2019 Volume 21 Issue 6 Published: 28 December 2019
  

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  • Thoughts on several problems of drug interactions
    Liu Zhijun
    2019, 21(6): 401-405. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.001
    Abstract ( ) PDF ( )
    With the gradual improvement of people′s awareness of medication safety, drug interaction has become a hot topic in the field of medicine. However, there are still some misunderstandings about drug interactions and incompatibility, drug interactions and adverse drug reactions (ADR), the incidence of drug interactions, the clinical significance of case reports, and how to scientifically judge the clinical significance of drug interactions. Drug interactions refer to the pharmacokinetic or pharmacodynamic interactions of 2 or more drugs within the body, involving in drug absorption, distribution, metabolism, excretion, pharmacodynamics, pharmacogenomics, and etc. Compatibility refers to the changes of physical and chemical properties of 2 or more drugs in the same premixed container during the in vitro mixing process, the existence of physical incompatibility or chemical instability. Physical incompatibility and/or chemical instability are collectively referred to as incompatibility. Adverse drug interactions are not ADR. In clinical practice, attention should be paid to drug interactions with clinical significance, and contraindicated drug combinations should be actively avoided. On the premise of careful monitoring, some drugs with clinical significant interactions could also be used together. Due to the different criteria for judging drug interactions with clinical significance, it is not possible to get a generally accepted incidence of drug interactions at present. Case reports on drug interactions are important risk signals. Independent case reports of the same group of drugs have more reference value, whic
  • Analysis on self-assessment results of medication safety in 24 medical institutions in Linyi City
    Qiu Yanlong, Ma Ling, Xiang Longyun, et al
    2019, 21(6): 406-413. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.002
    Abstract ( ) PDF ( )
    ObjectiveTo understand preliminarily the current status of medication safety management in medical institutions in Linyi.MethodsSelf assessments of medication safety on the principle of voluntariness were conducted in the member units of the Clinical Pharmacy Committee of Linyi Medical Association (all were public hospitals), which were organized by the Linyi Pharmaceutical Affairs Quality Control Center. The investigation was conducted in using the questionnaires of "2011 ISMP Medication Safety Self Assessment for Hospitals (Chinese version)". The questionnaire included 10 key elements, 20 core indicators, and 270 assessment projects. Twenty-nine of the 67 member units expressed willingness to participate. A WeChat version of the questionnaire was sent on February 28, 2018 and required to complete and submit within 3 months. After the questionnaire was collected, the overall implementation status of each key element and each assessment project in all participated hospitals were counted. The results were expressed in the proportion of implementation, partial implementation, and non-implementation, and the implementation status in urban hospitals and rural hospitals were descriptively analyzed.ResultsAs of May 28, 2018, the questionnaires in 24 of 29 hospitals were submitted and the recovery rate was 82.8%. Twenty-four hospitals were from one district and 7 counties (3 districts and 9 counties in total), including 12 urban hospitals (4 tertiary hospitals and 8 secondary hospitals) and 12 rural hospitals (all were primary hospitals). Among the 10 key elements, the elements Ⅶ (environmental factors, workflow and staffing patterns) had the highest proportion of overall implementation ［56.55% (285/504)］ in the 24 hospitals, and the elements Ⅱ (drug information) had the lowest one ［26.77% (212/792)］ . In the 24 hospitals, the implementation proportion of 270 assessment projects was 37.11% (2 405/6 480), the partial implementation proportion was 26.33% (1 706/6 480), and the non-implementation proportion was 36.56% (2 369/6 480). The key elements with the highest and lowest implementation proportions in the 12 urban hospitals were Ⅶ［62.70% (158/252)］ and Ⅱ［33.08% (131/396)］, respectively. The key elements with the highest and lowest implementation proportion in the 12 rural hospitals were Ⅶ ［50.40% (127/252)］ and Ⅳ ［drug labeling, packaging, and nomenclature, 15.28% (33/216)］, respectively. The proportions of implementation, partial implementation, and non-implementation of 270 assessment projects in the urban hospitals were 49.32% (1 598/3 240), 29.48% (955/3 240), and 21.20% (687/3 240), respectively, and 24.91% (807/3 240), 23.18% (751/3 240), and 51.91% (1 682/3 240) in the rural hospitals, respectively. The implementation proportion of key elements in the rural hospitals was lower than that in the urban hospitals.ConclusionsThe results of the questionnaire preliminarily reflected the current status of medication safety management in urban and rural hospitals in Linyi City. There are great differences in the implementation of key elements related to medication safety between the urban and the rural hospitals, but the levels of medication safety management in both rural and urban hospitals need to be improved.
