Acetazolamide
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Acetazolamide Worsening acidosis following an off-label use: 2 case reports
In a case report, two men aged 72 years and 67 years were described, who developed worsening acidosis following an off-label use of acetazolamide for metabolic alkalosis [times to reactions onsets not stated; not all outcomes stated]. Case 1: A 72-year-old man had severe COPD. He presented to an emergency department (ED) with dyspnoea, cough and increased yellow sputum production. He was non-compliant with bilevel positive airway pressure (BiPAP) therapy at home. He was receiving various concomitant medications for different co-morbidities. Following investigations, he was diagnosed with pneumonia and chronic hypercapnic ventilatory failure. The ventilator failure worsened by severe metabolic alkalosis. He then received off-label oral acetazolamide 500mg along with various other medications. BiPAP was started at pressures of 16/8cm H2O, and the fraction of inspired oxygen (FiO2) was set to 40%. He was transferred to the ICU, where he became more somnolent and confused. Supplemental oxygen was administered via nasal cannula, as he refused BiPAP. However, BiPAP was resumed and increased to pressures of 20/12cm H2O and the FiO2 was set to 30%. He was given further fluid boluses, and dopamine was started in order to maintain mean arterial pressure above 65mm Hg. The next morning, his arterial blood gas values worsened. No further doses of acetazolamide was given. His bicarbonate continued to decrease slightly, and he remained acidotic with eventual improvement with continued standard therapy [specific drugs not stated]. On hospital day 2, he was weaned off vasopressors. Theophylline, steroids, antibiotics and bronchodilator treatments were continued. He eventually returned to his baseline condition, and was discharged to home on hospital day 5. Case 2: A 67-year-old man had underlying chronic COPD, and was dependent on supplemental oxygen. He presented to the ED with worsening shortness of breath over 4 days after a viral illness. He was on various concomitant medications. He was noncompliant with home BiPAP therapy. He denied chest pain or sputum production, and he had expiratory wheezing on examination using accessory muscles. Following further investigations, he was diagnosed with status asthmaticus, with a severe metabolic alkalosis worsening his hypercapnia. He then received off-label IV acetazolamide 250mg along with various other medications. He was also started on BiPAP with pressures of 14/8cm H20 and the FiO2 was set to 32%. He was admitted to the ICU, and a second acetazolamide dose 250mg orally was given. Twelve hours later, his acidaemia did not improve. He was then transitioned back to 3L nasal cannula, as he was uncomfortable in the BiPAP mask. This continued 36h following acetazolamide administration. He became confused and drowsy, and was unable to follow simple commands. Ipratropium bromide/salbutamol nebulised bronchodilator treatments, theophylline, montelukast and steroids were continued. No additional doses of acetaz
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