratory depression, but also persistent arrhythmias. The lethal effects are due to loperamide's potassium channel blocker properties causing profound QT prolongation, sinusoidal waves and can lead to cardiac arrest. Potassium channel blockade is difficult to treat. ACLS drugs, electrolyte normalization like magnesium infusions, and even Narcan can be given, but more than likely these incredibly sick patients will need ECMO. Ibuprofen:  Ibuprofen is, overall, a safe drug. Large quantities of the drug have to be taken for toxic effects. If taking over 200mg/kg if Ibuprofen, a patient is likely to have some GI symptoms and possibly an acute kidney injury. treatment would include possible admission for antiemetics and IV fluids. Ibuprofen is metabolized as a propionic acid anion. If ore than 400mg/kg are taken, it will result in an anion gap metabolic acidosis. At over 600mg/kg, a whole constellation of symptoms results: seizures, hypotension, and cardiac shock. These patients are severely ill and may require ECMO for an extended period of time. At this dosage, a 100kg patient would need to take 300 pills. Which leads to the question, "How did they fit that many pills in their stomach?"  Activated Charcoal:  Finally, a note on activated charcoal. It works great for almost everything, except alcohol ingestion and metals, by binding drugs in the GI tract. Drug absorption is decreased by 60% if given within an hour. It should be avoided if the airway is compromised or if the patient is a risk for seizure. In an intubated patient with recent ingestion, it's given via nasogastric tube. Thank-you for listening.

Loperamide 2mg Hard Capsules are used to treat two types of diarrhea. The two types have different age limits for adults and children aged 12 and over to treat attacks that can last up to 48 hours.https://recoverypartnernetwork.com/drug/opioid/loperamide-abuse

Loperamide abuse has been on the rise within the past ten years. When high doses of the drug are consumed, it can produce effects similar to opioids. https://recoverypartnernetwork.com/drug/opioid/loperamide-abuse

Imodium overdose can lead to symptoms that scale from mild nausea and vomiting to problems with the liver and heart. The FDA has recently introduced a new Imodium warning label, alerting the users that taking a higher dose than recommended may cause cardiac arrhythmias or heart attacks.https://recoverypartnernetwork.com/drug/opioid/loperamide-abuse

Loperamide typically starts working within 1 hour to ease your diarrhea. Most people will have to take Loperamide only for 1 to 2 days but, you may need to take it for longer if you have diarrhea due to intestinal problems such as Crohn's disease, ulcerative colitis, or short bowel syndrome.https://recoverypartnernetwork.com/drug/opioid/loperamide-abuse

Loperamide is a very safe, non-addictive drug that can be taken at doses of up to 8 capsules (16 milligrams) per day over a long period of time. However, It is not advised to consume more than 16 milligrams a day without seeking medical advice.https://recoverypartnernetwork.com/drug/opioid/loperamide-abuse

Loperamide is usually administered once at the beginning of the treatment and then up to four times a day after each loose stool until the diarrhea is better. It must not be taken more often than every 3 hours or longer than two days.https://recoverypartnernetwork.com/drug/opioid/loperamide-abuse

In this episode, recorded just before the New Year, I discuss recent news in brain cancer research. This includes:How the drug loperamide (brand name Imodium), induces cell death in glioblastoma cell lines and if this could have promise for real, human applications. Metabolic reprogramming via inhibition of a key cancer metabolite- D-2-Hydroxyglutarate (D-2-HG).Developments of liquid biopsies for glioma. 