  • Clinical case analysis of heparin-induced thrombocytopenia
    Wang Yingkai, Cui Xiangli, Hou Kelu,Ma Zhuo,Wang Ying, Wang Xin
    2019, 21(6): 414-419. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.003
    Abstract ( ) PDF ( )
    ObjectiveTo explore the clinical characteristics, treatment and  prognosis of heparin-induced thrombocytopenia (HIT) in patients with pulmonary embolism after using unfractionated heparin (UFH) or low molecular weight heparin (LMWH).MethodsThe medical records of patients with pulmonary embolism, who were diagnosed between January 1, 2014 and September 30, 2018, and HIT after using UFH and LMWH were collected, which were searched from the Electronic Medical Record System in Beijing Chao-Yang Hospital, Capital Medical University. The improved pretest clinical scoring system (the 4 T′s score) was used to evaluate the possibility of HIT occurrence in patients. For the patients with HIT, the use of heparins, combined medication, the platelet count (PLT) before heparins use, the time from the beginning of heparin use to the onset of PLT decline, the lowest PLT, HIT specific antibody(HIT-Ab), as well as the treatment and outcome were further analyzed retrospectively.ResultsA total of 57 patients with thrombocytopenia after heparin treatment were collected, in which 11 (19.3%) were judged to be HIT using the 4 T′s score. Of the 11 patients, 6 were male and 5 were female, aged 27-87 years; 9 patients were given LMWH subcutaneously and 2 patients were given UFH by continuous intravenous pumping; the PLT decreased by (97±59)×109/L with the range of (30-233)×109/L after 2-10 days of heparin treatments (with an average of 7 days); 2 developed new pulmonary embolism and 1 developed multiple cerebral infarction; 2 patients underwent HIT-Ab test and they both had positive results. After the decrease of PLT, 1 of the 11 patients who continued to use heparin and infused fresh plasma had multiple organ failure and died of critical illness, other 10 patients stopped using heparin drugs immediately. Among the 10 patients, 8 switched to non-heparin anticoagulants and no thrombocytopenia occurred again; 2 stopped anticoagulation therapy, of which 1 died and 1 had unknown prognosis after hospital transfer.ConclusionsHIT in patients with pulmonary embolism mostly occurred about 1 week after heparin treatment. The HIT-Ab test may be positive and new thrombosis may occur in a few patients. The effect of HIT treatment is good when heparin was discontinued and replaced with non-heparin anticoagulants. The prognosis of patients who continue to use heparin or stop anticoagulation is poor.
  • Effects of modified hydration method on acute-phase reaction of zoledronic acid injection
    Wu Rui, Zhu Congcong, Li Xiaoyu, Wang Leiming, Zhao Yi
    2019, 21(6): 420-424. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.004
    Abstract ( ) PDF ( )

    ObjectiveTo explore the effects of self-established method of modified hydration on the acute-phase reaction (APR)of zoledronic acid injection.MethodsThis study was designed as randomized controlled trial. The subjects were inpatients with rheumatism and osteoporosis who were intended to receive zoledronic acid injection for the first or second time in Department of Rheumatology & Immunology, Xuanwu Hospital, Capital Medical University from August 2016 to December 2017. The patients who meet the inclusion criteria were randomly divided into the modified hydration group and the routine hydration group. The patients in the modified hydration group received IV infusions of 0.9% sodium chloride injection 500 ml before and after IV infusion of zoledronic acid injection, respectively and water 750 ml measured with mould under the care of nurses within 2 hours before and after medication, respectively. The total amount of liquid was more than 2 500 ml. The patients in the routine hydration group were only told to drink a large amount of water before and after IV infusion of zoledronic acid injection. The total amount of liquid was required to be more than 2 000 ml, but the water measuring mould was not provided. After IV infusion, the intravenous infusion tube was washed by 0.9% sodium chloride injection 100 ml. The total amount of liquid was more than 2 000 ml. The incidence of APR within 3 days of medication and levels of serum creatine on day 3 of medication in patients in the 2 groups were compared. ResultsA total of 190 patients were enrolled in the study, including100 and 90 patients in the modified hydration group and the routine hydration group, respectively. The differences of sex distribution, age, proportion of patients with zoledronic acid injection for the first or second time, minimum bone mineral density T value before medication, and the levels of serum creatine before medication between the 2 groups were not statistically significant (P>0.05 for all). The incidences of APR and fever in the modified hydration group were significantly lower than those in the routine hydration group ［40.0% (40/100) vs.68.9% (62/90), P＜0.01; 23.0% (23/100) vs. 44.4% (40/90), P＜0.01］ within 3 days of IV infusion of zoledronic acid injection. The incidences of APR and fever in patients treatment with zoledronic acid injection for the first or second time in the modified hydration group were significantly lower than those in the routine hydration group ［first medication: 53.3% (32/60) vs. 73.6% (39/53), 30% (18/60) vs. 50.9% (27/53); second medication:20.0% (8/40) vs.62.2% (23/37), 12.5% (5/40) vs. 35.1% (13/37)］; the incidences of APR and weakness in patients treatment with zoledronic acid injection for the second time were significantly lower than those for the first time［20.0% (8/40) vs. 53.3% (32/60), 17.5%(7/40) vs. 41.7% (25/60)］; the incidence of headache in patients treatment with zoledronic acid injection for the second time in the routine hydration group were significantly lower than those for the first time［0 (0/37) vs. 13.2% (7/53)］; all above-mentioned differences were statistically significant (P＜0.05 or P＜0.01). No patients developed acute kidney injury in the 2 groups. The levels of serum creatine in the 2 groups were (52±20) and (52±13) μmol/L, respectively.ConclusionThe modified hydration method can decrease the incidence of APR effectively in patients with zoledronic acid injection treatment for the first or second time.

