EXPERIENCE
Subarachnoid hemorrhage in a patient taking phentermine for weight loss Jonathan A. Bain, Jeremy S. Dority, and Aaron M. Cook
Abstract Objective: To report the case of an angiography-negative subarachnoid hemorrhage (SAH) in association with increased use of the sympathomimetic phentermine. Summary: A 45-year-old woman taking phentermine for weight loss presented with the “worst headache of her life,” as well as nausea and some confusion. Her prior medical history was largely negative for pathology except for a 20-pack–year history of smoking. Results: Upon admission to an inpatient facility, the patient was normotensive with a Glasgow Coma Score of 15. She was found on computed tomography to have a diffuse SAH (Hunt and Hess grade 2, Fisher grade 3). Digital subtraction angiography, performed on hospital day 2, was negative for aneurysm. The patient convalesced in the intensive care unit for 8 days and was treated as a typical patient with SAH (i.e., vasospasm prophylaxis with nimodipine and atorvastatin, ad lib diet with strict attention to fluid balance to maintain euvolemia). A repeat angiographic study on hospital day 8 also did not reveal an aneurysm or other cause for her SAH. She was discharged thereafter with intensive smoking cessation education and counseled to discontinue phentermine. Upon follow-up 6 weeks later, the patient was without complaints or neurologic deficits and had resumed her previous activities and work.
Received November 5, 2013, and in revised form January 26, 2014. Accepted for publication February 18, 2014. Published online in advance of print August 22, 2014. Jonathan A. Bain, PharmD, BCPS, is Critical Care Pharmacist, Cedars-Sinai Medical Center, Los Angeles, CA; at the time of the research, he was a PGY-2 Critical Care Resident, University of Kentucky, Lexington. Jeremy S. Dority, MD, is Assistant Professor, Department of Anesthesiology, College of Medicine, University of Kentucky, Lexington. Aaron M. Cook, PharmD, BCPS, is Associate Adjunct Professor, College of Pharmacy, University of Kentucky, Lexington. Correspondence: Jonathan A. Bain, PharmD, BCPS, Cedars-Sinai Medical Center, Department of Pharmacy Services, 8700 Beverly Boulevard, Los Angeles, CA 90048. Fax: 310-423-0412. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interest in any product or service mentioned in this article, including grants, employment, gifts, stock, holdings, or honoraria.
Conclusion: Phentermine is a sympathomimetic agent found commonly in weight-loss products. Sympathomimetics have been linked to the development of hypertension, which can lead to cardiovascular and neurologic hemorrhages. We believe that the SAH in this patient was likely secondary to drug-induced hypertension or vasculopathy from the phentermine. Keywords: Subarachnoid hemorrhage, phentermine, sympathomimetic, adverse events. J Am Pharm Assoc. 2014;54:548–551. doi: 10.1331/JAPhA.2014.13226
548 JAPhA | 5 4:5 | S E P /OCT 2 0 1 4
ja p h a.org
Journal of the American Pharmacists Association
SUBARACHNOID HEMORRHAGE WITH PHENTERMINE EXPERIENCE
S
ubarachnoid hemorrhage (SAH) is a form of hemorrhagic stroke that involves bleeding into the area of the brain located between the arachnoid membrane and the pia mater surrounding the brain. This bleeding is most commonly the result of either a ruptured cerebral aneurysm or a traumatic brain injury.1 Infrequently, SAH is the result of other etiologies such as stimulant medications.2,3 Phentermine is one of the many sympathomimetic medications used for appetite suppression.4 Because phentermine is pharmacologically similar to amphetamine, it has been designated as a Schedule IV controlled substance by the Drug Enforcement Administration (DEA). Phentermine is currently approved by the U.S. Food and Drug Administration (FDA) for shortterm obesity treatment, and it is commonly prescribed in combination with the lipase inhibitor orlistat or the anticonvulsant topiramate for improved efficacy.5 Phentermine has been associated with specific adverse effects such as primary pulmonary hypertension, palpitations, tachycardia, ischemic events, and dry mouth.4 We report a case of nonaneurysmal SAH in a patient who was taking phentermine.
