Transitioning From Methadone to Buprenorphine in a Patient With Prolonged QTc Interval in the Setting of Acute Liver Failure: A Case Report.

IF 4.2 3区 医学 Q1 SUBSTANCE ABUSE
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.

急性肝衰竭QTc间隔延长患者从美沙酮过渡到丁丙诺啡:一例报告。
背景:美沙酮是一种多阿片受体激动剂,是fda批准的治疗阿片使用障碍(OUD)的3种药物之一。急性肝功能障碍可损害肝脏代谢,增加镇静风险。美沙酮可诱导QT间期延长,从而增加足尖扭转的风险,在剂量高于100mg的患者中更为常见。管理美沙酮相关QT间期延长的选择包括降低美沙酮剂量或改用丁丙诺啡,丁丙诺啡是一种部分阿片受体激动剂,也是fda批准用于OUD的药物。当从美沙酮过渡到丁丙诺啡时,急性停药带来了挑战,美沙酮的急性肝代谢受损导致临床医生在开始使用全剂量丁丙诺啡之前必须等待多长时间的不确定性。关于这一转变的指导有限。病例总结:我们报告一例37岁男性丙型肝炎、酒精使用障碍和OUD患者,每日美沙酮210毫克长期缓解,因急性肝衰竭转至第四护理中心进行肝移植评估。在就诊时,心电图显示QTc为785毫秒,提示停用美沙酮。根据需要每6小时服用羟考酮10mg,戒断症状几乎完全改善。在最后一次美沙酮给药后11天、最后一次羟可酮给药后12小时给予丁丙诺啡8 mg SL,患者出现严重的沉淀性停药。讨论:本病例报告强调了评估严重急性肝功能障碍患者美沙酮半衰期的挑战,这些患者需要从美沙酮转向丁丙诺啡。丁丙诺啡低剂量诱导策略可降低急性停药的风险和严重程度。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Journal of Addiction Medicine
Journal of Addiction Medicine 医学-药物滥用
CiteScore
6.10
自引率
9.10%
发文量
260
审稿时长
>12 weeks
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.
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