  • Economic evaluation on closed infusion of human albumin based on the risk of hospital-acquired infections
    Liu Xueli, Zheng Liying, Hu Xin, et al
    2019, 21(6): 425-430. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.005
    Abstract ( ) PDF ( )
    International Research Center for Medicinal Administrations, Peking University, Beijing 100191, China; Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China; Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatrics, Chinese Academy of Medical Sciences, Beijing 100730, China; et al
  • Analysis of adverse reactions on cognition, language, and bone metabolism of antiepileptic drugs based on Side Effect Resource Database (SIDER)
    Fu Zhengran, Wang Xiaoling, Fang Fang
    2019, 21(6): 431-434. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.006
    Abstract ( ) PDF ( )
    ObjectiveTo understand the incidences of adverse reactions on cognition, language, and bone metabolism  related to 8 commonly used antiepileptic drugs in China using SIDER database.MethodsThe integrated incidences of adverse reactions on cognition, language, and bone metabolism related to 8 commonly used antiepileptic drugs (carbamazepine, oxcarbazepine, valproate, clonazepam, lamotrigine, levetiracetam, topiramate, and zonisamide) marketed in China was searched in the SIDER database.ResultsThe main drugs that affected cognition were topiramate and valproate. The incidences of memory impairment caused by topiramate and abnormal thinking related to valproate were 1.2%-10.8% and 6.0%, respectively. Topiramate was the main drug that affected language. The incidences of dysarthria and speech disorder caused by topiramate were 1.6%-6.2% and 1.0%-16.8%, respectively. The main antiepileptic drugs that affected bone metabolism were carbamazepine, oxcarbazepine, and valproate. But there was no incidence information because of the limited small amount of literature reports after marketing.ConclusionsThe results of data analysis in this database indicate that different antiepileptic drugs have different effects on cognitive function, language function and bone metabolism, and the frequency of adverse reactions is different. The clinical use of antiepileptic drugs needs to weigh the advantages and disadvantages according to the specific situation of patients.
  • Research progress on the relationship between new hypoglycemic drugs and fracture risk
    Peng Jing, Ma Jie, Cao Xiaofu, Liu Zhen, Zhao Yanyan, Wang Hui, Chen Jing, Zhang Zhengjun
    2019, 21(6): 435-440. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.007
    Abstract ( ) PDF ( )
    Patients with diabetes mellitus are at high risk for osteoporotic and fractures. Some hypoglycemic drugs may increase the risk of fracture in diabetic patients. At present, the commonly used new hypoglycemic agents include incretin mimetic drugs and sodium-glucose co-transporter protein 2 (SGLT2) inhibitors. The incretin mimetic drugs include dipeptidyl peptidase 4 (DPP4) inhibitors and glucagon-like peptide (GLP) 1 receptor agonists. It was found in clinical studies that GLP1 receptor agonist liraglutide and DPP4 inhibitor alogliptin may reduce the risk of fracture events in patients with type 2 diabetes mellitus, while GLP1 receptor agonist exenatide may increase the risk of fracture when its daily dose is more than 22.5 μg. SGLT2 inhibitors can inhibit the reabsorption of sodium and glucose in renal tubules and increase the reabsorption of phosphate. The increase of blood phosphorus can indirectly promote bone absorption, which would lead to osteoporosis and increase the risk of fracture. However, there was no evidence in clinical studies that other SGLT2 inhibitors except canagliflozin may be associated with the increase of fracture risk.
  • Elevated blood concentration and liver injury due to oral administration of overdose voriconazole
    Gao Jie, Chen Ruihuan, Zheng Xiaoxian
    2019, 21(6): 441-442. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.008
    Abstract ( ) PDF ( )
    A 51-year-old female patient with lymphadenoma developed neutrophil deficiency with fever after chemotherapy. Voriconazole 1.0 g twice daily was given orally following the doctor’s advice (the recommended dose by drug label is 0.2-0.4g twice daily).  the patient took voriconazole 3 times with total dose of 3.0 g within 24 hours. The medication error was found by a pharmacist and voriconazole was stopped. The voriconazole blood concentrations after 12, 24, 36, and 48 hours of drug withdrawal were 12.20, 10.20, 6.55, and 4.45 mg/L, respectively. The laboratory tests showed alanine aminotransferase (ALT) 11 U/L, aspartate aminotransferase (AST) 6 U/L, and γ-glutamyl transpeptidase (γ-GT) 44 U/L before medication and ALT 327 U/L, AST 153 U/L, andγ-GT 627 U/L after 2 days of drug withdrawal, respectively. Overdose of voriconazole-induced liver injury were considered. The patient received the liver-protective therapy including an IV infusion of compound glycyrrhizin injection and oral bicyclol. After 3 days of drug withdrawal, the voriconazole blood concentration was 0.67 mg/L and the laboratory tests showed ALT 191 U/L, AST 31 U/L, and γ-GT 522 U/L. After 16 days of drug withdrawal, the laboratory tests showed 24 U/L, 15 U/L, and 224 U/L, respectively.
