Cetirizine-Induced Atrial Fibrillation

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258 Cetirizine-Induced Atrial Fibrillation. 261 Von Meyenburg Complex: Report of a Case and Review of Literature. 264 Mesenteric Panniculitis: A Rare Entity, ...
ISSN: 2321-4848

Volume 4 | Issue 2 | July-December 2016

AMHS ARCHIVES OF MEDICINE

Archives of Medicine and Health Sciences

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HEALTH SCIENCES

The Official Journal of Yenepoya University

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233 Isolated Dilated Pupil: Is it Adie's Pupil?

161 Doctors' White Coat and the Evidence Boondoggle: Microbiology, Desiderata, Symbolism, or Professionalism Decorum?

235 Classification Conundrum: Persistent Mullerian Duct Syndrome with Hypospadias

INVITED EDITORIAL 166 Medical Humanities in Medical Schools in India ORIGINAL ARTICLES

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169 Diabetes Treatment Satisfaction, Medication Adherence, and Glycemic Control among Ambulatory Type 2 Diabetic Nigerians in a Primary Care Clinic of a Tertiary Hospital Situated in a Resource-limited Environment of Southeast Nigeria



175 Immunoglobulin E is Associated with Markers of Mast Cell Degranulation and Microalbuminuria in Obese Subjects with Type 2 Diabetes

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180 Assessment of Abuse of Self-medication for Oral and Dental Problems among 21–60 Years Aged Populace Residing in the Rural Areas of Belgaum Taluk, Karnataka, India: A Questionnaire Study

238 Leiomyoma of Scrotum

241 Oleogranuloma of Rectum Co-existing With Primary Malignant Melanoma: Report of a Rare Occurrence 244 Assessment and Rehabilitation of Scapular Dyskinesis: A Case Study 248 Successful Rescue Cerclage at Advanced Cervical Dilatation in the Second Trimester 251 Calf Muscle Hypertrophy in Late Onset Pompe's Disease 253 Diagnostic Enigma of a Maxillary Unilocular Radiolucency With Multiple Impacted Teeth: A Case Report and Review of Literature 258 Cetirizine-Induced Atrial Fibrillation 261 Von Meyenburg Complex: Report of a Case and Review of Literature

• July-December 2016

264 Mesenteric Panniculitis: A Rare Entity, Report of Two Cases with Review of the Literature

185 Effect of Stretching and Proprioceptive Loading in Hand Function among Patients with Cerebellar Tremor

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189 A Study of Spectrum of Histopathological Features in Patients Presenting with Hyperpigmented Skin Lesions

267 Museums of Materials Used in Dentistry: Our Experience and Literature Review

196 Clinical Profile of Acute Flaccid Paralysis

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201 Histomorphology of Fallopian Tubes in Ectopic Pregnancy

271 Mitigating India's Health Woes: Can Health Insurance be a Remedy to Achieve Universal Health Coverage?



205 Digital Panoramic Radiography: An Aid in the Early Detection of Osteoporotic Signs

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212 Hospital Pharmacy Services in Teaching Hospitals in Nepal: Challenges and the Way Forward

286 Footprints of Phineas Gage: Historical Beginnings on the Origins of Brain and Behavior and the Birth of Cerebral Localizationism

CASE REPORTS

287 Eponyms in Tuberculosis

218 Pancreatic Pleural Effusion: A Diagnosis Not to be Missed!

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222 Pure Epithelioid Angiomyolipoma of Kidney in Tuberous Sclerosis Patient: A Case Report and Review of Literature

290 Schwartz–Jampel Syndrome: Clinical and Diagnostic Phenotype of a Rare Genetic Disorder

225 An Extremely Rare Case Report of Sinonasal Undifferentiated Carcinoma of Paranasal Sinuses

292 Primary Failure of Eruption

229 Eosinophilic Infiltration in Lymph Node in a Child with Idiopathic Hypereosinophilic Syndrome

294 Obstructive Sleep Apnea: Awareness among Health-care Professionals – Dilemma or Reality?

LETTER TO EDITOR

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Case Report

Cetirizine-Induced Atrial Fibrillation Altuğ Ösken, Regayip Zehir, Sibel Ösken1, Selçuk Yaylacı2, Ercan Aydın3, Salih Şahinkuş3, Yusuf Can3 Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, ¹Department of Physical Medicine and Rehabilitation, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, 2Department of Internal Medicine, Rize Findikli Goiter Research Center, Rize, ³Department of Cardiology, Sakarya University Faculty of Medicine, Sakarya, Turkey

