To the Editor,
In 2016 we wrote a forward looking commentary about possible malicious exposure of people in the U.S. to second generation, long-acting (months) anticoagulant rodenticides (LAAR’s), such as brodifacoum, bromadiolone and difenacoum, and the need to develop effective countermeasures to mitigate their prolonged toxic effects [Citation1]. Our prediction materialized in March 2018, when more than 400 people in the U.S. were poisoned and developed severe coagulopathy and bleeding after inhaling synthetic cannabinoids laced with LAAR’s with 11 reported deaths [Citation2, Citation3]. In September 2021 a similar outbreak was reported from Israel where 95 people who inhaled synthetic cannabinoids laced with brodifacoum have been hospitalized with severe coagulopathy and bleeding with 3 deaths reported so far [Citation4] (Lurie Y. Personal communication). During December 2021, 45 mostly homeless individuals in Hillsborough County, Florida were hospitalized with severe coagulopathy and bleeding after inhaling synthetic cannabinoids laced with brodifacoum with 2 deaths reported so far [Citation5] (Mulay PR. Personal Communication).
Given informal input we have received from people involved with these global outbreaks, the medical community and policy makers are presently faced with ongoing challenges in delivering appropriate care to poisoned victims. First, there is lack of rapid, sensitive, point-of-care laboratory testing to detect the offending LAAR(s); development of quantitative, liquid chromatography tandem mass spectrometry methods which can simultaneously measure multiple LAARs in under 10 min would provide health care providers with objective means to address this need [Citation6]. Second, there is an inadequate supply of inexpensive vitamin K1 to counter prolonged coagulopathy. In view of the long duration and dose of oral vitamin K1 therapy required to maintain INR within the normal range, current cost estimates to treat one poisoned patient in the U.S. can amount to ∼$50,000 per month [Citation7, Citation8]. Third, there is no established intervention(s) to increase clearance of the offending LAAR(s) from the human body. Finally, previous experience indicates that long-term monitoring of victims after hospitalization is inefficient [Citation9]. In order to contain similar global outbreaks in the future, we propose that these shortcomings must be addressed and resolved soon through cohesive collaborations among all stakeholders.
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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References
- Feinstein DL, Brodsky S, Weinberg G, et al. Brodifacoum poisoning: a clear and present danger to public health in the USA. Toxicol Lett. 2017;268:71–72.
- Kelkar AH, Smith NA, Martial A, et al. An outbreak of synthetic cannabinoid-associated coagulopathy in Illinois. N Engl J Med. 2018;379(13):1216–1223.
- Devgun JM, Rasin A, Kim T, Mycyk MB, et al. An outbreak of severe coagulopathy from synthetic cannabinoids tainted with Long-Acting anticoagulant rodenticide. Clin Toxicol. 2020; 58(8):821–828.
- https://www.jpost.com/opinion/nice-guy-drug-is-not-very-nice-at-all-editorial-681791. (last accessed December 23, 2021).
- https://patch.com/florida/southtampa/42-hospitalized-2-dead-tampa-area-after-using-synthetic-pot. (last accessed December 23, 2021).
- van Breemen RB, Hafner JW, Nosal DG, et al. Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides. Toxicol Commun. 2021;5(1):93–96.
- Nosal DG, van Breemen RB, Haffner JW, et al. Brodifacoum pharmacokinetics in acute human poisoning: implications for estimating duration of vitamin K therapy. Toxicol Commun. 2021;5(1):69–72.
- Yip L, Stanton NV, Middleberg RA. Vitamin K1 treatment duration in patients with brodifacoum poisoning. N Engl J Med. 2020;382(18):1764–1765.
- Tole M, LaBedz S, Feinstein DL, et al. Adherence to Long-Term Follow-Up of patients with Life-Threatening, inhaled synthetic Cannabinoids-Associated coagulopathy in chicago. Lung. 2019;197(3):349–352.