  • Hemolytic jaundice due to Yinzhihuang oral solution(茵栀黄口服液) in a neonate with glucose-6-phosphate dehydrogenase deficiency
    Wang Xiaoyan, Ni Liming, Lei Ximei
    2019, 21(6): 443-444. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.009
    Abstract ( ) PDF ( )
    A 3-day-old newborn boy received Yinzhihuang oral solution 3 ml thrice daily because of jaundice. One day after the medication, the baby′s jaundice aggravated obviously, the laboratory tests showed total bilirubin (TBil) 385 μmol/L and hemoglobin (Hb) 163 g/L, and he had dark brown urine. Treatment with blue light phototherapy was added. Laboratory tests showed TBil 431 μmol/L and Hb 99 g/L on day 8 after birth. The baby′s TBil level was decreased provisionally after the peripheral arteriovenous exchange transfusion, but increased again several hours later. It was considered that the repeated increase of TBil might be related to Yinzhihuang oral solution. Yinzhihuang oral solution was stopped. On day 2 after drug withdrawal, the baby′s TBil decreased to 146 μmol/L and the urine turned clear. The baby was diagnosed as glucose-6-phosphate dehydrogenase (G-6-PD) deficiency by gene diagnosis after discharge. It was considered that hemolytic jaundice in the neonate with G-6-PD deficiency may be induced by Yinzhihuang oral solution.
  • Reversible posterior leukoencephalopathy syndrome caused by cyclosporine
    Zong Yutong, Wang Huaguang, Zhang Xingmao, Fan Hua, Liu Lihong
    2019, 21(6): 445-447. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.010
    Abstract ( ) PDF ( )
    A 50-year-old female patient received immunosuppressive treatment with tacrolimus after liver transplantation. Eighty-seven days later, tacrolimus was replaced by oral cyclosporine 75 mg twice daily due to liver injury. Nine days after cyclosporine treatment, she had an epileptic seizure. Antiepileptic drugs such as diazepam were given and the symptoms were relieved. But epilepsy still attacked sometimes on the next 3 days and it was considered to be reversible posterior leukoencephalopathy syndrome caused by cyclosporine, based on the CT examination of the head. The dose of cyclosporine was reduced and finally replaced by tacrolimus. The patient′s seizure was gradually reduced and finally disappeared after 8 days of tacrolimus treatment.
  • Amaurosis fugax due to oxaliplatin
    Xu Ying, Yang Yan, Li Zhihu, Zhang Lianxing, Fan Chunling
    2019, 21(6): 447-448. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.011
    Abstract ( ) PDF ( )
    A 47-year-old male patient received XELOX regimen ［an IV infusion of oxaliplatin 200 mg on day 1, oral capecitabine 3 500 mg on day 1 to 14 (1 500 mg at 8: 00 and 2 000 mg at 20: 00), the treatment course was 21 days］ after radical resection of colon cancer. During the 1st to 5th chemotherapy cycles, amaurosis fugax occurred 20 to 30 minutes after finishing the IV infusion of oxaliplatin each time. With the increase of the number of chemotherapy cycles, the number of amaurosis fugax decreased (5, 3, 1, 1, 1 times, respectively) and the duration each time also decreased. when amaurosis fugax appeared each time mecobalamin 0.5 mg was given orally thrice daily for 3 days. By the end of chemotherapy, no amaurosis recurred. The amaurosis did not recur after IV infusions of oxaliplatin in the 6th, 7th, and 8th chemotherapy cycles.
  • Death from interstitial lung disease caused by apatinib mesylate tablets
    Cai Xueying, Zeng Huiqing, Chen Xiaorong, Chen Xiangxing, Zhu Sihong, Huang Yemei
    2019, 21(6): 449-451. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.012
    Abstract ( ) PDF ( )
    A 53-year-old female patient with advanced lung cancer, who was negative for all types of driving genes, received apatinib mesylate tablets(apatinib) 500 mg/d orally after 2 cycles of ineffective chemotherapy of pemetrexed disodium plus cisplatin (21 days as 1 cycle). After 22 days of medication, apatinib was reduced to 250 mg/d because of the hand-foot skin reactions. After 7 months of treatment with apatinib, the pulmonary neoplasms shrank, but the patient developed shortness of breath. CT examination showed bilateral pulmonary interstitial fibrosis. Apatinib was discontinued and hormone therapy was given. The patient′s symptoms were progressively aggravated. On day 32 of drug discontinuation, CT scan showed that the pulmonary interstitial fibrosis was aggravated and the patient developed typeⅠrespiratory failure. An IV infusion of methylprednisolone 500 mg/d and oxygen inhalation were given. However, the patient′s condition was still deteriorating. On day 37 of drug discontinuation, the patient died.
