{"title":"拉莫三嗪引起的危及生命的皮疹和对其药理的不了解:法医侦探工作如何利用医学知识和临床药理学来破案。","authors":"Sheldon H Preskorn, David D Masolak","doi":"10.1097/PRA.0000000000000791","DOIUrl":null,"url":null,"abstract":"<p><p>This column is the second of a 3-part series describing cases where general medical knowledge, including psychiatric and clinical pharmacology, were instrumental in determining dereliction and direct cause in a malpractice suit. This case summarizes how lamotrigine can cause dangerous consequences if its pharmacology is not properly understood. The case also illustrates how the 4 Ds of a forensic malpractice suit were met in this case. First, there was duty on the part of the prescriber which, if followed, would have prevented or minimized the damages experienced by the patient. Dereliction in the performance of a patient-physician treatment contract was a direct cause of the development of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in this patient. An immune-mediated reaction to lamotrigine or one of its metabolites has been extensively reported in the literature, with the risk of this reaction increasing at higher doses and with more rapid titration, fulfilling the elements of direct cause. Dereliction implies a deviation from the standard of care. On the basis of the clinical information from the package insert, more likely than not a deviation from the standard of care occurred in this case when lamotrigine was titrated faster than recommended by the package insert.</p>","PeriodicalId":16909,"journal":{"name":"Journal of Psychiatric Practice","volume":null,"pages":null},"PeriodicalIF":1.3000,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Life-threatening Rash Due to Lamotrigine and a Failure to Understand Its Pharmacology: How Forensic Detective Work Uses Medical Knowledge and Clinical Pharmacology to Solve Cases.\",\"authors\":\"Sheldon H Preskorn, David D Masolak\",\"doi\":\"10.1097/PRA.0000000000000791\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><p>This column is the second of a 3-part series describing cases where general medical knowledge, including psychiatric and clinical pharmacology, were instrumental in determining dereliction and direct cause in a malpractice suit. This case summarizes how lamotrigine can cause dangerous consequences if its pharmacology is not properly understood. The case also illustrates how the 4 Ds of a forensic malpractice suit were met in this case. First, there was duty on the part of the prescriber which, if followed, would have prevented or minimized the damages experienced by the patient. Dereliction in the performance of a patient-physician treatment contract was a direct cause of the development of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in this patient. An immune-mediated reaction to lamotrigine or one of its metabolites has been extensively reported in the literature, with the risk of this reaction increasing at higher doses and with more rapid titration, fulfilling the elements of direct cause. Dereliction implies a deviation from the standard of care. On the basis of the clinical information from the package insert, more likely than not a deviation from the standard of care occurred in this case when lamotrigine was titrated faster than recommended by the package insert.</p>\",\"PeriodicalId\":16909,\"journal\":{\"name\":\"Journal of Psychiatric Practice\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":1.3000,\"publicationDate\":\"2024-07-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Journal of Psychiatric Practice\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1097/PRA.0000000000000791\",\"RegionNum\":4,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q3\",\"JCRName\":\"PSYCHIATRY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Psychiatric Practice","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/PRA.0000000000000791","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"PSYCHIATRY","Score":null,"Total":0}
引用次数: 0
摘要
本专栏是三部曲系列中的第二部,描述了一些案例,在这些案例中,医学常识(包括精神病学和临床药理学)在确定医疗事故诉讼中的失职和直接原因方面发挥了重要作用。本案例总结了如果不正确理解拉莫三嗪的药理学,它是如何导致危险后果的。该案例还说明了本案如何满足了法医渎职诉讼的 4 D 要求。首先,处方者有责任,如果他履行了这一责任,本可以避免或最大限度地减少患者遭受的损害。在履行患者与医生之间的治疗合同方面的失职是导致该患者发生史蒂文斯-约翰逊综合症/中毒性表皮坏死症(SJS/TEN)的直接原因。文献中广泛报道了拉莫三嗪或其代谢物引起的免疫介导反应,剂量越大、滴注越快,发生这种反应的风险越高,因此符合直接原因的要素。失职意味着偏离了护理标准。根据说明书中的临床信息,在本病例中,拉莫三嗪的滴定速度快于说明书的建议速度,很有可能是偏离了治疗标准。
Life-threatening Rash Due to Lamotrigine and a Failure to Understand Its Pharmacology: How Forensic Detective Work Uses Medical Knowledge and Clinical Pharmacology to Solve Cases.
This column is the second of a 3-part series describing cases where general medical knowledge, including psychiatric and clinical pharmacology, were instrumental in determining dereliction and direct cause in a malpractice suit. This case summarizes how lamotrigine can cause dangerous consequences if its pharmacology is not properly understood. The case also illustrates how the 4 Ds of a forensic malpractice suit were met in this case. First, there was duty on the part of the prescriber which, if followed, would have prevented or minimized the damages experienced by the patient. Dereliction in the performance of a patient-physician treatment contract was a direct cause of the development of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) in this patient. An immune-mediated reaction to lamotrigine or one of its metabolites has been extensively reported in the literature, with the risk of this reaction increasing at higher doses and with more rapid titration, fulfilling the elements of direct cause. Dereliction implies a deviation from the standard of care. On the basis of the clinical information from the package insert, more likely than not a deviation from the standard of care occurred in this case when lamotrigine was titrated faster than recommended by the package insert.
期刊介绍:
Journal of Psychiatric Practice® seizes the day with its emphasis on the three Rs — readability, reliability, and relevance. Featuring an eye-catching style, the journal combines clinically applicable reviews, case studies, and articles on treatment advances with practical and informative tips for treating patients. Mental health professionals will want access to this review journal — for sharpening their clinical skills, discovering the best in treatment, and navigating this rapidly changing field.
Journal of Psychiatric Practice combines clinically applicable reviews, case studies, and articles on treatment advances with informative "how to" tips for surviving in a managed care environment.