Opana Induced TTP Like Illness (1)(1)

5/22/2018 Opana Induced TTP Like Illness (1)(1)

1/11

YETANOTHERREASONTO

STAYAWAYFROMDRUGS

Dr. Heather Tarantino

Dr. Srikanth Nimmagadda


2/11

Introduction

Thrombotic thrombocytopenic purpura (TTP)

like illness is a rare but serious blood disorder

characterized by microangiopathic hemolytic

anemia and thrombocytopenia, in the

absence of certain known causes of TTP.

TTP has not been associated previously with

abuse of any opiate.


3/11

Inroduction:

This is the first report outside of Tennessee, TTP-like illness associated with abuse of an opioidpain reliever by injection.

Our case meets the current case definition byCDC for IV drug abuse-related TTP, a diagnosis ofTTP since February 1, 2012 in a person who hadused drugs intravenously for nonmedicalreasons.

This case also supports the findings previouslypublished in the one and only case control studyby Tennessee Department of Health.


4/11

Case Report

Patient is a 35 yr Old, Caucasian female,

CC: I have burning epigastric pain

Burning epigastric pain, 15/10 in intensity, since last 3 months,gradually getting worse, radiating to back, propping up and opanahelps to relieve pain.

Associated with nausea and decreased appetite, PMH: Hepatitis C, Chronic low back pain

Home Medication: Diclofenac Sodium 50 mg two times a day

PSH: C-Section X 4, D & C X 3,

FH: DM, CVA

Social History: 1 PPD X 24 years, Quit alcohol 7 years ago, IV drugabuse: Opana ER 20 mg per day, last abuse was 2 days ago, THCoccasional abuse, last time 1-2 months ago


5/11

Case Report

Clinical Examination:

Vitals: BP: 130/81, T: 36.6 C, PR: 88, RR: 18, 100%

saturation on RA,

Constitutional: Significant distress with severe pain,well nourished,

Abdomen: Epigastric and RUQ tenderness, Liver

palpable 2 inches below costal margin, No

splenomegaly, Bowel sounds , soft and present all 4quadrants

Skin: Multiple needle marks and tracks on fore arm


6/11

Case Report

Labs: CBC: WBC 11.9, Hb 7.4, MCV

100, Platelet count : 41,000

Cr: 1.1(Baseline 0.7-0.8),GFR:56

Direct coombs: Negative

UDS: Positive for opiates

LDH: 729, Haptoglobin:


7/11

Case Report

The diagnosis of TTP-AHUS(Atypical

hemolytic uremic syndrome)/TTP like illness

is made on basis of 3

Microangiopathic hemolytic anemia

Thrombocytopenia

Acute renal insufficiency

Ruling out other causes

case definition given by CDC


8/11

Hospital course

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9

ClinicalProgress

Time Line

LDH

Hemoglobin

Platelets

Plasmapheresis


9/11

Discussion

New formulation of Opana ER was released in Feb,2012, with the intent to inhibit crushing anddissolving the tablets.

Ingredients: polyethylene oxide (PEO) and polyethylene glycol.

Unclear what component or components of reformulated Opana ER might trigger TTP-like illness

In one study in rats, intravenously injected PEO caused thrombocytopenia.

Onaugust13,2012,a Nephrologist reported to the Tennessee Department of Health(TDH)threecases of unexplained thrombotic thrombocytopenic purpura (TTP),

By the end of October, a total of 15 such cases had been reported. Fourteen of the 15 patientsreported injecting reformulated Opana ER.

Seven of the 15 were treated for sepsis in addition to TTP-like illness. Twelve patients reportedchronic hepatitis C or had positive test results for anti-HCV antibody.

To test for an association between TTP like illness and injection of reformulated Opana ER, TDHconducted a case control study.

This study identified a strong association (odds ratio=35.0; 95% confidence interval=3.9-312.1)between TTP-like illness and injection of reformulated Opana ER.


10/11

Clinical implications

The extent of this problem is not clear because there is no requirement to report such cases andbecause IV drug use might not be suspected or reported among patients with TTP.

Recommendations from CDC for physicians prescribing Opana ER,2 A. Clinicians treating patients with TTP of unknown etiology should:

1. Ask patients about intravenous drug use. a. Patients who report IV drug use should be asked about the specific drugs injected.

2. Perform a urine drug test. a. A negative drug test is not definitive because the interval between the critical drug use and diagnosis might be

greater than the time during which a drug can be detected in the urine, which is probably not more than 4 days in thecase of opioids.

3. Request a copy of the patients prescriptions for controlled substances from the state prescription drugmonitoring program to determine if any doctor has prescribed the patient Opana ER. This informationmight be more accurate than the patients report of drug sources.

B. Clinicians treating patients with TTP who report IV use of Opana ER should: 1. Counsel patients regarding the risks of continued IV drug use, including blood-borne infections, fatal

overdose, and TTP.

2. Refer them to substance abuse treatment programs in their community. A list of substance abuse

treatment facilities is located at: http://www.samhsa.gov/treatment/index.aspx 3. Notify other clinicians who have prescribed the patient Opana ER of the diagnosis of TTP and the

reported association with that drug.

Prompt initiation of treatment on suspicion of diagnosis with plasmapheresis was also advised.


11/11

References

1. Morbidity and Mortality Weekly Report (MMWR) January

11, 2013 / 62(01);1-4

2. CDC Health Advisory CDCHAN-00331-2012-26-10-UPD-N

3. Uptodate, Diagnosis of thrombotic thrombocytopenic

purpura-hemolytic uremic syndrome in adults

4. Peripheral smear image: Cleveland Clinic Center for

Continuing Education, Disorders of Platelet Function and

Number

Opana Induced TTP Like Illness (1)(1)

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