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2CASE PRESENTATION

Dr. Pranesh PawaskarFirst year resident,Dept. of pharmacology,L.T.M.M.C. Sion, Mumbai 400022Date :- 02/12/2016.

3CHLOROQUINE INDUCED HYPOKALEMIA

4CASE

• Male

• 35 years

• No h/o any disease or comorbid condition.

• c/o Fever with chills … 7 days.

Generalised body pain … 7 days.

5COURSE OF REACTION

11/10/2016Patient started getting fever with chills

.

.Fever went on becoming high grade

.12/10/2016

Patient seek treatment from private practitioner

.

6COURSE OF REACTION

Private practitioner started him on Tab. Chloroquine 500mg B.D. Tab. Paracetamol 500mg T.D.S.Tab. Pantoprazole 20mg B.D.

.

.

.16/10/2016

Patient started experiencing Palpitation, Weakness

7COURSE OF REACTION

17/10/2016Weakness & fatigue went on increasing and patient started getting muscle cramps and

constipation.

18/10/2016Muscle cramp and weakness become so severe that patient had to be admitted in our institute for

treatment..

8COURSE OF REACTION

At our institute patient was examined and admitted to ward no. 5 under Dr. NDM

.

.After analysing patients blood reports

conclusion was drawn as Hypokalemia as a cause of patients symptoms.

.

.

9COURSE OF REACTION

19/10/2016Patient recovered from symptoms and K values

started improving..

ADR reported to our department ..

20/10/2016Patient discharged

10INVESTIGATIONS

DATE 18/10/2016 19/10/2016 20/10/2016

K+ (mEq/L) 2.80 2.74 4.02

Na (mEq/L) 142 140 139

Cl (mEq/L) 97 100 98

• PSMP negative.

• IgM dengue Negative.

11SERIOUSNESS OF REACTION

• Reaction was serious as it required hospitalisation of patient.

OUTCOME -• Patient fully recovered on 20/10/2016.• Patient discharged on 20/10/2016.

DIAGNOSIS –CHLOROQUINE INDUCED HYPOKALEMIA.

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NARANJO SCALE

13CAUSALITY ASSESSMENT

According to NARANJO SCALE score is 7

PROBABLE

BECAUSE1) Reasonable time-event relationship.2) De-challenge response positive.3) Could not be caused by other drugs and conditions.

14HYPOKALEMIA

• K+ levels <3.5 mEq/L (<2.5 mEq/L)

• Normal range = 3.5 to 5.0 mEq/L

• Feeling Tired, Leg Cramps, Weakness, And

Constipation.

• It increases the risk of an abnormal heart

rhythm such as bradycardia and cardiac

arrest.

15CAUSES OF HYPOKALEMIA

1. Decreased intake –

2. Redistribution into cells –

• Acid base

• Hormonal and drugs

• Anabolic state

3. Increased loss –

4. Genetic diseases -

16DRUGS CAUSING HYPOKALEMIA

• Epinephrine• Pseudo ephedrine• Bronchodilators • Tocolytics• Theophylline• Caffeine• Verapamil (OD)• Chloroquine (OD)• Insulin (OD)

• Diuretics• Mineralocorticois• Gossypol • High dose

glucocorticoids• Penicillin, Ampicillin

(OD)• Cisplatin, Foscarnet,

Amphotericine B

17CHLOROQUINE

• 1934 - Hans Andersag - Bayers Lab.

• Introduced - 1947 malaria prophylaxis.

• Given orally.

• Wide safety margin.

• Bioavailability = 89%

• PPB = 50%

• t1/2 = 3-10 days.

18USES

• MALARIA – Prevention & Treatment.• Extra Intestinal Amoebiasis.• Rheumatoid arthritis.• DLE.• Lepra Reaction. • Porphyria Cutaneous Tarda.• Glioblastoma.• IN CT with pt of HIV/AIDS + Chikungunya Fever.• Radio sensitising Agent Chemotherapy.• In-Vitro Lysosomal Degradation of proteins.

19SIDE EFFECTS

• Prolonged QT interval.• Diarrhoea.• Loss of appetite.• Nausea, Vomiting.• Muscle weakness, stomach cramps. • Retinopathy, accommodation problem, Headache.• Methemoglobinemia.• Haemolysis in G6PD deficiency.

20INTERACTIONS

• Quinidine.

• Dapsone

• Mefloquine.

• Influenza vaccine

• Aluminium Hydroxide.

• Ampicillin.

• Aspirin.

• Ciprofloxacin

• Thioridazine

• Carvedilol

• Cimetidine

• Haloperidol

• Metoprolol

• Efavirenz

21MECHANISM OF HYPOKALEMIA

• Retrospective Series of 191 consecutive acute chloroquine intoxications hypokalaemia was frequent (84%) (profound in less than 2 mmol/L in 11% of cases).• Mechanism = Depletion versus Intracellular transport.• It cannot be attributed to gastrointestinal losses, as no patient had diarrhoea; vomiting was inconstant (30%)

22MECHANISM OF HYPOKALEMIA• No significant difference between the mean

plasma potassium concentration of patients who

vomited and those who did not.

• Urinary potassium = as the urinary potassium

losses were low and there was no statistical

relation between kaliuretic and plasma potassium

concentrations.

• Alkalosis = not cause (on average, an acid ph.)

23MECHANISM OF HYPOKALEMIA

A shift of potassium from extracellular to

intracellular =

• Alkalosis.

• Insulin administration or glucose

administration.

• Intensive Beta Adrenergic stimulation.

• Hypokalaemia periodic paralysis.

• Hypothermia.

24MANAGEMENT OF HYPOKALEMIA

• Reduction of K loss.• Replenishment of K loss.• Oral replacement with K+-Cl– is the mainstay of therapy.• K2Co3 or potassium citrate = patients with concomitant metabolic acidosis.• If hypokalaemia is severe (<2.5 mmol/L) = intravenous K+-Cl– can be administered through a central vein (rates of 10–20 mmol/h)

25CONCLUSION

• A case of probable ADR presented due to overdose.• Wide safety margin drug.• Lots of side effects.• Proper dosage necessary.• Proper use necessary to avoid resistant.• Stop or reduce use once ADR detected.• Such ADR cases should be highlighted to provide better information and precaution to other health care providers.

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