exudates and Blood-Coagulation-Disorders

The Puff Adder (Bitis arietans) is a viper native to Africa and the Middle East. Envenomation by this species often requires the administration of appropriate antivenom in order to achieve a favorable outcome. A patient was bitten in both hands by a captive B. arietans presented to a teaching hospital in Malaysia. The patient developed painful progressive swelling on both limbs that extended to the chest, hypotension, hypokalemia with worsening anemia, thrombocytopenia, coagulopathy, and severe metabolic acidosis. The patient was managed supportively while waiting for the appropriate antivenom, Antivipmyn-Africa, from the Singapore Zoo. The patient developed cardiorespiratory arrest twice and did not recover from the second. The patient was pronounced dead 23 hours post-incident. The local unavailability of the appropriate antivenom may be the most important factor that contributed to the patient's death. There is also a need to amend the Malaysian Wildlife Act in order to prevent such cases from recurring.

Topics: Animals; Antivenins; Blood Coagulation Disorders; Malaysia; Snake Bites; Viper Venoms; Viperidae

VKORC1 and CYP2C9 genetic polymorphisms may not accurately predict warfarin dose requirements. We evaluated an existing warfarin dosing algorithm developed for Malaysian patients that was based only on VKORC1 and CYP2C9 genes.. Five Malay patients receiving warfarin maintenance therapy were investigated for their CYP2C9*2, CYP2C9*3, and VKORC1-1639G>A genotypes and their vitamin K-dependent (VKD) clotting factor activities. The records of their daily warfarin doses and international normalized ratio (INR) 2 years prior to and after the measurement of VKD clotting factors activities were acquired. The mean warfarin doses were compared with predicted warfarin doses calculated from a genotypic-based dosing model developed for Asians.. A patient with the VKORC1-1639 GA genotype, who was supposed to have higher dose requirements, had a lower mean warfarin dose similar to those having the VKORC1-1639 AA genotype. This discrepancy may be due to the coadministration of celecoxib, which has the potential to decrease warfarins metabolism. Not all patients' predicted mean warfarin doses based on a previously developed dosing algorithm for Asians were similar to the actual mean warfarin dose, with the worst predicted dose being 54.34% higher than the required warfarin dose.. Multiple clinical factors can significantly change the actual required dose from the predicted dose from time to time. The additions of other dynamic variables, especially INR, VKD clotting factors, and concomitant drug use, into the dosing model are important in order to improve its accuracy.

Topics: Anticoagulants; Asian People; Blood Coagulation; Blood Coagulation Disorders; Cytochrome P-450 CYP2C9; Dose-Response Relationship, Drug; Drug Interactions; Drug Monitoring; Female; Humans; International Normalized Ratio; Malaysia; Male; Middle Aged; Pharmacogenetics; Polymorphism, Genetic; Thrombosis; Vitamin K Epoxide Reductases; Warfarin

Topics: Adult; Autoanalysis; Blood Coagulation Disorders; Blood Coagulation Tests; Humans; Malaysia