Matthew Girard Hermenau, Gaurika Mester, Katrina Ciraldo
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引用次数: 0
Abstract
Background: Methadone, a mu-opioid receptor agonist, is one of 3 FDA-approved medications for opioid use disorder (OUD). Acute liver dysfunction can impair hepatic metabolism and increase sedation risk. Methadone can induce QT prolongation, which increases the risk of Torsades de Pointes, more commonly in patients on doses higher than 100 mg. Options for managing methadone-related QT prolongation include lowering the methadone dose or switching to buprenorphine, a partial mu-opioid agonist also FDA-approved for OUD. Precipitated withdrawal poses a challenge when transitioning from methadone to buprenorphine, and acute impaired hepatic metabolism of methadone contributes to uncertainty about how long clinicians must wait before initiating full-dose buprenorphine. Limited guidance exists on this transition.
Case summary: We report the case of a 37-year-old man with hepatitis C, alcohol use disorder, and OUD in long-term remission on methadone 210 mg daily who was transferred to a quaternary care center for liver transplant evaluation due to acute liver failure. On presentation, an EKG showed a QTc of 785 milliseconds prompting discontinuation of methadone. Oxycodone 10 mg every 6 hours as needed was started, with nearly full amelioration of withdrawal symptoms. Eleven days after the last methadone dose, and 12 hours after the last oxycodone dose, buprenorphine 8 mg SL was administered, and the patient experienced severe precipitated withdrawal.
Discussion: This case report highlights the challenge of estimating methadone half-life in a patient with severe acute liver dysfunction who needs to switch from methadone to buprenorphine. A buprenorphine low-dose induction strategy may reduce the risk and severity of precipitated withdrawal.
期刊介绍:
The mission of Journal of Addiction Medicine, the official peer-reviewed journal of the American Society of Addiction Medicine, is to promote excellence in the practice of addiction medicine and in clinical research as well as to support Addiction Medicine as a mainstream medical sub-specialty.
Under the guidance of an esteemed Editorial Board, peer-reviewed articles published in the Journal focus on developments in addiction medicine as well as on treatment innovations and ethical, economic, forensic, and social topics including:
•addiction and substance use in pregnancy
•adolescent addiction and at-risk use
•the drug-exposed neonate
•pharmacology
•all psychoactive substances relevant to addiction, including alcohol, nicotine, caffeine, marijuana, opioids, stimulants and other prescription and illicit substances
•diagnosis
•neuroimaging techniques
•treatment of special populations
•treatment, early intervention and prevention of alcohol and drug use disorders
•methodological issues in addiction research
•pain and addiction, prescription drug use disorder
•co-occurring addiction, medical and psychiatric disorders
•pathological gambling disorder, sexual and other behavioral addictions
•pathophysiology of addiction
•behavioral and pharmacological treatments
•issues in graduate medical education
•recovery
•health services delivery
•ethical, legal and liability issues in addiction medicine practice
•drug testing
•self- and mutual-help.