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Duloxetine Associated with Smoking Cessation

Cold Medicine. Severe neurologic and cardiologic complications can result from improper dosing of these medications.1 We present a case of acute psychosis induced by a patient using double the manufacturer’s recommended dose of Coricidin HBP Cough and Cold Medicine. Case Report. A 54-year-old white man was admitted to an inpatient psychiatric facility for management of acute psychotic symptoms. He presented to the emergency department (ED) with paranoid thoughts, auditory hallucinations, and preoccupation with religion. While in the ED, he stated that the care providers were “dogs with the power of darkness.” He also described being possessed by demons and used as a messenger by them. He said that these symptoms started 3 days earlier, soon after using Coricidin HBP Cough and Cold tablets to relieve cold symptoms; he had taken up to 8 capsules in 24 hours, although the recommended dose on the packaging is 4 doses in 24 hours. The next day he experienced severe auditory hallucinations, paranoia, and hyper-religiosity. A thorough medical evaluation in the ED was negative. He had no previous history of drug allergy, psychiatric problems, or substance abuse; however, his medical history was significant for myocardial infarction and lymphoma. There was no family history of psychosis. Medications on admission were aspirin 375 mg/day, lisinopril 20 mg/day, clopidogrel 75 mg/day, and simvastatin 40 mg/day. He had received aspirin, lisinopril, and simvastatin for a few years. Clopidogrel was started a few months before presentation. Although the possibility of this reaction occurring from his current drugs is very low, their contribution could not be ruled out. The patient received intramuscular haloperidol 5 mg, and Coricidin HBP was discontinued. A computed tomography scan revealed a low attenuation lesion in the left cerebellar hemisphere consistent with an old infarct. He was admitted to an inpatient psychiatric facility. The symptoms resolved over 2 days with no additional psychotropic medication, and he was discharged. Discussion. Coricidin HBP Cough and Cold Medicine is an OTC product containing dextromethorphan 30 mg and chlorpheniramine 4 mg per tablet. Dextromethorphan, an antitussive agent with affinity for the sigma opiate receptor, may cause psychosis by its metabolite dextrophan, which is a noncompetitive antagonist of the NMDA receptor.2 Individuals who have rapid metabolizer phenotype CYP2D6 may be more susceptible to the psychotogenic effects.3 Chlorpheniramine is an antihistamine that antagonizes histamine H1 receptors. At the time of writing, only one interaction involving the drugs our patient received has been reported. Clopidogrel potentiates the effects of aspirin on collagen-induced platelet aggregation, but coadministration in our patient did not significantly alter the bleeding time.4 At high doses, Coricidin HBP can lead to agitation, hallucinations, tachycardia, and confusion.5 Clinical manifestations of dextromethorphan and chlorpheniramine overdose are similar to some extent. However, a possibility of an unexplained mechanism involving the causation of these symptoms with the use of Coricidin could not be ruled out. According to the Naranjo probability scale, the relationship of the adverse reaction to Coricidin HBP is possible.6 Patients and healthcare providers should be reminded of the adverse effects described here from fairly safe OTC drugs when used in doses exceeding those recommended.