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Activated charcoal safe and effective for digoxin toxicity
Letters to the Editor
Table. Multivariate Analysis by Cox Proportional Hazards Regression Using Backward Selection Approach Variables
Hazard Ratio (95% Confidence Interval)
P Value
GG Genotype Lipid-lowering drugs Family history of CAD
5.55 (1.28–24.16) 0.39 (0.14–1.10) 3.26 (1.23–8.65)
0.02 0.07 0.02
variant is associated with coronary artery disease in French-Canadians. Am Heart J. 2001;142(2):336 –339. 9. Pecoits-Filho R, Stenvinkel P, Marchlewska A, et al. A functional variant of the myeloperoxidase gene is associated with cardiovascular disease in end-stage renal disease patients. Kidney Int Suppl. 2003;(84):172– 176.
CAD ⫽ coronary artery disease.
genotype and family history of coronary artery disease (Table). Zhang and colleagues showed that levels of myeloperoxidase in neutrophils and serum were associated with the presence of angiographically demonstrated coronary atherosclerosis (7). In French Canadian patients, the GG genotype was associated with an increased incidence of coronary artery disease (8). Recently, the aforementioned results were confirmed in patients with end-stage renal disease (9). Both studies concluded that the presence of the A allele is associated with a lower frequency of cardiovascular disease. The frequency of the A allele in our study is similar to the findings of previous studies (4,9). This report shows that subjects with two copies of the G allele have an increased risk of developing a cardiovascular event. Future studies are necessary to confirm and assess the clinical effect of this data. Folkert W. Asselbergs, MD University of Groningen Groningen, The Netherlands Wanda F. Reynolds, PhD Sidney Kimmel Cancer Center San Diego, California Jan W. Cohen-Tervaert, MD, PhD University of Maastricht Maastricht, The Netherlands
430
March 15, 2004
Gillian A.J. Jessurun, MD, PhD, MBA Rene´ A. Tio, MD, PhD University Hospital Groningen Groningen, The Netherlands 1. Diaz MN, Frei B, Vita JA, Keaney JF Jr. Antioxidants and atherosclerotic heart disease. N Engl J Med. 1997;337(6):408 –416. 2. Sugiyama S, Okada Y, Sukhova GK, et al. Macrophage myeloperoxidase regulation by granulocyte macrophage colony-stimulating factor in human atherosclerosis and implications in acute coronary syndromes. Am J Pathol. 2001;158(3):879 –891. 3. Piedrafita FJ, Molander RB, Vansant G, et al. An Alu element in the myeloperoxidase promoter contains a composite SP1-thyroid hormone-retinoic acid response element. J Biol Chem. 1996;271(24):14412–14420. 4. Reynolds WF, Chang E, Douer D, et al. An allelic association implicates myeloperoxidase in the etiology of acute promyelocytic leukemia. Blood. 1997;90(7):2730 –2737. 5. Asselbergs FW, Monnink SH, Veeger NJ, et al. Coronary vasomotor response is related to the angiographic extent of coronary sclerosis in patients with stable angina pectoris. Clin Sci (Lond). 2004;106:115–120. 6. Reynolds WF, Stegeman CA, Cohen Tervaert JW. – 463 G/A myeloperoxidase promoter polymorphism is associated with clinical manifestations and the course of disease in MPO-ANCA-associated vasculitis. Clin Immunol. 2002;103(2):154 –160. 7. Zhang R, Brennan ML, Fu X, et al. Association between myeloperoxidase levels and risk of coronary artery disease. JAMA. 2001; 286(17):2136 –2142. 8. Nikpoor B, Turecki G, Fournier C, et al. A functional myeloperoxidase polymorphic
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116
ACTIVATED CHARCOAL SAFE AND EFFECTIVE FOR DIGOXIN TOXICITY To the Editor: I read with interest the article (1) in the July 2003 issue of the Journal regarding the assessment and treatment of digoxin toxicity. In addition to administering potassium, discontinuing digoxin, and assessing the patient’s magnesium-calcium status, the administration of activated charcoal (the kind used in overdose patients) is very helpful. It usually allows one to avoid using digoxin antibodies, as the administration of activated charcoal causes the digoxin level to drop 30% to 40% in 12 to 18 hours, thus avoiding the nadir of digoxin’s medical benefits that occur when one administers digoxin antibodies. William H. Fee, Jr., MD Chest Medicine Associates Franklin, Pennsylvania 1. Piccini J, Zaas A. Cases from the Osler Medical Service at Johns Hopkins University. Digitalis toxicity with bidirectional ventricular tachycardia. Am J Med. 2003;115:70 – 71.