Abstract Atrial fibrillation (AF) is the most common observed arrhythmia in clinical practice. In the literature, AF events associated with drug induction are available. Cetirizine is a second-generation histamine antagonist used in the treatment of allergies, angioedema, and urticaria. We wish to present an atypical case who took cetirizine medication for relieving symptoms of upper tract respiratory system infection, experienced rapid ventricular response AF and treated successfully. To best of our knowledge, this is the first case of cetirizine-induced AF. Key words: Arrhythmia, atrial fibrillation, cetirizine

Introduction Atrial fibrillation (AF) is the most common observed arrhythmia in clinical practice. AF significantly increases the risk of thromboembolic ischemic stroke, and it results in affecting hemodynamic impairment.[1] Although AF is often associated with structural heart disease and other co-occurring chronic conditions, it can also occur without an identified cause (lone AF). In the literature, AF events associated with drug induction are available. For these drugs, arguments have been made on the mechanisms which can lead to AF and some drugs have been put into the riskier class.[2] Antihistamine drugs are one of them. Cetirizine is a second-generation antihistamine used in the treatment of allergies, angioedema, and urticaria. To best of our knowledge, this is the first case of cetirizine-induced AF.

Case Report A 26-year-old male patient presented to the emergency department with sudden onset of palpitations. He had admitted to the family physician with complaints of a runny nose and cough for 2 days, and he had been prescribed 10 mg of cetirizine once a day. After 1 h of the first usage of cetirizine, he suddenly felt increasing of heart rate and admitted to our hospital. His electrocardiography (ECG) revealed AF with rapid ventricular response [Figure 1]. The patient had no history of structural heart disease and had no history of substance or drug abuse. No

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There are many different pathways for the onset of AF. From different categories of drugs are thought to be associated with the development of AF by the way of different mechanisms. Almost all drug-induced AF is reported to have the following main mechanisms: Adrenergic or vagal stimulation, a direct effect on atrial electrophysiological properties (increasing atrial ectopic activity, slowing atrial conduction velocity and/ or shortening atrial potential duration and refractoriness), coronary vasoconstriction or thrombosis, direct cardiotoxicity Address for correspondence: Dr. Altuğ Ösken, Cardiology Clinic, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center, Tibbiye Cad., 13, Haydarpasa, Kadikoy, Istanbul 34846, Turkey. E-Mail: [email protected]

For reprints contact: [email protected]

DOI: 10.4103/2321-4848.196192

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Discussion

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other medications or supplements were started within 2 months. The initial physical examination was unremarkable. A chest radiograph was normal and transthoracic echocardiography revealed normal systolic and diastolic function, normal heart chambers. Whole laboratory tests were normal. First, metoprolol therapy was applied for rate control, but at 12-h follow-up, effective rate and rhythm control could not be achieved. Therefore, 600 mg propafenone was administered to the patient orally and after 2 h at track restoration of sinus rhythm was observed [Figure 2].

How to cite this article: Osken A, Zehir R, Ösken S, Yaylacı S, Aydın E, Şahinkuş S, et al. Cetirizine-Induced atrial fibrillation. Arch Med Health Sci 2016;4:258-60.