Objective To report the case of an angiography-negative SAH in association with increased use of the sympathomimetic phentermine.
At a Glance
Synopsis: Use of sympathomimetic agents such as the commonly prescribed appetite suppressant phentermine may be associated with neurologic hemorrhage. In this case report, a 45-year-old woman taking phentermine arrived at the emergency department complaining of an extreme, long-lasting headache. Her medical history was notable only for a regular smoking habit. Computed tomography subsequently revealed the presence of a subarachnoid hemorrhage (SAH). The patient was taken off her phentermine, provided standard treatment for the condition, advised to quit smoking, and released without event after an 8-day hospital stay. Analysis: Considering the patient’s largely unremarkable medical history, the report authors believe her phentermine use led to SAH. The authors advise clinicians to consider the potential risk factors for severe adverse effects in certain patients taking sympathomimetics for weight loss, particularly smokers and those with preexisting hypertension. Additionally, use of such medications in these patient populations should be monitored more closely.
Journal of the American Pharmacists Association
Case report A 45-year-old white woman presented to the emergency department complaining of the “worst headache of her life” over the preceding 24 hours. She had no loss of consciousness, but did have some episodes of confusion. Her past medical history was significant for smoking 20-pack–year history and hysterectomy. She had no history of bleeding, bleeding disorders, or hypertension, and her only home medication was phentermine 37.5 mg daily. While the patient said she typically took the medication 2–3 times a week during the past year, she had increased her use to 1–2 times a day for 2 weeks before arrival at the hospital in preparation for an upcoming social event. Her last dose was taken within 24 hours of the onset of headache and confusion.
Results The patient’s vital signs and laboratory values on arrival were all within normal range. Her blood pressure was 121/72 mm Hg, heart rate 101 beats per minute, and troponin concentration 0.01 ng/mL (normal:
Subarachnoid hemorrhage in a patient taking phentermine for weight loss Jonathan A. Bain, Jeremy S. Dority, and Aaron M. Cook
Abstract Objective: To report the case of an angiography-negative subarachnoid hemorrhage (SAH) in association with increased use of the sympathomimetic phentermine. Summary: A 45-year-old woman taking phentermine for weight loss presented with the “worst headache of her life,” as well as nausea and some confusion. Her prior medical history was largely negative for pathology except for a 20-pack–year history of smoking. Results: Upon admission to an inpatient facility, the patient was normotensive with a Glasgow Coma Score of 15. She was found on computed tomography to have a diffuse SAH (Hunt and Hess grade 2, Fisher grade 3). Digital subtraction angiography, performed on hospital day 2, was negative for aneurysm. The patient convalesced in the intensive care unit for 8 days and was treated as a typical patient with SAH (i.e., vasospasm prophylaxis with nimodipine and atorvastatin, ad lib diet with strict attention to fluid balance to maintain euvolemia). A repeat angiographic study on hospital day 8 also did not reveal an aneurysm or other cause for her SAH. She was discharged thereafter with intensive smoking cessation education and counseled to discontinue phentermine. Upon follow-up 6 weeks later, the patient was without complaints or neurologic deficits and had resumed her previous activities and work.
Received November 5, 2013, and in revised form January 26, 2014. Accepted for publication February 18, 2014. Published online in advance of print August 22, 2014. Jonathan A. Bain, PharmD, BCPS, is Critical Care Pharmacist, Cedars-Sinai Medical Center, Los Angeles, CA; at the time of the research, he was a PGY-2 Critical Care Resident, University of Kentucky, Lexington. Jeremy S. Dority, MD, is Assistant Professor, Department of Anesthesiology, College of Medicine, University of Kentucky, Lexington. Aaron M. Cook, PharmD, BCPS, is Associate Adjunct Professor, College of Pharmacy, University of Kentucky, Lexington. Correspondence: Jonathan A. Bain, PharmD, BCPS, Cedars-Sinai Medical Center, Department of Pharmacy Services, 8700 Beverly Boulevard, Los Angeles, CA 90048. Fax: 310-423-0412. E-mail: [email protected] Disclosure: The authors declare no conflicts of interest or financial interest in any product or service mentioned in this article, including grants, employment, gifts, stock, holdings, or honoraria.
