Loperamide overdose and misuse
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Various toxicities: case report A 25-year-old woman developed nausea, fatigue, exertional lightheadedness, syncope, bradycardia, long QT syndrome and left and right bundle branch block due to drug toxicity secondary to overdose and misuse of loperamide. The woman presented to an emergency department with a 1-day history of nausea, fatigue, exertional lightheadedness and a syncopal event. Her BP was 75/42mm Hg, HR was 61 beats/min, body temperature was 36.3°C, respiration was 16 breaths/min and oxygen saturation was 99% by pulse oximetry. Her physical examination was significant for ongoing near-syncopal events and an irregular cardiac rhythm with variable S1 and S2 without murmurs, rubs or gallops. Initial ECG demonstrated bradycardia with a wide-complex rhythm and QTc prolongation to 554ms. On admission, a serum creatinine concentration was 1.6 mg/dL. A complete blood count showed normocytic anaemia. Her haemoglobin was 10.8 g/dL and mean corpuscular volume was 89.5fL. A transthoracic echocardiogram showed abnormal septal motion consistent with a conduction abnormality. The woman was treated with isoprenaline [isoproterenol] for tachycardia and to shorten the QTc interval. She also received empirical treatment with sodium bicarbonate. She continued to deny substance ingestion. Subsequently, on days 2 and 3 of hospitalisation, serum and urine testing was performed, which was found to be positive for fentanyl, which she received in the emergency department and noroxycodone a metabolite of oxycodone. She became more alert in appearance, but ECGs continued to show a wide QRS (upto 192ms) and prolonged QTc intervals (upto 739ms) with alternating left bundle branch block and right bundle branch block morphologies despite continuous isoprenaline and sodium bicarbonate infusions. On day 4 of hospitalisation, she admitted the ingestion of over-the-counter loperamide [Imodium A-D; dosage not stated] to wean off from oxycodone therapy. The amount of ingestion was unknown; however, serum loperamide was found to be at 280 ng/mL and serum desmethylloperamide was 810 ng/mL (typical plasma concentrations for normal loperamide dose are: for loperamide
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