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|Example of Acute Exposure data from MEDITEXT.|
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Example Content from MEDITEXT for Arsenic trioxide:
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ACUTE EXPOSURE INFORMATION
- USES: Arsenic trioxide is used for induction of remission and consolidation in patients with acute promyelocytic leukemia (APL). Arsenic trioxide is the primary material used to produce all arsenical compounds, and is used as an intermediate for insecticides, herbicides, and fungicides, as a wood preservative, a decoloring and refining agent in the manufacture of glass, and a textile mordant. It is also used in pharmaceutical preparations, pigments, and in sheep and cattle dip for preserving hides.
- PHARMACOLOGY: The precise mechanism of action of arsenic trioxide in acute promyelocytic leukemia (APL) remains to be clearly defined. However, in vitro studies indicated that morphological changes and DNA fragmentation characteristic of apoptosis occur in NB4 human promyelocytic leukemia cells following arsenic trioxide administration. Selective apoptosis of APL cells mediated by activation of cysteine-proteases (caspases) may be involved. Additionally, arsenic trioxide induces damage and degradation of the fusion protein PML/RAR-alpha.
- TOXICOLOGY: Trivalent arsenic (As3+) disrupts oxidative phosphorylation, leading to free radical formation via inhibition of pyruvate dehydrogenase, which subsequently decreases gluconeogenesis due to lack of acetyl-CoA. Chronically, arsenic may cause DNA damage, mutation in the p-53 suppressor gene, and inhibition of DNA repair mechanisms leading to cancer.
- EPIDEMIOLOGY: INTRAVENOUS ROUTE: Overdose is rare. OTHER ROUTES: Toxicity from arsenic is uncommon and major effects are rare.
- WITH THERAPEUTIC USE
- INTRAVENOUS ROUTE: COMMON (greater than 20%): Nausea, vomiting, diarrhea, constipation, abdominal pain, fatigue, fever, edema, rigors, chest pain, injection site pain, sore throat, hypokalemia, hypomagnesemia, hyperglycemia, elevated liver enzymes, headache, insomnia, paresthesia, dizziness, cough, dyspnea, epistaxis, hypoxia, pleural effusion, dermatitis, pruritus, ecchymosis, tachycardia, hypotension, sinusitis, arthralgia, myalgia, bone pain, leukocytosis, anemia, anxiety. OTHER ADVERSE EFFECTS: Palmar keratosis, rashes, hyperkalemia, hypocalcemia, nausea, vomiting, diarrhea, anorexia, abdominal pain, thrombocytopenia, neutropenia, neutropenia, noncirrhotic portal hypertension, hypersensitivity reaction, tremor, peripheral neuropathy, seizure, coma, and acidosis.
- Patients receiving arsenic trioxide may develop QT interval prolongation, complete atrioventricular block, premature ventricular contractions (PVCs), ventricular tachycardia, and a potentially fatal torsade de pointes ventricular dysrhythmia.
- Retinoic acid syndrome (retinoic-acid-Acute Promyelocytic Leukemia, RA-APL, or APL differentiation syndrome), a serious adverse effect, may also occur. It is characterized by fever, skin rash, lower leg edema, weight gain, dyspnea, pulmonary infiltrates, and pleural or pericardial effusions, with or without leukocytosis and death.
- WITH POISONING/EXPOSURE
- INTRAVENOUS ROUTE
- Data is limited. Seizures, muscle weakness, confusion may occur; other effects are similar to exposure by other routes (see below).
- OTHER ROUTES
- ACUTE OVERDOSE: Arsenic compounds are mainly absorbed through the gastrointestinal tract, but some absorption may occur through intact skin or inhalation. Acute arsenic ingestion generally produces signs and symptoms within 30 minutes but symptoms may be delayed for several hours if ingested with food. Many arsenic compounds are severe irritants of the skin, eye, and mucous membranes; some may be corrosive. Contact produces local hyperemia, followed by vesicular or pustular eruptions. Trivalent compounds are particularly caustic. Acute inhalation exposures have resulted in irritation of the upper respiratory tract.
- MILD TO MODERATE TOXICITY: Gastrointestinal symptoms occur rapidly after acute ingestion. Initial signs and symptoms include burning lips, throat constriction, and dysphagia. Excruciating abdominal pain, severe nausea, vomiting, and profuse "rice water-like" diarrhea that may lead to hypovolemia follows these symptoms. In addition, hypovolemia from capillary leakage (third-spacing of fluids) is a common early effect. QTc prolongation may occur. Muscle cramps, facial edema, bronchitis, dyspnea, chest pain, dehydration, intense thirst, and fluid-electrolyte disturbances are also common following significant exposures. A garlic-like odor of the breath and feces may also develop. Subacute toxicity can produce neuropathies, both motor and sensory, and can progress to a Guillain-Barre like syndrome.
- SEVERE TOXICITY: Hypotension and tachycardia are common early signs of severe poisoning. Hypotension may be resistant to fluid resuscitation and multi-organ failure may ensue. Fever and tachypnea may occur. These patients can develop ventricular dysrhythmias including torsade de pointes. Encephalopathy, seizures and coma have been reported. Acute renal failure, hemolytic anemia, rhabdomyolysis, and hepatitis may occur several days after ingestion.
- CHRONIC TOXICITY: Inhalation is the most common route of exposure in arsenic workers. The sequence of chronic poisoning involves weakness, anorexia, hepatomegaly, jaundice, and gastrointestinal complaints, followed by conjunctivitis, irritation of the upper respiratory tract, hyperpigmentation, and eczematoid and allergic dermatitis. A hoarse voice and chronic upper respiratory septum is a common result after prolonged inhalation of white arsenic dust or fume. Peripheral nervous system symptoms may include numbness, burning, and tingling of the hands and feet; pain; paresthesias; tenderness; muscle fasciculations; gross tremors; ataxia; discoloration; and mental confusion. Muscular weakness, limb tenderness and difficulty walking may follow. The final phase consists of peripheral sensory neuropathy of the hands and feet. Associated motor neuropathy may occur as well. Certain arsenic compounds are known human carcinogens. Chronic exposure in either occupational settings or by drinking contaminated groundwater can cause poisoning and carries an increased risk of skin, lung, bladder, and possibly liver cancers.
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