Buying as much loperamide as you possibly can Loperamide history1969- Synthesized (1)1976 FDA Approved as schedule V (2)Jaffe trial of "abuse potential"- https://pubmed.ncbi.nlm.nih.gov/7438696/1982- Descheduled (3)2010-Annually Increasing in # of poison center calls, cases of arrhythmia and hospitalization (4,5,6)2016- Submission to DEA for rescheduling of loperamide denied (7)2019- FDA works with manufactures to reduce package size to 48 tablets (8)Pharmacist knowledge of abuse remains low https://pubmed.ncbi.nlm.nih.gov/32641253/Toxic MechanismFun theories about co evolution of PGP and CYP https://pubmed.ncbi.nlm.nih.gov/10837556/Inhibition of sodium channels, and to a higher affinity, Human Ether a Go-Go Related (HERG) channel leads to prolonged repolarization (9)IC50 for HERG Ikr ~ 40 nm/l (1908 ng/dl), inhibits as low as 10 nm/l (10)Case reports of conduction disturbance with level of 22 ng/ml (14)Levels in fatalities vary but  reported as high as 270 ng/ml in some studies  (15)Prolonged re polarization leads to torsadesEarly after depolarizations may trigger, which are then propagated torsades via re entrant rhythms (11)TreatmentACMT loperamide guidelines (12)Supportive careArrhythmia managementTorsades (13)Electrical cardioversion (terminates re entrant rhythm)Magnesium (prevents early after depolarization)Target Mg >2 and K >4Lidocaine-> Recommended in 2006 Sudden cardiac death guidlines, not mentioned in 2017, however one of the only VT recommended antiarryhtmics that do not prolong QTc (others, sotalol, amiodarone, and procainamide, do)If preceded by bradycardia, Overdrive pacing with isoproterenol to target HR~ 100Beta blockers are recommended in patients with LQTSSodium channel blockade induced wide QRS complex tachycardia (12)Hypertonic sodium to over whelm sodium channel blockade (1-2 amps of 8.4% Sodium Bicarbonate given IV)Where do we go in the future?More research will help us understand the true incidence of how often this occurs and what impact the FDA decisions will haveAny concerned citizen can submit for rescheduling of loperamide. Interested? Reach out at toxtalk1@gmail.comDrug Enforcement Agency. The Controlled Substances Act. Available at: https://www.dea.gov/controlled-substances-act.Florey, Klaus (1991). Profiles of Drug Substances, Excipients and Related Methodology, Volume 19. Academic Press. p. 342. ISBN9780080861142."IMODIUM FDA Application No.(NDA) 017694". U.S. Food and Drug Administration (FDA). 1976.https://www.deadiversion.usdoj.gov/schedules/orangebook/orangebook.pdf.Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45eS50.Feldman R, Everton E. National assessment of pharmacist awareness of loperamide abuse and ability to restrict sale if abuse is suspected [published online ahead of print, 2020 Jul 5]. J Am Pharm Assoc (2003). 2020;S1544-3191(20)30264-8. doi:10.1016/j.japh.2020.05.021Eggleston W, Marraffa JM, Stork CM, et al. Notes from the Field: Cardiac Dysrhythmias After Loperamide Abuse — New York, 2008–2016. MMWR Morb Mortal Wkly Rep 2016;65:1276–1277. DOI: http://dx.doi.org/10.15585/mmwr.mm6545a7https://www.chpa.org/PDF/09_05_17_CommentsCitizenPetitionLoperamide.aspxhttps://www.fda.gov/drugs/drug-safety-and-availability/fda-limits-packaging-anti-diarrhea-medicine-loperamide-imodium-encourage-safe-useKang J, Compton DR, Vaz RJ, Rampe D. Proarrhythmic mechanisms of the common anti-diarrheal medication loperamide: revelations from the opioid abuse epidemic. Naunyn Schmiedebergs Arch Pharmacol. 2016;389(10):1133-1137. doi:10.1007/s00210-016-1286-7Klein MG, Haigney MCP, Mehler PS, Fatima N, Flagg TP, Krantz MJ. Potent Inhibition of hERG Channels by the Over-the-Counter Antidiarrheal Agent Loperamide. JACC Clin Electrophysiol. 2016;2(7):784-789. doi:10.1016/j.jacep.2016.07.008https://www.sciencedirect.com/science/article/pii/S1880427611800050Eggleston W, Palmer R, Dubé PA, et al. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol (Phila). 2020;58(5):355-359. doi:10.1080/15563650.2019.1681443Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society [published correction appears in J Am Coll Cardiol. 2018 Oct 2;72(14):1760]. J Am Coll Cardiol. 2018;72(14):e91-e220. doi:10.1016/j.jacc.2017.10.054Marraffa JM, Holland MG, Sullivan RW, et al. Cardiac conduction disturbance after loperamide abuse. Clin Toxicol (Phila). 2014;52(9):952-957. doi:10.3109/15563650.2014.969371Miller H, Panahi L, Tapia D, Tran A, Bowman JD. Loperamide misuse and abuse. J Am Pharm Assoc (2003). 2017;57(2S):S45-S50. doi:10.1016/j.japh.2016.12.079