  • Drug fever due to bladder irrigation with high concentration of amphotericin B solution
    Deng Yufei, Wang Liping, Cao Hongfu, Zhao Yin, Wang Xiaodan
    2019, 21(6): 451-453. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.013
    Abstract ( ) PDF ( )
    A 92-year-old male patient received bladder irrigation with amphotericin B 25 mg dissolved in sterilized water for injection 250 ml once daily for Candida tropicalis urinary system infection. On day 3 to 5 of the treatment, the patient had a fever around 16：00 every day and the temperature was up to 38.0 ℃.On day 5, laboratory tests showed white blood cell (WBC) 7.2×109/L, neutrophil 0.67, eosinophils 0.015,and C-reactive protein 0.18 mg/L. Drug fever due to bladder irrigation with amphotericin B was considered. Amphotericin B was stopped. Twenty-four hours after the drug withdrawal, his body temperature decreased to 37.6 ℃. Forty-eight hours after the drug withdrawal, his body temperature returned to normal. Laboratory tests showed WBC 6.2×109/L, neutrophil 0.66, and eosinophils 0.034.
  • Atrioventricular block induced by hydroxychloroquine
    Shi Chunhuan, Wang Weibo, Li Zhenqing, Wang Jimei, Zhang Yonggang, Zhang Cuifang
    2019, 21(6): 453-454. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.014
    Abstract ( ) PDF ( )
    A 48-year-old male patient received oral hydroxychloroquine 100 mg thrice daily, oral total glucosides of white paeony 60 mg twice daily, and intravenous infusion of methylprednisolone 40 mg once daily, which was replaced by oral prednisone 45 mg once daily 10 days later. The electrocardiogram of the patient was normal before the medication. On day 11 of medication, the patient developed palpitation about 2 hours after taking hydroxychloroquine. His electrocardiogram showed atrioventricular block, which returned to normal about 2 hours later. Then the patient was monitored by dynamic electrocardiogram. On day 17, the patient developed palpitation again about 2 hours after taking hydroxychloroquine and the dynamic electrocardiogram showed atrioventricular block, atrial premature beat, and occasional premature ventricular beat. These symptoms were considered to be related to hydroxychloroquine. Then hydroxychloro-quine was discontinued and other drugs were continued. Metoprolol sustained-release tablets 23.75 mg were given once daily. On day 3 of hydroxychloroquine withdrawal, the patient had normal electrocardiogram. At 9 days of follow-up, palpitation and atrioventricular block did not recur.
  • Interstitial lung disease induced by paclitaxel
    Chen Wen, Wang Lixia, Mu Jizheng, Liu Shuo
    2019, 21(6): 455-456. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.015
    Abstract ( ) PDF ( )
    A 55-year-old male patient with small-cell lung cancer received single agent chemotherapy with an IV infusion of paclitaxel injection 300 mg after surgery, which was given once only on the first day and 21 days was a treatment cycle. On day 6 after the first dose, he developed cough with white phlegm. On day 7 after the first dose, he developed fever. Piperacillin sodium and sulbactam sodium was empirically given but his symptoms were not relieved. On day 9 after the first dose, the patient developed obvious asthmatic symptoms. The chest CT result showed multiple patchy and ground glass shadows in bilateral lungs. Interstitial pneumonia caused by paclitaxel was considered. After 5 days of treatments with antibiotics and glucocorticoids, his body temperature returned to normal and asthmatic symptoms were relieved. The patient was transferred to the local hospital and his condition improved after further treatments.
  • Liver injury caused by oxcarbazepine
    Zhao Yan, Zhu Liyao, Zhou Jian
    2019, 21(6): 457-458. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.016
    Abstract ( ) PDF ( )
    A 30-year-old male patient received oral oxcarbazepine (300 mg in the morning and 600 mg at night) for epilepsy recurrence after drug withdrawal. The patient′s liver function was normal before taking oxcarbazepine ［alanine aminotransferase (ALT) 24 U/L, aspartate aminotransferase (AST) 22 U/L, alkaline phosphatase (ALP) 61 U/L, gamma-glutamyltransferase (γ-GT) 55 U/L, total bilirubin (TBil) 8.7 μmol/L, and direct bilirubin (DBil) 5.2 μmol/L］. After 12 days of treatment, the patient developed mild liver injury (ALT 70 U/L). Tiopronin was given and oxcarbazepine was continued. However, the liver injury gradually worsened and the patient developed anorexia and yellow urine after 23 days of oxcarbazepine treatment. On day 30 of treatment. Laboratory tests showed ALT 2 763 U/L, AST 1 291 U/L, ALP 115 U/L, γ-GT 365 U/L, TBil 65.9 μmol/L, and DBil 41.4 μmol/L. Drug-induced liver injury was considered. Oxcarbazepine and tiopronin were stopped, topiramate 50 mg once daily was given orally (changed to 50 mg twice daily 1 week later), and the liver-protective treatments such as diammonium glycyrrhizinate and reduced glutathione were given. The liver function of the patient gradually improved. After 20 days, his liver function basically returned to normal (ALT 38 U/L, AST 30 U/L, ALP 71 U/L, γ-GT 84 U/L, TBil 13.4 μmol/L, and DBil 5.5 μmol/L). Long-term use of topiramate orally was advised by doctor. At 3 months of follow-up, the patient had no seizures and his liver function stayed normal.