Table. Multivariate Analysis by Cox Proportional Hazards Regression Using Backward Selection Approach Variables
Hazard Ratio (95% Confidence Interval)
P Value
GG Genotype Lipid-lowering drugs Family history of CAD
5.55 (1.28–24.16) 0.39 (0.14–1.10) 3.26 (1.23–8.65)
0.02 0.07 0.02
variant is associated with coronary artery disease in French-Canadians. Am Heart J. 2001;142(2):336 –339. 9. Pecoits-Filho R, Stenvinkel P, Marchlewska A, et al. A functional variant of the myeloperoxidase gene is associated with cardiovascular disease in end-stage renal disease patients. Kidney Int Suppl. 2003;(84):172– 176.
CAD ⫽ coronary artery disease.
genotype and family history of coronary artery disease (Table). Zhang and colleagues showed that levels of myeloperoxidase in neutrophils and serum were associated with the presence of angiographically demonstrated coronary atherosclerosis (7). In French Canadian patients, the GG genotype was associated with an increased incidence of coronary artery disease (8). Recently, the aforementioned results were confirmed in patients with end-stage renal disease (9). Both studies concluded that the presence of the A allele is associated with a lower frequency of cardiovascular disease. The frequency of the A allele in our study is similar to the findings of previous studies (4,9). This report shows that subjects with two copies of the G allele have an increased risk of developing a cardiovascular event. Future studies are necessary to confirm and assess the clinical effect of this data. Folkert W. Asselbergs, MD University of Groningen Groningen, The Netherlands Wanda F. Reynolds, PhD Sidney Kimmel Cancer Center San Diego, California Jan W. Cohen-Tervaert, MD, PhD University of Maastricht Maastricht, The Netherlands
430
March 15, 2004
Gillian A.J. Jessurun, MD, PhD, MBA Rene´ A. Tio, MD, PhD University Hospital Groningen Groningen, The Netherlands 1. Diaz MN, Frei B, Vita JA, Keaney JF Jr. Antioxidants and atherosclerotic heart disease. N Engl J Med. 1997;337(6):408 –416. 2. Sugiyama S, Okada Y, Sukhova GK, et al. Macrophage myeloperoxidase regulation by granulocyte macrophage colony-stimulating factor in human atherosclerosis and implications in acute coronary syndromes. Am J Pathol. 2001;158(3):879 –891. 3. Piedrafita FJ, Molander RB, Vansant G, et al. An Alu element in the myeloperoxidase promoter contains a composite SP1-thyroid hormone-retinoic acid response element. J Biol Chem. 1996;271(24):14412–14420. 4. Reynolds WF, Chang E, Douer D, et al. An allelic association implicates myeloperoxidase in the etiology of acute promyelocytic leukemia. Blood. 1997;90(7):2730 –2737. 5. Asselbergs FW, Monnink SH, Veeger NJ, et al. Coronary vasomotor response is related to the angiographic extent of coronary sclerosis in patients with stable angina pectoris. Clin Sci (Lond). 2004;106:115–120. 6. Reynolds WF, Stegeman CA, Cohen Tervaert JW. – 463 G/A myeloperoxidase promoter polymorphism is associated with clinical manifestations and the course of disease in MPO-ANCA-associated vasculitis. Clin Immunol. 2002;103(2):154 –160. 7. Zhang R, Brennan ML, Fu X, et al. Association between myeloperoxidase levels and risk of coronary artery disease. JAMA. 2001; 286(17):2136 –2142. 8. Nikpoor B, Turecki G, Fournier C, et al. A functional myeloperoxidase polymorphic
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116
ACTIVATED CHARCOAL SAFE AND EFFECTIVE FOR DIGOXIN TOXICITY To the Editor: I read with interest the article (1) in the July 2003 issue of the Journal regarding the assessment and treatment of digoxin toxicity. In addition to administering potassium, discontinuing digoxin, and assessing the patient’s magnesium-calcium status, the administration of activated charcoal (the kind used in overdose patients) is very helpful. It usually allows one to avoid using digoxin antibodies, as the administration of activated charcoal causes the digoxin level to drop 30% to 40% in 12 to 18 hours, thus avoiding the nadir of digoxin’s medical benefits that occur when one administers digoxin antibodies. William H. Fee, Jr., MD Chest Medicine Associates Franklin, Pennsylvania 1. Piccini J, Zaas A. Cases from the Osler Medical Service at Johns Hopkins University. Digitalis toxicity with bidirectional ventricular tachycardia. Am J Med. 2003;115:70 – 71.