Acute Gastroenteritis- Author: Dr. Brian Geyer Introduction: Do both vomiting and diarrhea have to be present? No 1996 AAP guidelines, 2016 ACG guidelines, and 2017 IDSA guidelines all note diarrhea illness but may be vomiting predominant. Studies use more vague definitions like: > 1 episode of vomiting and/or > 3 episodes of diarrhea in 24 hours without known chronic cause like inflammatory bowel disease. Diarrhea is at least 3 unformed stools per day. Acute episode 29 days Patients in the ED may present with only some of these symptoms depending their time in course of illness. Literature Review: There is abundant literature on pediatric AGE but sparse research on AGE in adults. Therefore, many recommendations are extrapolated from the pediatric literature. Causes: 70% of US cases are estimated to be caused by viruses, norovirus being most common. o 26% norovirus o 18% rotavirus Among bacterial causes: o 5.3% Salmonella, most common o 5.3% Clostridium o 3% Campylobacter o 3% parasitic infections Large portion, 51%, have no cause identified. (In ED patients) Interestingly, 79% of cases never have a cause identified (not ED specific) In ED patients, only 25% ever have a cause identified, this increases to 49% when a stool sample is obtained. (not ED specific) Food poisoning is responsible for 5% of AGE but results in 30% of deaths. Most commonly: Salmonella, Clostridium perfringens, and Campylobacter Majority of foodborne illness is still viral, mostly norovirus E Coli is normal in the gut, but two most common causes are: Shiga toxin Ecoli (STEC) AKA enterohemorrhagic Ecoli (EHEC) - causes Hemolytic Uremic Syndrome in 5-10% Entertoxigenic Ecoli (ETEC) - causes traveler's diarrhea Both cause self-limited illness. Alternate Diagnoses: Appendicitis: In the peds literature, misdiagnosis of appendicitis as AGE leads to 47% absolute increased risk of perforation. Suggestive findings include: Migration of pain to RLQ RLQ tenderness on exam (initial or repeat) Absence of diarrhea Pain not improved with episodes of diarrhea Negative factors include multiple ill family members, recent international travel, presence of diarrhea (as defined above). Ciguatera Fish Poisoning Toxin produced by algae consumed by reef fish like grouper, red snapper, sea bass and Spanish mackerel. Symptoms begin 6-24 hours post ingestion. Fish tastes normal. Patients may develop neurological symptoms like paresthesias, generalized pruritis, and reversal of hot/cold sensation. Symptoms resolve spontaneously, and treatment with mannitol is controversial. Scombroid Poisoning Ingesting fish in the Scombroidae family - mackerel, bonito, albacore, and skipjack - that have been stored improperly Bacteria produce histidine decarboxylase which converts histidine to histamine Causes abdominal cramps and diarrhea, and may cause metallic bitter or peppery taste in mouth, and facial flushing within 20-30 min of ingestion Can be confused with allergic reaction Symptoms resolve in 6-8 hours Notification of health dept may prevent others from being infected. Page 5 Table 1- Distinguishing Factors in the Differential Diagnosis of AGE History: Table 2, page 6 has key questions to ask. Onset, timing, number of stools, presence of blood, fever, quality of abdominal pain and location, recent antibiotics, etc. Extremes of age, immunosuppression, and pregnancy should be identified. Mortality is highest in the patients >65 yo. Physical Exam: We talked about RLQ abd pain, but what about bloody stool? An observational study of 889 adults and 151 pediatric with AGE showed that a negative fecal occult test showed accurately excluded invasive bacterial etiology with a NPV 87% in adults and 96% in children. But PPV was only 24%. Laboratory Testing and Imaging: Dehydration is the biggest contributor to mortality, especially in the very young and elderly. Lab evaluation for dehydration is recommended in these populations. No consistent association between lab abnormalities and bacterial etiology. WBC and differential does not differentiate bacterial vs viral, but may help in identifying severity of illness. Hemoglobin and platelets are helpful if HUS is suspected. Stool Cultures: 2017 IDSA guidelines recommends them in patients with fever, bloody or mucoid stools, severe abdominal cramping or tenderness, or signs of sepsis, noting these patients are at higher risk of bacterial infection. Specifically, Salmonella, shigella, Campylobacter, and Yersinia 2016 ACG guidelines recommend them for patients with watery diarrhea and moderate to severe illness with fever for at least 72 hours. Consider them for immunocompromised patients and those with recent abx use or hospitalization. C Difficile testing is recommended for all patients with AGE who are age >2 with a history of recent abx use or recent hospitalization Blood cultures are recommended for patients

