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April 07, 2020; 94 (14) Article

Triptan and ergotamine overdoses in the United States

Analysis of the National Poison Data System

View ORCID ProfileJennifer V. Robblee, Richard J. Butterfield, View ORCID ProfileA. Min Kang, Jonathan H. Smith
First published December 2, 2019, DOI: https://doi.org/10.1212/WNL.0000000000008685
Jennifer V. Robblee
From the Departments of Neurology (J.V.R., J.H.S.) and Biostatistics (R.J.B.), Mayo Clinic, Scottsdale; Departments of Child Health and Medicine, Division of Medical Toxicology and Precision Medicine (A.M.K.), University of Arizona College of Medicine–Phoenix; and Department of Medical Toxicology and Banner Poison and Drug Information Center (A.M.K.), Banner–University Medical Center Phoenix, AZ.
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  • ORCID record for Jennifer V. Robblee
Richard J. Butterfield
From the Departments of Neurology (J.V.R., J.H.S.) and Biostatistics (R.J.B.), Mayo Clinic, Scottsdale; Departments of Child Health and Medicine, Division of Medical Toxicology and Precision Medicine (A.M.K.), University of Arizona College of Medicine–Phoenix; and Department of Medical Toxicology and Banner Poison and Drug Information Center (A.M.K.), Banner–University Medical Center Phoenix, AZ.
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A. Min Kang
From the Departments of Neurology (J.V.R., J.H.S.) and Biostatistics (R.J.B.), Mayo Clinic, Scottsdale; Departments of Child Health and Medicine, Division of Medical Toxicology and Precision Medicine (A.M.K.), University of Arizona College of Medicine–Phoenix; and Department of Medical Toxicology and Banner Poison and Drug Information Center (A.M.K.), Banner–University Medical Center Phoenix, AZ.
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Jonathan H. Smith
From the Departments of Neurology (J.V.R., J.H.S.) and Biostatistics (R.J.B.), Mayo Clinic, Scottsdale; Departments of Child Health and Medicine, Division of Medical Toxicology and Precision Medicine (A.M.K.), University of Arizona College of Medicine–Phoenix; and Department of Medical Toxicology and Banner Poison and Drug Information Center (A.M.K.), Banner–University Medical Center Phoenix, AZ.
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Triptan and ergotamine overdoses in the United States
Analysis of the National Poison Data System
Jennifer V. Robblee, Richard J. Butterfield, A. Min Kang, Jonathan H. Smith
Neurology Apr 2020, 94 (14) e1460-e1469; DOI: 10.1212/WNL.0000000000008685

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Abstract

Objective To examine the clinical outcomes of intentional overdoses involving triptans and ergotamines with a retrospective review of the National Poison Data System (NPDS).

Methods This was a 5-year retrospective cross-sectional study (2014–2018) using the NPDS. Demographics, exposure characteristics, and outcomes were described. Univariate logistic regression was used to estimate the odds ratio (OR) for major effect or death. A multivariable logistic regression model with inclusion criteria of p < 0.1 in univariate analysis was implemented with backwards selection.

Results In this population (n = 1,489), multiple exposure was most common (n = 1,145). The mean age was 31.2 years and 1,197 (80.4%) participants were female. Major effects from a single exposure were seen in <1% with no recorded deaths. Triptan ingestion (n = 328) resulted in hypertension (14%), tachycardia (10.7%), drowsiness (11%), nausea (6.4%), vomiting (4.6%), vertigo (4%), chest pain (3.7%), and diaphoresis (2.4%). Ergotamine ingestion (n = 16) resulted in abdominal pain (16%), vomiting (12.5%), numbness (12.5%), nausea (6.3%), diarrhea (6.3%), and vertigo (6.3%). No clinical effect was seen in 90 (26.2%). No cases met Hunter criteria for serotonin syndrome. There is risk of major event or death due to age (OR 1.02; 95% confidence interval [CI] 1.01–1.04; p = 0.004), multiple product exposure (OR 9.50; 95% CI 2.29–39.48; p = 0.002), and concomitant overdose with benzodiazepines (OR 1.71; 95% CI 1.05–2.78; p = 0.032) or tricyclic antidepressants (OR 3.16; 95% CI 1.88–5.31; p < 0.001).

Conclusion The risk of major effect or death was low and predicted by age, multiple product exposure, and concomitant benzodiazepine or tricyclic antidepressant. The triptan toxidrome consists of hypertension, tachycardia, and drowsiness. The toxic effects of ergotamine are acute gastrointestinal syndrome with vertigo and numbness. No cases of serotonin syndrome were seen.

Glossary

AAPCC=
American Association of Poison Control Centers;
CI=
confidence interval;
CYP=
cytochrome P450 enzyme;
NPDS=
National Poison Data System;
OR=
odds ratio;
PCC=
Poison Control Center;
SSRI=
selective serotonin reuptake inhibitor;
TCA=
tricyclic antidepressant

Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • CME Course: NPub.org/cmelist

  • Received June 6, 2019.
  • Accepted in final form October 9, 2019.
  • © 2019 American Academy of Neurology
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  • Reader response: Triptan and ergotamine overdoses in the United States: Analysis of the National Poison Data System
    • Vinod K. Gupta, Physician, Migraine-Headache Institution, Gupta Medical Center (New Delhi, India)
    Submitted December 14, 2019
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