Case Report
Post-operative cyclizine misuse J Woodfield1 and EJ St George2
Scottish Medical Journal 58(4) e1–e2 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013508039 scm.sagepub.com
Abstract Cyclizine is commonly prescribed as an anti-emetic post-operatively. We report a case of a 51-year-old woman who developed addiction to intravenous cyclizine following regular administration at recommended doses. This is the first report of cyclizine misuse post-operatively. We compare this case to cyclizine abuse reported amongst other populations. Prescribers should be aware of the potential of cyclizine as a drug of abuse.
Keywords Cyclizine, anti-emetics, substance abuse
Introduction Cyclizine is a piperazine-derived anti-histamine that is commonly prescribed to treat post-operative nausea and vomiting. As well as H1 antagonist activity, cyclizine also has central anti-muscarinic action. The British National Formulary recommended dosage of cyclizine is 50 mg three times a day.1 We report a case of addiction to cyclizine developing at this dose.
Case report A 51-year-old woman who had previously experienced three haemorrhages from a superior cerebellar peduncle cavernoma (Figure 1(a)) was admitted electively for resection of the lesion. Post-operatively, she suffered from ataxia, nausea and vomiting and was prescribed multiple anti-emetics. Cyclizine was the only antiemetic to provide symptomatic benefit and she received regular eight-hourly administration of 50 mg of cyclizine intravenously. Within 10 days, her ataxia had resolved but she requested continuation of the intravenous drug for persistent nausea. Post-operative imaging (Figure 1(b)) showed good resection of the cavernoma without any cause for nausea. She began to exhibit aggressive behaviour before the dose of cyclizine was due and would become very agitated and upset if the dose was delayed for any reason. These mood and behavioural changes would quickly settle with administration of the cyclizine dose, prompting her to apologise for her previous behaviour. On further questioning, she described a feeling of euphoria with the administration of intravenous cyclizine, later followed
by a period of low mood which was relieved with further doses. She had also experienced visual hallucinations following cyclizine administration. After discussing these effects with her, the intravenous cyclizine was replaced with intravenous granisetron and eventually all anti-emetics were stopped.
Discussion Cyclizine is one of the most commonly prescribed anti-emetics post-operatively, yet it is known to have addictive potential and hallucinogenic properties. A population of opiate dependents in Nottingham were reported to inject between 50 and 800 mg of cyclizine intravenously either with methadone or alone.2 The reported reasons for injecting cyclizine were the stimulant effect, hallucinations and to increase the effect of opiates.2 The stimulant effect of cyclizine was reported to last between 30 and 180 min after which a period of depression and craving for cyclizine or other drugs could occur.2 Cyclizine has also been identified as a drug of abuse amongst teenagers in Utah, USA.3 In this region, cyclizine was obtained over the counter and ingested orally producing hallucinations,
1
Neurosurgery Specialty Trainee, Institute of Neurological Sciences, Southern General Hospital, UK 2 Consultant Neurosurgeon, Institute of Neurological Sciences, Southern General Hospital, UK Corresponding author: Julie Woodfield, Institute of Neurological Sciences, Southern General Hospital, Glasgow, G51 4TF, UK. Email: [email protected]
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Scottish Medical Journal 58(4)
Figure 1. T2 MRI of superior cerebellar peduncle cavernoma: (a) pre-operative appearance and (b) post resection appearance.
confusion, agitation, dysarthria, drowsiness, ataxia, chest pain and seizures.3 In both of these populations, cyclizine was used intentionally as a drug of abuse at higher doses than those prescribed for use as an antiemetic. However, abuse of cyclizine has also been reported in the hospital setting in patients originally prescribed recommended doses. Bailey and Davies4 described a series of oncology patients who got a ‘buzz’ from cyclizine injections, became abusive in requests for cyclizine, and one who recruited his wife’s assistance with injecting cyclizine via his Hickmann line towards the end of his life. The experience of our patient is similar to that described with cyclizine addiction in other populations. She experienced improved mood and occasional hallucinations with cyclizine doses and became aggressive and demanding, behaving out of character when requesting additional doses. This case illustrates that cyclizine addiction may develop with the use of the standard dose of cyclizine in patients with no history of substance abuse. Cyclizine abuse is not restricted to patients with nausea and vomiting induced by chemotherapy or an underlying oncological condition, but may occur in elective surgical admissions. Healthcare professionals prescribing and administering cyclizine need to be aware of the potential for cyclizine misuse.
. There is a risk of cyclizine addiction developing with recommended doses. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Author contributions Both authors wrote and researched the report.
References 1. Joint Formulary Committee. British National Formulary, 63rd ed. London: BMJ Group and Pharmaceutical Press, 2012. 2. Ruben SM, Mclean PC and Melville J. Cyclizine abuse amongst a group of opiate dependents receiving methadone. Br J Addict 1989; 84: 929–934. 3. Bassett KE, Schunk JE and Crouch BI. Cyclizine abuse by teenagers in Utah. Am J Emerg Med 1996; 14: 472–474. 4. Bailey F and Davies A. The misuse/abuse of antihistamine antiemetic medication (cyclizine) by cancer patients. Palliat Med 2008; 22: 869–871.
Learning points . Administration of cyclizine can cause euphoria and hallucinations.
