Eur J Clin Pharmacol (2014) 70:377–378 DOI 10.1007/s00228-013-1629-y
LETTER TO THE EDITORS
Pharmacokinetic changes after placement of a transjugular intrahepatic portosystemic shunt Sabrina De Winter & Sandra Verelst & Joost Wauters & Lorenz Van der Linden & Chris Verslype & Ludo Willems & Isabel Spriet
Received: 15 November 2013 / Accepted: 8 December 2013 / Published online: 19 December 2013 # Springer-Verlag Berlin Heidelberg 2013
To the Editor, Cirrhotic patients with a transjugular intrahepatic portosystemic shunt (TIPS) may be particularly vulnerable to exaggerated effects of drugs [1, 2]. We report for the first time a case with ß-adrenergic blocker (BB) and calcium channel antagonist (CCA) toxicity caused by pharmacokinetic alterations after placement of TIPS. A 76-year-old man with end-stage liver cirrhosis (ChildPugh score B8) was admitted electively to the hepatology ward for placement of a TIPS [expanded polytetrafluorethylenecovered nitinol stent (Viatorr®10/20/70; WL Gore & Associates, Flagstaff, Ariz., USA) dilated with a 9 mm angioplasty balloon (Wanda®; Boston Scientific, Natick, Mass., USA)] for esophageal and rectal variceal bleeding and refractory ascites, secondary to portal hypertension. Pre-procedure portosystemic shunt pressure gradient (PSSPG) was 14 mmHg which decreased to 2 mmHg after TIPS placement. The patient had an extensive medical history: arterial hypertension, stable angina, atrial fibrillation, amiodarone-induced cirrhosis and hypothyroidism; treatments included endarterectomy and stent implantation. His home medication included longacting diltiazem 300 mg, atorvastatin 40 mg, acetylsalicylic S. De Winter (*) : L. Van der Linden : L. Willems : I. Spriet Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium e-mail: [email protected] S. Verelst Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium J. Wauters Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium C. Verslype Hepatology Department, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
acid 100 mg, levothyroxine 75 mcg, bisoprolol 2.5 mg, brotizolam 0.25 mg, propranolol 10 mg twice daily, lisinopril 20 mg, and rapid-acting insulin four times a day. Three days after TIPS placement, the patient developed dyspnea and drowsiness due to severe sinus bradycardia. Intravenous atropine (500 mcg) was administered but did not relieve the bradycardia. Therefore, the patient was transferred from the ward to the emergency department (ED) for upgrade of care. On arrival at the ED, the patient was bradycardic and hypotensive and did not suffer from chest pain. Rectal temperature was 38.8 °C. On electrocardiogram, a sinusbradycardia was observed without other alterations in QRS complex or ST interval. Cardiac troponins were negative. An arterial blood gas (with 15 L O2) revealed PaO2 of 118 mmHg [70–108], PaCO2 of 20 mmHg [35–48], serum bicarbonate level of 13 mmol/L [22–29], pH of 7.46 [7.35–7.45] and serum lactate level of 5.9 mmol/L [0.5–1.6]. Lab results showed a decreased sodium of 124.6 mmol/L [135–145], a normal potassium, magnesium and ionized calcium, CRP level of 244.3 mg/L [
LETTER TO THE EDITORS
Pharmacokinetic changes after placement of a transjugular intrahepatic portosystemic shunt Sabrina De Winter & Sandra Verelst & Joost Wauters & Lorenz Van der Linden & Chris Verslype & Ludo Willems & Isabel Spriet
Received: 15 November 2013 / Accepted: 8 December 2013 / Published online: 19 December 2013 # Springer-Verlag Berlin Heidelberg 2013
To the Editor, Cirrhotic patients with a transjugular intrahepatic portosystemic shunt (TIPS) may be particularly vulnerable to exaggerated effects of drugs [1, 2]. We report for the first time a case with ß-adrenergic blocker (BB) and calcium channel antagonist (CCA) toxicity caused by pharmacokinetic alterations after placement of TIPS. A 76-year-old man with end-stage liver cirrhosis (ChildPugh score B8) was admitted electively to the hepatology ward for placement of a TIPS [expanded polytetrafluorethylenecovered nitinol stent (Viatorr®10/20/70; WL Gore & Associates, Flagstaff, Ariz., USA) dilated with a 9 mm angioplasty balloon (Wanda®; Boston Scientific, Natick, Mass., USA)] for esophageal and rectal variceal bleeding and refractory ascites, secondary to portal hypertension. Pre-procedure portosystemic shunt pressure gradient (PSSPG) was 14 mmHg which decreased to 2 mmHg after TIPS placement. The patient had an extensive medical history: arterial hypertension, stable angina, atrial fibrillation, amiodarone-induced cirrhosis and hypothyroidism; treatments included endarterectomy and stent implantation. His home medication included longacting diltiazem 300 mg, atorvastatin 40 mg, acetylsalicylic S. De Winter (*) : L. Van der Linden : L. Willems : I. Spriet Clinical Pharmacology and Pharmacotherapy, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium e-mail: [email protected] S. Verelst Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium J. Wauters Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium C. Verslype Hepatology Department, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
acid 100 mg, levothyroxine 75 mcg, bisoprolol 2.5 mg, brotizolam 0.25 mg, propranolol 10 mg twice daily, lisinopril 20 mg, and rapid-acting insulin four times a day. Three days after TIPS placement, the patient developed dyspnea and drowsiness due to severe sinus bradycardia. Intravenous atropine (500 mcg) was administered but did not relieve the bradycardia. Therefore, the patient was transferred from the ward to the emergency department (ED) for upgrade of care. On arrival at the ED, the patient was bradycardic and hypotensive and did not suffer from chest pain. Rectal temperature was 38.8 °C. On electrocardiogram, a sinusbradycardia was observed without other alterations in QRS complex or ST interval. Cardiac troponins were negative. An arterial blood gas (with 15 L O2) revealed PaO2 of 118 mmHg [70–108], PaCO2 of 20 mmHg [35–48], serum bicarbonate level of 13 mmol/L [22–29], pH of 7.46 [7.35–7.45] and serum lactate level of 5.9 mmol/L [0.5–1.6]. Lab results showed a decreased sodium of 124.6 mmol/L [135–145], a normal potassium, magnesium and ionized calcium, CRP level of 244.3 mg/L [