© 2016 Archives of Medicine and Health Sciences | Published by Wolters Kluwer - Medknow

Ösken, et al.: Cetirizine-induced Atrial Fibrillation

(including hypertrophy, fibrosis, heart failure, abnormalities in Ca2 handling, myocarditis, pericarditis) and local electrolyte disturbances.[3,4] AF is often seen in elderly patients; therefore, a detailed cardiac evaluation should be performed to confirm the diagnosis of AF associated with the drug. If we look at our case, our patient was a young 26-year-old man, and there is no known history of cardiac disease, drug or alcohol usage. We did not find any abnormalities in laboratory parameters and cardiac imaging modalities that could lead to the development of AF. He took cetirizine treatment to suppress the symptoms of upper respiratory tract infections. Typically, in druginduced AF, there is a direct time relationship between the administration of the drug and the onset of AF. In 95% of patients after oral administration of 10 mg cetirizine, it has been showed that the highest blood levels achieved 60 min later. Our patient was admitted to the emergency department with complaints of palpitations exactly 1 h after taking the drug, and AF was documented on emergency ECG. We could not measure plasma concentration of cetirizine due to the lack of laboratory facilities. Presented in the literature reviews, it is known that antihistamine drugs can lead to ventricular tachyarrhythmias with adrenergic stimulation; whereas these

drugs have not been the high-risk range for the development of AF. Cetirizine is a selective H1 receptor antagonist. Anticholinergic effects of this drug along with sympathetic stimulation can increase excitability and atrioventricular node transition by eliminating the effects of the vagus. As a result, the use of this drug may increase the number of premature atrial beats and facilitate the development of AF. Therefore, the several studies showing that the risk of QT prolongation and arrhythmias is lower with cetirizine compared to other anti-H1 medications. Hekkala et al. assessed the use of cetirizine in patients with inherited Type 1 and Type 2 long QT syndrome. They did not observe prolonged QT intervals, neither during rest nor after physical exertion, having administered a therapeutic dose of 10 mg to the patients or 50 mg doses to the healthy volunteers.[5] Hydroxyzine, a compound from which cetirizine is derived, does not appear to induce ventricular arrhythmias, though T-wave changes have been reported, associated with high doses of this drug. Its metabolite, cetirizine, is fundamentally eliminated through the kidneys, with scant liver metabolization. Cetirizine does not block the Kv11.1 potassium

Figure 1: Admission electrocardiography consistent with rapid ventricular response atrial fibrillation

Figure 2: Control electrocardiography after restoration of sinus rhytm

Archives of Medicine and Health Sciences / Jul-Dec 2016 / Vol 4 | Issue 2

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Ösken, et al.: Cetirizine-induced Atrial Fibrillation

channel even at high concentrations in different models and circumstances. The drug has only rarely been associated with cardiac adverse effects.[6]

Conflicts of interest

We could not find any publication on our detailed screening that leads to atrial tachyarrhythmias. From this perspective, we think this is the first case report in the literature.

References

There are no conflicts of interest.

1. 2.

Conclusion Cetirizine is a potent antihistamine drug which commonly used in routine clinical practice, although it is known to be safe, use of antihistaminic drugs should be kept in mind in the absence of well-known causes that may lead to arrhythmias. These therapies must be individualized and avoid unnecessary usage.

Financial support and sponsorship Nil.

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Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham study. Stroke 1991;22:983-8. van der Hooft CS, Heeringa J, van Herpen G, Kors JA, Kingma JH, Stricker BH. Drug-induced atrial fibrillation. J Am Coll Cardiol 2004;44:2117-24. Jung F, DiMarco JP. Treatment strategies for atrial fibrillation. Am J Med 1998;104:272-86. Tamargo J, Caballero R, Delpón E. Drug-induced atrial fibrillation. Expert Opin Drug Saf 2012;11:615-34. Hekkala AM, Swan H, Väänänen H, Viitasalo M, Toivonen L. The effect of antihistamine cetirizine on ventricular repolarization in congenital long QT syndrome. J Cardiovasc Electrophysiol 2007;18:691-5. Dávila I, Sastre J, Bartra J, del Cuvillo A, Jáuregui I, Montoro J, et al. Effect of H1 antihistamines upon the cardiovascular system. J Investig Allergol Clin Immunol 2006;16 Suppl 1:13-23.

Archives of Medicine and Health Sciences / Jul-Dec 2016 / Vol 4 | Issue 2