Downloaded from scm.sagepub.com at Stockholm University Library on August 4, 2015
Post-operative cyclizine misuse J Woodfield1 and EJ St George2
Scottish Medical Journal 58(4) e1–e2 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933013508039 scm.sagepub.com
Abstract Cyclizine is commonly prescribed as an anti-emetic post-operatively. We report a case of a 51-year-old woman who developed addiction to intravenous cyclizine following regular administration at recommended doses. This is the first report of cyclizine misuse post-operatively. We compare this case to cyclizine abuse reported amongst other populations. Prescribers should be aware of the potential of cyclizine as a drug of abuse.
Keywords Cyclizine, anti-emetics, substance abuse
Introduction Cyclizine is a piperazine-derived anti-histamine that is commonly prescribed to treat post-operative nausea and vomiting. As well as H1 antagonist activity, cyclizine also has central anti-muscarinic action. The British National Formulary recommended dosage of cyclizine is 50 mg three times a day.1 We report a case of addiction to cyclizine developing at this dose.
Case report A 51-year-old woman who had previously experienced three haemorrhages from a superior cerebellar peduncle cavernoma (Figure 1(a)) was admitted electively for resection of the lesion. Post-operatively, she suffered from ataxia, nausea and vomiting and was prescribed multiple anti-emetics. Cyclizine was the only antiemetic to provide symptomatic benefit and she received regular eight-hourly administration of 50 mg of cyclizine intravenously. Within 10 days, her ataxia had resolved but she requested continuation of the intravenous drug for persistent nausea. Post-operative imaging (Figure 1(b)) showed good resection of the cavernoma without any cause for nausea. She began to exhibit aggressive behaviour before the dose of cyclizine was due and would become very agitated and upset if the dose was delayed for any reason. These mood and behavioural changes would quickly settle with administration of the cyclizine dose, prompting her to apologise for her previous behaviour. On further questioning, she described a feeling of euphoria with the administration of intravenous cyclizine, later followed
by a period of low mood which was relieved with further doses. She had also experienced visual hallucinations following cyclizine administration. After discussing these effects with her, the intravenous cyclizine was replaced with intravenous granisetron and eventually all anti-emetics were stopped.
Discussion Cyclizine is one of the most commonly prescribed anti-emetics post-operatively, yet it is known to have addictive potential and hallucinogenic properties. A population of opiate dependents in Nottingham were reported to inject between 50 and 800 mg of cyclizine intravenously either with methadone or alone.2 The reported reasons for injecting cyclizine were the stimulant effect, hallucinations and to increase the effect of opiates.2 The stimulant effect of cyclizine was reported to last between 30 and 180 min after which a period of depression and craving for cyclizine or other drugs could occur.2 Cyclizine has also been identified as a drug of abuse amongst teenagers in Utah, USA.3 In this region, cyclizine was obtained over the counter and ingested orally producing hallucinations,
1
Neurosurgery Specialty Trainee, Institute of Neurological Sciences, Southern General Hospital, UK 2 Consultant Neurosurgeon, Institute of Neurological Sciences, Southern General Hospital, UK Corresponding author: Julie Woodfield, Institute of Neurological Sciences, Southern General Hospital, Glasgow, G51 4TF, UK. Email: [email protected]
Downloaded from scm.sagepub.com at Stockholm University Library on August 4, 2015
e2
Scottish Medical Journal 58(4)
Figure 1. T2 MRI of superior cerebellar peduncle cavernoma: (a) pre-operative appearance and (b) post resection appearance.
confusion, agitation, dysarthria, drowsiness, ataxia, chest pain and seizures.3 In both of these populations, cyclizine was used intentionally as a drug of abuse at higher doses than those prescribed for use as an antiemetic. However, abuse of cyclizine has also been reported in the hospital setting in patients originally prescribed recommended doses. Bailey and Davies4 described a series of oncology patients who got a ‘buzz’ from cyclizine injections, became abusive in requests for cyclizine, and one who recruited his wife’s assistance with injecting cyclizine via his Hickmann line towards the end of his life. The experience of our patient is similar to that described with cyclizine addiction in other populations. She experienced improved mood and occasional hallucinations with cyclizine doses and became aggressive and demanding, behaving out of character when requesting additional doses. This case illustrates that cyclizine addiction may develop with the use of the standard dose of cyclizine in patients with no history of substance abuse. Cyclizine abuse is not restricted to patients with nausea and vomiting induced by chemotherapy or an underlying oncological condition, but may occur in elective surgical admissions. Healthcare professionals prescribing and administering cyclizine need to be aware of the potential for cyclizine misuse.
. There is a risk of cyclizine addiction developing with recommended doses. Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Author contributions Both authors wrote and researched the report.
References 1. Joint Formulary Committee. British National Formulary, 63rd ed. London: BMJ Group and Pharmaceutical Press, 2012. 2. Ruben SM, Mclean PC and Melville J. Cyclizine abuse amongst a group of opiate dependents receiving methadone. Br J Addict 1989; 84: 929–934. 3. Bassett KE, Schunk JE and Crouch BI. Cyclizine abuse by teenagers in Utah. Am J Emerg Med 1996; 14: 472–474. 4. Bailey F and Davies A. The misuse/abuse of antihistamine antiemetic medication (cyclizine) by cancer patients. Palliat Med 2008; 22: 869–871.
Learning points . Administration of cyclizine can cause euphoria and hallucinations.
Downloaded from scm.sagepub.com at Stockholm University Library on August 4, 2015