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Loperamide abuse, heart failure quality measures, and the CASTLE-AF ablation study are discussed in this week's podcast.

This episode covers Chapter 31 of Rosen's Emergency Medicine. Episode Overview: 1)  Define Acute, Persistent, Chronic Diarrhea 2)  Describe the 4 mechanisms of diarrhea 3)  List 15 historical factors that increase the risk of probability of non-benign diarrhea 4)  What are the indications for empiric antibiotic treatment? 5)  List 6 organisms that cause bloody diarrhea WiseCracks 1)  When is Loperamide indicated? 2)  When should you use stool cultures / O&P 3)  Best way to give children pedialyte?

This episode covers Chapter 31 of Rosen's Emergency Medicine. Episode Overview: 1)  Define Acute, Persistent, Chronic Diarrhea 2)  Describe the 4 mechanisms of diarrhea 3)  List 15 historical factors that increase the risk of probability of non-benign diarrhea 4)  What are the indications for empiric antibiotic treatment? 5)  List 6 organisms that cause bloody diarrhea WiseCracks 1)  When is Loperamide indicated? 2)  When should you use stool cultures / O&P 3)  Best way to give children pedialyte?

Loperamide, an opiate agonist of high specificity for p-receptors, was recently reported to suppress ACTH and cortisol levels in normal subjects, but not in patients with proven ACTH-dependent Cushing’s disease. However, there is little information on the site of action of loperamide in the hypothalamo-pituitary-adrenal axis of man. We investigated the effect of loperamide on pituitary hormone secretion in uiuo and in vitro. In seven normal subjects, basal ACTH plasma levels were significantly suppressed 3 h after loperamide administration (16 mg, orally) from 5 + 1 to 2 f 0 pmol/L (P < 0.0001). After the combined pituitary stimulation test (100 pg human CRH, 100 rg GnRH, 100 pg GH-releasing hormone, and 200 pg TRH), the ACTH peak (maximum increase at 30 min) was significantly blunted by loperamide from 9 + 1 to 4 of: 1 pmol/L (P < 0.001) and the area under the curve of ACTH from O-120 min was reduced from 35 + 5 to 23 + 4 pmol/L.2 h (P < 0.05). In the insulin-hypoglycemia test (0.15 IU/kg BW), neither the ACTH peak nor the area under the curve of ACTH was affected by loperamide. In six patients with Cushing’s disease and one patient with secondary adrenal insufficency due to hypothalamic failure, neither basal ACTH and cortisol levels nor CRH-stimulated levels were influenced by loperamide. In four cultured human corticotropic adenomas, loperamide was not able to reduce basal and CRH-induced ACTH secretion. In summary, loperamide is able to reduce basal and CRHinduced ACTH and cortisol levels in normal subjects, but not in patients with Cushing’s disease or secondary adrenal failure of hypothalamic origin. Loperamide has no significant effect on insulin-hypoglycemia- induced ACTH and cortisol levels and, therefore, no effect on stress-induced elevation of cortisol levels. Loperamide might act at a suprapituitary site in man in viuo, but, nevertheless, a pituitary site cannot be excluded.