Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Laced synthetic cannabinoid leads to bleeding
Kelkar AH et al. N Engl J Med. 2018;379:1216-23.
Key clinical point: An outbreak of coagulopathy was linked to superwarfarin-adulterated synthetic cannabinoids.
Major finding: There were more than 150 cases in Illinois with four deaths among patients who developed spontaneous intracranial bleeding.
Study details: A single-institution case series of 15 patients.
Disclosures: Dr. Kelkar reported having no conflicts of interest. Two coinvestigators reported relationships outside the submitted work with Shire, CSL Behring, HEMA Biologics, and other companies.
Citation:
Kelkar AH et al. N Engl J Med. 2018;379:1216-23.
Treating patients who are exposed to synthetic cannabinoid and a superwarfarin such as brodifacoum “requires more than the usual ‘treat ’em and street ’em’ approach,” wrote Jean M. Connors, MD.
“Brodifacoum is a successful rodenticide because of its extremely long half-life (approximately 16-36 days in humans),” Dr. Connors noted.
The drug also is lipophilic, causing tissue sequestration. Once exposed, patients often develop coagulopathy lasting 9 months or longer, she said.
Compared with warfarin poisoning, brodifacoum therefore requires substantially higher-dose and longer-term vitamin K1 therapy. Among the patients in this case series, the maximum outpatient dose was 50 mg, three times daily, and one patient was prescribed 25 mg, twice daily for 270 days, Dr. Connors noted.
“[Dr. Kelkar and his associates] highlight the resources and coordination needed for dealing with a public health crisis that has a prolonged duration of effect,” she added. “Because the synthetic cannabinoid market is lucrative, new products with new toxicity profiles are likely to crop up.”
Dr. Connors is with Brigham and Women’s Hospital, Dana-Farber Cancer Institute, and Harvard Medical School, all in Boston. She reported personal fees from Bristol-Myers Squibb, Portola, Dova Pharmaceuticals, and Unum Therapeutics outside the submitted work. These comments are from her accompanying editorial (N Engl J Med. 2018;379:1275-7).