  • Death due to severe cardiotoxicity and hematotoxicity caused by combined chemotherapy with epirubicin, cyclophosphamide, and vindesine
    Zhang Yingpei, Wu Dongfang
    2019, 21(6): 459-460. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.017
    Abstract ( ) PDF ( )
    A 46-year-old female patient with gastric high-grade B-cell lymphoma received CHOP chemotherapy (IV infusions of epirubicin 120 mg, cyclophosphamide 1 200 mg, and vindesine 2 mg on day 1; oral prednisolone tablets 100 mg on days 1 to 5). Before the chemotherapy, her cardiac function was grade Ⅱ and her routine blood parameters and coagulation function were normal. On the 3rd day of chemotherapy, the patient had a transient afibrinogenemia followed by heart failure, extensive myocardial infarction, and severe myelosuppression (white blood cell count 1.65×109/L, neutrophil percentage 0.85, and platelet count 57×109/L). Despite active treatments, the patient died on the 11th day of the chemotherapy.
  • Hypoglycemia caused by misuse of super-high-dose of insulin glargine injection
    Cai Jun, Wei Jing, Ji Liwei
    2019, 21(6): 461-462. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.018
    Abstract ( ) PDF ( )
    A 61-year-old female patient with type 2 diabetes mellitus were prescribed a subcutaneous injection of insulin glargine 12 U at bedtime by the doctor because of the poor effect of oral hypoglycemic drugs. Because she used the drug for the first time and didn′t master the skills of use, a total of 300 U of insulin glargine was mistakenly injected subcutaneously at one time. About 3 hours later, the patient developed hypoglycemia symptoms such as palpitation, profuse sweating, hunger, and etc. The finger-prick blood glucose was 3.0 mmol/L and her symptoms improved after eating. No antidiabetic drugs were used that day and normal meals were taken, including sweet food. At about 3:00 am the next day (about 25 hours after the administration of insulin glargine injection), hypoglycemia recurred, the finger-prick blood glucose was 3.3 mmol/L, and the symptoms was improved after eating. On the 4 consecutive days after then, no hypoglycemic drugs were used. From the 5th day, acarbose, metformin and insulin glargine injection were added successively. One week later, the fasting finger-prick blood glucose was 5.9-6.7 mmol/L, and the finger-prick blood glucose was 6.0-7.7 mmol/L at 2 hours after meal. Hypoglycemia did not recur.
  • Severe lacrimal duct obstruction in both eyes induced by tegafur, gimeracil and oteracil potassium capsules
    Gao Feng, Bai Fang, Tao Hai
    2019, 21(6): 463-464. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.019
    Abstract ( ) PDF ( )
    A 49-year-old male patient received 2 tegafur, gimeracil and oteracil potassium capsules (each capsule containing tegafur 25 mg, gimeracil 7.25 mg, and oteracil potassium 24.5 mg) orally twice daily for 2 weeks continuously following 1 week of withdrawal (every 3 weeks was a cycle) for colon cancer. After 2 cycles of treatment, the patient developed epiphora in both eyes. He continued to take the medicine and his epiphora aggravated. After 3 cycles of treatment, the drug was discontinued but his epiphora did not improve. Lacrimal duct obstruction in both eyes was diagnosed, which did not improve after the lacrimal passage irrigation treatment for 22 months. Then the patient underwent consecutive surgical treatments on his left and right eyes, including dacryocystectomy (with tiny incision for exploration), retrograde drainage of lacrimal canaliculi, punctoplasty, modified dacryocystorhinostomy, and artificial lacrimal canaliculus implantation. After the above operations, his epiphora disappeared. Based on the previous literature, the lacrimal duct obstruction in both eyes induced by tegafur, gimeracil and oteracil potassium capsules was considered.
  • Sleep attack induced by piribedil sustained-release tablets in a patient with Parkinson disease
    Zhou Yuling, Yang Xinglong
    2019, 21(6): 465-466. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.020
    Abstract ( ) PDF ( )
    A 76-year-old male patient with Parkinson disease received long-term treatments with levodopa and benserazide hydrochloride tablets, carbidopa and levodopa controlled release tablets, and amantadine hydrochloride tablets. Due to the aggravation of the symptoms, oral piribedil sustained-release tablets 50 mg twice daily was added, whose dose was increased to thrice daily 1 month later. On day 3 of dose increase, the patient′s family member found that the patient developed unresponsiveness to verbal stimuli and the doctor found that the patient was in a state of sudden deep sleep. During the deep sleep attacks, his vital signs were normal and about 40 minutes later, the patient was awake. No abnormalities were found in cranial magnetic resonance imaging and electroencephalogram that same day. On day 10, the patient developed 2 times of deep sleep again, each time lasted for 30-40 minutes, and then relieved by himself. No abnormality was found in EEG. Sleep attacks caused by piribedil was considered. The dose of piribedil sustained-release tablets was gradually reduced and finally withdrawn. Sleep attacks did not recur.
