Hospital Pharmacy - February 2018 - 16

Vilazodone-Induced Nightmares
A 37-year-old female with a history of major depressive disorder was diagnosed with a recurrence. The patient had been
treated with fluoxetine and escitalopram separately with success for 2 prior episodes of major depression. However, the
patient reported she was apprehensive to utilize fluoxetine or
escitalopram because she experienced abdominal pain, gastritis, and acidity while receiving these medications. She
requested to be initiated on a different antidepressant, and
vilazodone (Viibryd) was started at a dose of 20 mg daily. The
patient reported that after taking the first 3 daily doses, she
developed frightening and terrorizing nightmares on 2 consecutive nights. The patient decided to stop taking vilazodone
for 2 days, and the nightmares did not recur. She restarted the
vilazodone after her self-imposed 2-day drug holiday, and the
nightmares appeared again. The patient then decided to stop
vilazodone and see her physician. The patient's vilazodone
was discontinued, and duloxetine therapy was started and the
patient is currently better and recovering.
Vilazodone is a potent selective serotonin reuptake inhibitor and serotonin 1A receptor partial agonist. The author
states, "The neurobiological basis for the nightmares associated with vilazodone is unknown and whether neurobiological changes of depression play a role is an area that is nascent
and needs further research."2 The author hypothesized that
the action of vilazodone on 5-hydroxytryptophan-2 receptors
may contribute to this phenomenon such as that that has
occurred in selective serotonin reuptake inhibitors.

Dabigatran-Induced Pustular Eruptions
A 71-year-old female was initiated on dabigatran (Pradaxa) for
stroke prevention secondary to atrial fibrillation. After taking
two 150-mg doses of dabigatran, she noticed numerous mildly
tender and itchy eruptions on her palms and on the bottom of
her feet; however, she did not experience respiratory or oropharyngeal symptoms. Her other current medications included
pantoprazole, methimazole, and amiodarone. She had no
known drug allergies, but she once had a palmar rash after eating shellfish. She otherwise had never had any problems with
her skin and had not family history of psoriasis.
On physical examination, the patient had numerous discrete pustules on the bilateral palmar and plantar surfaces
with minimal erythema of the underlying skin. She denied
any recent shellfish ingestion that could have caused her dermatologic reaction. A punch biopsy was performed, and
although the skin lesions clinically appeared pustular, the
results were consistent with an eczematous drug reaction. A
full battery of laboratory tests were performed including a
complete blood count, iron studies, chemistry panels, liver
function, thyroid function, and coagulation studies, and all
were within normal limits except for a mild anemia.
The patient declined any topical or systemic treatment
for her palmar and plantar symptoms. Her dabigatran was

Hospital Pharmacy 53(1)
discontinued and her lesions began to clear at once. The
patient was not restarted on dabigatran, and enoxaparin was
initiated for anticoagulation without a recurrence of palmar
and plantar symptoms. The authors evaluated this adverse
reaction with the Naranjo scale, and it scored a 7 which indicates the patients' adverse reaction was probably due to
dabigatran.
The authors point out that the most common adverse reaction with dabigatran therapy is dyspepsia; however, there are
very rare instances of allergic edema and anaphylaxis. The
authors searched the medical literature and found 4 case
reports of cutaneous eruption due to dabigatran. The first
report occurred in a 20-year-old male who received dabigatran for stroke prevention due to atrial fibrillation. This patient
had an eruption on his thigh and forearm after 2 weeks of
receiving dabigatran 150 mg twice daily. His condition
resolved after dabigatran discontinuation and a topical corticosteroid. The second case occurred in a 78-year-old male
who had a diffuse, full-body, pruritic rash after receiving 2
doses of dabigatran 150 mg. This patient's condition resolved
after discontinuation of dabigatran and administration of
diphenhydramine. The third case occurred in a 59-year-old
male who developed a rash after receiving dabigatran 150 mg
twice daily for 5 days. The fourth case occurred in a 74-yearold female who developed leukocytoclastic vasculitis 1 week
after taking dabigatran 150 mg twice daily.
In closing, the authors state, "It is important to monitor for
and report hypersensitivity reactions in patient taking dabigatran. Drug exanthems may cause discomfort or even herald
more serious hypersensitivity reactions. Patients experiencing these reactions may discontinue therapy without notifying a physician and consequently place themselves at risk for
embolism or stroke."3

Neurotoxic and Cardiotoxic Symptoms
After Cannabis Concentrate Exposure
A 17-year-old athletic male was discovered naked in his bed
with seizure-like activity. He had no medical history or recent
illness. When emergency services arrive, the patient was agitated with a temperature of 102°F and was hypertensive with a
systolic blood pressure in the 190's; however, he was not
hypoxic. The patient then proceeded to try to escape the ambulance several times and eventually required intubation for safe
transport. The patient did not have any signs of trauma, and he
exhibited twitches and jerks of his extremities mixed with purposeful movements. The patient had an undetectable serum
alcohol concentration, and urine drug screen was positive only
for tetrahydrocannabinol metabolite (carboxy-THC).
The patient was sedated with propofol, midazolam, and
fentanyl and sent for a brain magnetic resonance imaging
(MRI). The brain MRI did not reveal baseline or provoked
activity suggestive of epileptogenic foci. The patient continued to be hypertensive, hyperthermic, and tachycardiac
despite sedation. The patient had a persistently elevated

Table of Contents for the Digital Edition of Hospital Pharmacy - February 2018