A DOCS Education member seeks the faculty’s assistance:
A 47-year-old healthy female whose appearance is consistent with her stated age is currently taking:
- 2.5-lisinoprofile
- Max Air as needed
- Viactiv®, Multivitamin, fish oil, calcium
- Lysteda® - 650 mg only during menstruation
- Volatren topical for her arthritis
- She was exposed to DES (diethylstilbestrol) in utero.
She gives the following history:
"After typically taking half the prescribed dose of a narcotic, I will pass out if not lying down. The first time this occurred was in the emergency room after Percocet®. I passed out (post-discharge) and awoke in the middle of the waiting room on a gurney, sweating profusely, to someone saying ‘I can't find her pulse.’ I believe it went as low as 60/40, if that is possible. The following evening I took another half dose—after eating—since they thought I had passed out because I hadn't eaten. At that time I was lying in bed. Prior to getting out of bed I checked my blood pressure. It was again obscenely low and I knew I would pass out upon standing.
With both vicodin and tramadol I experience the above symptoms with an added twist: I vomit violently after almost passing out.
This same sequence of events occurs post-sedation. It happened 30 years ago with wisdom teeth extraction and just a handful of years ago after conscious sedation for a colonoscopy."
Could this be a "hyped-up" Cytochrome P450 or just a bizarre reaction to the drugs? Thanks for your input and consideration.
Dr. Jerome Wellbrock, DOCS Education faculty, offers his advice:
It sounds like this patient is very sensitive to narcotic/opioid medications. I would try to learn which medications she may have been exposed to in past sedation experiences such as the colonoscopy.
Narcotics are routinely used along with benzodiazepines. After a little research you may find your patient is okay with the benzos and that the narcotics are the problem.
The DOCS Education Member responds:
What is the etiology of narcotic hypersensitivity like she describes? Can it be CNS, CP450, blood enzymes? Particularly with such a precipitous drop in BP I'd love to know the mechanism. Thanks.
Dr. Jerome Wellbrock responds:
Some of the opioid/narcotic meds such as codeine are metabolized from an inactive to an active form by the P450 2D6 cytochrome aka the CYP2D6.
It could be that she is rapidly converting, therefore having a rapid response to the medications. Narcotics can also cause histamine release and mimic an allergic reaction but this is not a true allergy. Nausea and vomiting are possible with most of the narcotic medications. It is possible that if she was NPO and therefore hypovolemic that it could result in the hypotension, and the drop in BP could worsen upon standing resulting in syncope.
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