  • Cardiotoxic reactions induced by apatinib mesylate tablets
    He Sumei, Jiang Yiguo, Cheng Wenxiu, Feng Lin, Sun Xiaoming
    2019, 21(6): 467-468. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.021
    Abstract ( ) PDF ( )
    A 59-year-old female patient received targeted therapy with apatinib mesylate tablets (500 mg orally, once daily) for neuroendocrine tumor-derived intraperitoneal metastasis. On the 3rd day of treatment, the patient suddenly developed chest distress and shortness of breath, her blood pressure was 170/102 mmHg, and heart rate was 43 beats/min. The electrocardiogram showed sinus bradycardia and prolonged QT interval from 412 ms before treatment to 502 ms. Her N-terminal probrain natriuretic peptide (NT-proBNP) was 2 945 ng/L. Apatinib was withdrawn and symptomatic treatments such as oxygen inhalation, antihypertension, and myocardial nutrition were given. Two days later, her symptoms gradually relieved, blood pressure returned to normal, and NT-proBNP decreased to 291 ng/L. After the symptoms disappeared, the patient took apatinib (125 mg once daily) again. Seven days later, dizziness and hypertension occurred again and her NT-proBNP was 782 ng/L. After apatinib withdrawal and symptomatic treatments, the patient′s symptoms improved.
  • Successful desensitization treatment for a patient with aspirin allergy
    Zhang Xiaolan, He Chuan, Zhao Ping, Jiang Yiguo
    2019, 21(6): 469-470. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.022
    Abstract ( ) PDF ( )
    A 77-year-old female patient received combined antiplatelet therapy with aspirin enteric-coated tablets (100 mg once daily) and clopidogrel (75 mg once daily) orally because of acute ischemic stroke. Three days after medication, she developed rashes all over the body, accompanied by itching. No treatment was given. Three weeks later, clopidogrel was stopped and single antiplatelet therapy (aspirin enteric-coated tablets 100 mg once daily) was given. After that, the rashes did not subside for more than a month. Aspirin was stopped by herself. About 1 week later, the rashes subsided. Then the patient took original dose of aspirin again by herself for about 1 month, the above-mentioned symptoms recurred. Because she needed long-term single antiplatelet therapy, aspirin desensitization was given. Firstly, aspirin enteric-coated tablets were dissolved in warm water to make up the solution of 5 mg/ml. After the initial oral administration of 0.2 ml (equivalent to aspirin 1 mg), 1, 2, 4, 8 and 20 ml (equivalent to aspirin 1, 5, 10, 20, 40 and 100 mg) were given orally at 30, 60, 90, 210 and 330 minutes, respectively. The desensitization therapy lasted 5.5 hours. Anaphylactic reaction did not appear during the process of desensitization therapy. Then she took original dose of aspirin enteric-coated tablets followed the doctor′s advice. At 4 months of follow-up, rashes did not recur, suggesting that desensitization therapy was successful.
  • Anaphylactic shock induced by fluorescein sodium injection in 2 patients with negative anaphylactic test
    Tian Dongdong, Wu Huizhen, He Lien, Qiu Zhihong
    2019, 21(6): 471-472. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.023
    Abstract ( ) PDF ( )
    Fundus fluorescein angiography was performed in the 2 ophthalmic outpatients (patient 1, a 61-year-old female with ischemic optic neuropathy; patient 2, a 63-year-old male with vitreous hemorrhage in the right eye) after exclusion of contraindications and signing of informed consent. Both of them had no history of drug allergy and heart disease, and their liver and kidney functions were normal. Before angiography, allergy tests were performed by intravenous injection of fluorescein sodium diluent. After 5 minutes of observation, the test results in the 2 patients were all negative. Then fluorescein sodium injections were given intravenously. The 2 patients developed anaphylactic shock about 2 minutes and 17 minutes after injections. Their blood pressure decreased to 50/32 mmHg and 49/36 mmHg, respectively. The patient 1 had transient atrial fibrillation and the patient 2 once had a heart rate of 0. After anti-allergic and antishock therapy, the blood pressure and heart rate in the 2 patients gradually returned to normal.
  • Death due to severe diarrhea with electrolyte disturbance and gastrointestinal hemorrhage induced by gefitinib
    Yang Ge, Xu Wei
    2019, 21(6): 473-474. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.024
    Abstract ( ) PDF ( )
    A 67-year-old woman was treated with oral gefitinib 250 mg once daily for multiple metastasis of lung adenocarcinoma. After 23 days of treatment, the patient developed severe diarrhea with more than 10 times of watery stools within 24 hours. Gefitinib was stopped, montmorillonite powder and rehydration therapy were given. The patient was admitted to hospital on the 5th day of diarrhea. But her diarrhea was not improved and persistent hypokalemia, electrolyte disturbance, and paralytic ileus gradually appeared. The paralytic ileus was improved by fasting, gastrointestinal decompression, potassium and sodium supplementation, and supportive treatment. On day 11 of admission, the patient developed gastrointestinal bleeding. Pantoprazole, octreotide, aminomethylbenzoic acid, and transfusion of red blood cells and platelets were given. However, the patient′s condition continued to deteriorate. On day 16 of admission, he died of respiratory and circulatory failure.
