Intrathecal Clonidine Pump Failure Causing Acute Withdrawal Syndrome With 'Stress-Induced' Cardiomyopathy

J Med Toxicol. 2016 Mar;12(1):134-8. doi: 10.1007/s13181-015-0505-9.

Abstract

Clonidine is a central alpha(2)-agonist antihypertensive used widely for opioid/alcohol withdrawal, attention deficit hyperactivity disorder and chronic pain management. We describe a case of clonidine withdrawal causing life-threatening hypertensive crisis and stress-induced cardiomyopathy. A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24 h), presented following a collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump malfunctioned. On presentation, vital signs included pulse 100 bpm, BP 176/103 mmHg, temperature 37.8 °C and O2 saturation 100 % (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. Intravenous clonidine loading dose and a 50 mcg/h infusion were commenced. Five hours later, severe chest pain, dyspnoea, tachycardia, hypoxia, with BP 180/120 mmHg and pulmonary edema ensued. ECG showed sinus tachycardia with no ST elevation. Repeated intravenous clonidine doses were given (25 mcg every 5-10 min), with ongoing clonidine infusion to control blood pressure. Glyceryl trinitrate infusion, positive pressure ventilation and intravenous benzodiazepines were added. Bedside echocardiogram showed stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. His coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in the ICU, drug infusions were weaned. Discharge was 12 days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone-SR. Two months later, his echocardiogram was normal. The intrathecal pump was removed. We report a case of stress-induced cardiomyopathy resulting from the sudden cessation of long-term intrathecal clonidine. This was managed by re-institution of clonidine and targeted organ-specific therapies.

Keywords: Cardiomyopathy; Clonidine; Intrathecal; Sympathomimetic; Withdrawal.

Publication types

  • Case Reports

MeSH terms

  • Adrenergic alpha-2 Receptor Agonists / administration & dosage
  • Adrenergic alpha-2 Receptor Agonists / adverse effects*
  • Back Pain / diagnosis
  • Back Pain / drug therapy*
  • Chronic Pain / diagnosis
  • Chronic Pain / drug therapy*
  • Clonidine / administration & dosage
  • Clonidine / adverse effects*
  • Electrocardiography
  • Equipment Failure*
  • Humans
  • Infusion Pumps, Implantable*
  • Infusions, Spinal
  • Male
  • Middle Aged
  • Substance Withdrawal Syndrome / diagnosis
  • Substance Withdrawal Syndrome / etiology*
  • Substance Withdrawal Syndrome / physiopathology
  • Substance Withdrawal Syndrome / therapy
  • Takotsubo Cardiomyopathy / chemically induced*
  • Takotsubo Cardiomyopathy / diagnosis
  • Takotsubo Cardiomyopathy / physiopathology
  • Takotsubo Cardiomyopathy / therapy

Substances

  • Adrenergic alpha-2 Receptor Agonists
  • Clonidine