Department of Clinical Pharmacology and Toxicology and Drug health services, Royal Prince Alfred Hospital, Level 6, King George Building, Missenden Rd, Camperdown, NSW, Australia.
Emergency Department, Royal North Shore Hospital, St Leonards, NSW, Australia.
Cardiovasc Toxicol. 2021 May;21(5):349-353. doi: 10.1007/s12012-020-09624-z. Epub 2021 Jan 22.
This case report describes a 65-year-old female with iatrogenic opioid use disorder for chronic lower back pain, who developed Takotsubo cardiomyopathy on multiple occasions following buprenorphine induction. This patient had three opioid transfers to buprenorphine, over 4 years, two of which were complicated by Takotsubo cardiomyopathy. In the transfer where she did not develop Takotsubo cardiomyopathy, she was treated with high doses of the centrally acting agonist, clonidine (three times a day, total of 600 mcg/day), up to and including the day of her transfer. This case highlights the potential consequences of a precipitated withdrawal with buprenorphine in an opioid transfer and its possible prevention with clonidine. To our knowledge, this is the first description of the recurrent Takotsubo cardiomyopathy in an opioid transfer setting. Given that buprenorphine is a partial agonist, in the presence of a full opioid agonist, it can precipitate withdrawal within minutes to hours of its administration. Opioid withdrawal can result in a sympathetic overdrive. Although complications of opioid withdrawal are extensively documented, cardiotoxicity is uncommon. As the use of buprenorphine and its new injectable formulations rise, it is important for prescribers to be aware of this life threatening complication. The prophylactic administration of clonidine can be considered to reduce the risk of cardiotoxicity, as well as manage opioid withdrawal symptoms.
本病例报告描述了一位 65 岁女性，因慢性腰痛而长期使用阿片类药物，在多次接受丁丙诺啡诱导后出现 Takotsubo 心肌病。该患者在 4 年内经历了三次阿片类药物转用丁丙诺啡，其中两次并发 Takotsubo 心肌病。在未发生 Takotsubo 心肌病的转用中，她接受了高剂量的中枢作用激动剂可乐定（每天三次，总量 600mcg/天），直至转用当天。本病例突出了丁丙诺啡转用中戒断引起的潜在后果及其用可乐定预防的可能性。据我们所知，这是首例描述阿片类药物转用背景下复发性 Takotsubo 心肌病的病例。由于丁丙诺啡是部分激动剂，在存在完全阿片类激动剂的情况下，其给药后数分钟至数小时内即可引发戒断。阿片类药物戒断可导致交感神经亢进。尽管阿片类药物戒断的并发症已有广泛记载，但心脏毒性并不常见。随着丁丙诺啡及其新的注射制剂的使用增加，医生有必要了解这种危及生命的并发症。预防性给予可乐定可降低心脏毒性的风险，同时也可治疗阿片类药物戒断症状。
