vitamin-k-1 and difenacoum

A large-scale outbreak of life-threatening, inhaled synthetic cannabinoids (Spice/K2)-associated coagulopathy with bleeding complications was recently reported in Illinois. The causative agents were brodifacoum, difenacoum, and bromadiolone, potent, long-acting, 4-hydroxycoumarin anticoagulant rodenticides (LAAR) that were mixed with Spice/K2 products procured and then inhaled by the victims. We report on 3 poisoned patients who reside in underserved, socioeconomically disadvantaged neighborhoods of Chicago that were admitted and treated successfully at two inner-city, tertiary care hospitals in Chicago. The patients were discharged from the hospitals on daily long-term high-dose oral vitamin K

Topics: 4-Hydroxycoumarins; Administration, Inhalation; Adult; Aftercare; Anticoagulants; Antifibrinolytic Agents; Blood Coagulation Disorders; Cannabinoids; Chicago; Female; Hemorrhage; Humans; International Normalized Ratio; Lost to Follow-Up; Male; Medication Adherence; Middle Aged; Patient Compliance; Synthetic Drugs; Vitamin K 1

Difenacoum is a long-acting superwarfarin-type anticoagulant that exerts its effect through inhibiting vitamin K 2,3-epoxide reductase. Inhibition of this enzyme leads to reduced bioavailability of the metabolically active form of vitamin K resulting in decreased production of vitamin K-dependent proteins including coagulation factors II, VII, IX and X. A 45-year-old woman with psychiatric illness presented with haematuria. Laboratory test results indicated she had been exposed to a vitamin K antagonist which was subsequently identified as difenacoum. She was initially treated with phytomenadione, red cell suspension and octaplex. She was discharged on 30 mg phytomenadione daily but monitoring of vitamin K markers indicated that compliance was poor, and 152 days post-admission she presented with haemoptysis. Difenacoum and other superwarfarin rodenticides are freely available for purchase by the public. Cases such as this continue to raise issues about their availability and regulation.

Topics: 4-Hydroxycoumarins; Blood Coagulation Factors; Drug Overdose; Erythrocyte Transfusion; Female; Hematuria; Hemoptysis; Humans; Medication Adherence; Mental Disorders; Middle Aged; Rodenticides; Vitamin K 1; Vitamin K Epoxide Reductases

Topics: 4-Hydroxycoumarins; Anticoagulants; Blood Coagulation; Blood Coagulation Tests; Blood Component Transfusion; Contusions; Epistaxis; Female; Gastrointestinal Hemorrhage; Humans; Middle Aged; Rodenticides; Vitamin K 1

1. The coumarin anticoagulant difenacoum was detected by high performance liquid chromatography (HPLC) with multi-wavelength UV detection in plasma from a 41 years old man who presented with a severe deficiency of vitamin K-dependent clotting factors of unknown aetiology. A longitudinal toxicological study of the consequent coagulopathy is described. 2. Plasma concentrations of difenacoum declined from 0.97 to 0.11 mgl-1 in 47 days with a terminal half life of 11.7 days. Rifampacin (300 mg bd) had no apparent effect on the terminal half life of the drug. Subsequently plasma concentrations of difenacoum and descarboxyprothrombin (DCP) unexpectedly increased. 3. Seven months after exposure clotting times were prolonged. The patient continued to have episodes of epistaxis, haematoma, purpurae and bruising and he required frequent treatment with Fresh Frozen Plasma in additional to oral phylloquinone (200 mg day-1). 4. Intermittent and unexpected increases in plasma concentrations of difenacoum and descarboxypro-thrombin suggested that covert, repeated ingestion of the anticoagulant was the most likely cause of the poisoning. The measurement of low concentrations of plasma phylloquinone except following supervised ingestion of the vitamin indicated that as an outpatient, the subject was not compliant with treatment despite his protestations to the contrary. He continued to deny this even when confronted by laboratory findings and at no time did he ever admit to self-poisoning.

Topics: 4-Hydroxycoumarins; Adult; Antibiotics, Antitubercular; Anticoagulants; Antifibrinolytic Agents; Biomarkers; Blood Coagulation Factors; Chromatography, High Pressure Liquid; Half-Life; Humans; Longitudinal Studies; Male; Plasma; Protein Precursors; Prothrombin; Rifampin; Rodenticides; Spectrophotometry, Ultraviolet; Vitamin K 1

We have investigated the actions of the coumarin anticoagulant, difenacoum, in male and female rats and mice. In our first experiment difenacoum (0.5 mg kg-1) killed 50% of male mice within 9 days of its administration, whereas no female mice died during this study. In a second group of experiments, the anticoagulant effect of difenacoum in male and female rats was determined. Under resting conditions, the prothrombin complex activities (PCA) of male and female rats were not significantly different. Over the first 24 h after administration of difenacoum (0.4 mg kg-1 i.p.), there was a monoexponential fall in PCA in both sexes. However, 6, 12 and 24 h after difenacoum, the PCA in male rats was significantly (P less than 0.05) lower than in female rats. PCA began to recover over the subsequent 48 h in both sexes, during which time there was marked variability in recovery in female rats. The difference between the onset of action of difenacoum in male and female rats did not appear to be due to a greater rate of elimination of the drug in female rats, since the plasma concentrations of difenacoum 24 h after its administration were the same in both sexes. The concentration of vitamin K1 in rat liver was also investigated. Vitamin K1 levels were 35.1 +/- 18.6 ng (g liver)-1 (male), and 29.4 +/- 5.4 ng (g liver)-1 (females) in control rats, but 24 h after difenacoum, vitamin K1 levels were either very low, or undetectable in all rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Topics: 4-Hydroxycoumarins; Animals; Female; Kinetics; Liver; Male; Mice; Prothrombin; Rats; Sex Characteristics; Vitamin K 1

The case histories of two patients exposed to the novel anticoagulants brodifacoum and difenacoum are reported. Abnormal vitamin K1 metabolism, as indicated by elevated vitamin K1 2,3-epoxide plasma concentrations after i.v. administration of vitamin K1, could be detected for more than 18 months after exposure to the anticoagulants. There was a marked prolongation of prothrombin time (greater than 50 s) in both cases, at the time of exposure. However, subsequent haematological investigations (prothrombin time and vitamin K-dependent clotting factor activity) have been shown to be normal in both cases for at least 18 months. These cases confirm the long-acting nature of brodifacoum and difenacoum and present an apparent dissociation between the effect of coumarin anticoagulants on vitamin K1 metabolism and clotting factor activity.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Disorders; Blood Coagulation Tests; Humans; Male; Occupational Diseases; Prothrombin Time; Vitamin K 1

Topics: 4-Hydroxycoumarins; Adolescent; Animals; Female; Humans; Male; Rabbits; Rodenticides; Suicide, Attempted; Vitamin K 1