  • Anaphylaxis induced by haemocoagulase agkistrodon for injection: report of 2 cases
    Shi Yang, Hou Baolin, Cao Yonghong, Fan Dengfeng, Zhang Hongxia, Chen Xiaoli
    2019, 21(6): 475-476. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.025
    Abstract ( ) PDF ( )
    Two patients (patient 1, a 54-year-old male; patient 2, a 39-year-old female) received intravenous injection of haemocoagulase agkistrodon for injection (2 U, once daily) to reduce bleeding after percutaneous holmium laser lithotripsy and hysteroscopic diagnostic curettage, respectively. Patient 1 developed urticaria on the third day of treatment. Haemocoagulase agkistrodon was stopped and cured after anti allergy treatment. Patient 2 developed palpitation, dyspnea, nausea, tremor of limbs, and etc. after about 5 minutes of medication. Her body temperature was 36.6 ℃, heart rate was 88 beats/min, breath rate was 23 times/min, blood pressure was 117/63 mmHg, and erythema appeared on her limbs and chest skin. Haemo-coagulase agkistrodon was stopped and antiallergic treatments and oxygen inhalation were given. Her symptoms disappeared about 30 minutes later and the rash disappeared 1 week later. The allergic reactions in the 2 patients were considered to be caused by haemocoagulase agkistrodon.
  • Abnormal uterine bleeding induced by rivaroxaban in a patient with pulmonary embolism
    Wang Xin, Wang Shihui, Wang Yingkai, Cui Xiangli
    2019, 21(6): 477-478. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.026
    Abstract ( ) PDF ( )
    A 49-year-old female patient received anticoagulation therapy with rivaroxaban due to pulmonary embolism (initial dose: 15 mg, twice daily; maintenance dose 3 weeks later: 20 mg, once daily). From the month of treatment, the patient′s menstrual volume increased and menstrual period extended from 4-5 days to 8-9 days. Five months later, she developed anemia, with hemoglobin (Hb) 53 g/L. Uterine bleeding was considered to be related to rivaroxaban. Rivaroxaban was stopped, oxytocin and blood transfusion were given, and her anemia was improved. But 2 weeks later, pulmonary embolism recurred in the patient. Low-molecular-weight heparin and enoxaparin were given and 7 days later, enoxaparin was gradually adjusted to warfarin therapy (4.5 mg/d). The symptoms of chest tightness and short of breath were improved and anemia was Hb 125 g/L. After discharge, warfarin was taken continuously. At 1 month of follow-up, her INR was maintained at 2.00-3.33 and menstruation returned to normal.
  • Epidermolysis bollosa due to montelukast sodium tablets
    Liu Ying, Zhao Rongsheng
    2019, 21(6): 478-480. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.027
    Abstract ( ) PDF ( )
    A 71-year-old male patient received montelukast sodium tablets 10 mg every night because of bronchiectasis with asthma. On day 4 of the medication, he developed itchy skin. On day 5, he developed blisters on his neck and wrist skin. On day 11, he developed scattered blisters filled with clear fluid on his limbs and trunk skin and part of them fused into lamella. Epidermolysis bollosa and the relationship to montelukast sodium were considered. Montelukast sodium tablets were stopped and antianaphylactic treatments including external triamcinolone acetonide and econazole nitrate cream and ethacriding lactate acid solution and oral cetirizine hydrochloride dispersible tablets were given. On day 3 of montelukast withdrawal, the blisters subsided and shriveled on his neck skin and on his limbs and trunk skin, respectively. Ulceration appeared on the skin of those subsided or shriveled blisters but no exudate. No new blisters were found. A week later, the blisters subsided basically and desquamation occurred in the skin where some blisters subsided.
  • Epidermolysis bullosa due to compound aminopyrine phenacetin tablets
    Yu Pingzi, Chen Zeyu, Li Weize, Lin Shu, Yang Fan
    2019, 21(6): 480-481. https://doi.org/10.3760/cma.j.issn.1008-5734.2019.06.028
    Abstract ( ) PDF ( )
    A 51-year-old male patient took by himself oral compound aminopyrine phenacetin tablets (each tablet containing aminopyrine 150 mg, phenacetin 150 mg, caffeine 50 mg, and phenobarbital 15 mg) 2 tablets twice daily for headache. On the second day, the patient developed erythematous rash all over the body, accompanied by obvious itching and pain. Then the compound aminopyrine phenacetin tablets were stopped. On the third day, some of the macula fused into a piece, on which different sizes of loose blisters or bullae appeared. And erosion occurred at the junction of the skin and mucous of the mouth and genitals. Intravenous infusions of methylprednisolone and calcium gluconate injection, oral ebastine tablets and ketotifen fumarate tablets, and skin care were given. Six days later, his rash became lighter, most of the blisters and bullae dried up and scabbed. The dose of methylprednisolone was gradually reduced. Eleven days later, the erythema obviously improved, blisters and bullae dried up, and flaky desquamation on the epidermis occurred. Intravenous infusion of methylprednisolone was changed to oral prednisolone (20 mg/d). Thirteen days later, the rash subsided basically.
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