Conclusion: Phentermine is a sympathomimetic agent found commonly in weight-loss products. Sympathomimetics have been linked to the development of hypertension, which can lead to cardiovascular and neurologic hemorrhages. We believe that the SAH in this patient was likely secondary to drug-induced hypertension or vasculopathy from the phentermine. Keywords: Subarachnoid hemorrhage, phentermine, sympathomimetic, adverse events. J Am Pharm Assoc. 2014;54:548–551. doi: 10.1331/JAPhA.2014.13226
548 JAPhA | 5 4:5 | S E P /OCT 2 0 1 4
ja p h a.org
Journal of the American Pharmacists Association
SUBARACHNOID HEMORRHAGE WITH PHENTERMINE EXPERIENCE
S
ubarachnoid hemorrhage (SAH) is a form of hemorrhagic stroke that involves bleeding into the area of the brain located between the arachnoid membrane and the pia mater surrounding the brain. This bleeding is most commonly the result of either a ruptured cerebral aneurysm or a traumatic brain injury.1 Infrequently, SAH is the result of other etiologies such as stimulant medications.2,3 Phentermine is one of the many sympathomimetic medications used for appetite suppression.4 Because phentermine is pharmacologically similar to amphetamine, it has been designated as a Schedule IV controlled substance by the Drug Enforcement Administration (DEA). Phentermine is currently approved by the U.S. Food and Drug Administration (FDA) for shortterm obesity treatment, and it is commonly prescribed in combination with the lipase inhibitor orlistat or the anticonvulsant topiramate for improved efficacy.5 Phentermine has been associated with specific adverse effects such as primary pulmonary hypertension, palpitations, tachycardia, ischemic events, and dry mouth.4 We report a case of nonaneurysmal SAH in a patient who was taking phentermine.
Objective To report the case of an angiography-negative SAH in association with increased use of the sympathomimetic phentermine.
At a Glance
Synopsis: Use of sympathomimetic agents such as the commonly prescribed appetite suppressant phentermine may be associated with neurologic hemorrhage. In this case report, a 45-year-old woman taking phentermine arrived at the emergency department complaining of an extreme, long-lasting headache. Her medical history was notable only for a regular smoking habit. Computed tomography subsequently revealed the presence of a subarachnoid hemorrhage (SAH). The patient was taken off her phentermine, provided standard treatment for the condition, advised to quit smoking, and released without event after an 8-day hospital stay. Analysis: Considering the patient’s largely unremarkable medical history, the report authors believe her phentermine use led to SAH. The authors advise clinicians to consider the potential risk factors for severe adverse effects in certain patients taking sympathomimetics for weight loss, particularly smokers and those with preexisting hypertension. Additionally, use of such medications in these patient populations should be monitored more closely.
Journal of the American Pharmacists Association
Case report A 45-year-old white woman presented to the emergency department complaining of the “worst headache of her life” over the preceding 24 hours. She had no loss of consciousness, but did have some episodes of confusion. Her past medical history was significant for smoking 20-pack–year history and hysterectomy. She had no history of bleeding, bleeding disorders, or hypertension, and her only home medication was phentermine 37.5 mg daily. While the patient said she typically took the medication 2–3 times a week during the past year, she had increased her use to 1–2 times a day for 2 weeks before arrival at the hospital in preparation for an upcoming social event. Her last dose was taken within 24 hours of the onset of headache and confusion.
Results The patient’s vital signs and laboratory values on arrival were all within normal range. Her blood pressure was 121/72 mm Hg, heart rate 101 beats per minute, and troponin concentration 0.01 ng/mL (normal:
