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MDMA (XTC, ecstasy) is a monoaminergic agonist, often used as a
recreational drug. MDMA is frequently used but leads to relatively
few emergency department visits. In 2003 about 2.1 million
Americans reported using MDMA at least once in the past year. US
Emergency Department visits related tot MDMA use declined from
5,542 visits in 2001 to 4026 in 2002
(http://oas.samhsa.gov/2k4/clubdrugs/clubdrugs.cfm). MDMA-tablets
frequently contain mixtures of MDMA with other amphetamines,
fillers or drugs like cocaine. MDMA concentration ranges from 5 -
150 mg per tablet. Peak plasma concentrations are reached in about
2 hours after oral ingestion; half-life is about 8 hours. MDMA is
mainly metabolized through the CYP2D6 system. Some enzymes in the
metabolization cascade are easily saturated, and consequently
plasma levels can rise sharply with ingestion of only a few extra
tablets. Patients with severe intoxications often present with
seizures and coma. Jaw clenching, impaired gate, and tachycardia
are common signs. Diagnosis is based on urinary gas chromatography
or spectrometry as the urinary dip stick is often false-negative
for amphetamines, but management decisions should not be deferred
pending laboratory confirmation of amphetamine toxicity. For GHB
testing (which is one of the differentials), urine samples must
quickly be frozen if analysis is not available immediately.
Complications of MDMA use are:
- hyperthermia
- SIADH and excessive fluid intake leading to hyponatremia and
seizures
- delirium
- rhabdomyolysis
- diffuse intravascular coagulation
- hypertension and tachycardia
- hepatotoxicity due to glutathion depletion
Treatment is directed at symptomatic control of the clinical
manifestations of toxicity. It is mainly based on expert opinion,
since few randomized clinical trials have been performed. The
mainstay of therapy is correction of hyperthermia and hyponatremia
along with supportive measures (Kalant et al.). Hyponatremia is
often caused by sweating and excessive hypotonic fluid intake while
dancing. However, MDMA may also induce SIADH and patients should be
treated accordingly. Agitation and delirium can best be treated
with a butyrophenone or otherwise with benzodiazepines (Richards et
al.). Thus far no randomized controlled trial for the treatment of
hyperthermia in MDMA intoxication has been published. Studies in
rat and swine, however, have shown evidence for the beneficial
effect of dantrolene (Fiege et al.), carvedilol (Jackson et al.,
Sprague et al.) and baclofen (Bexis et al.). Similarly, there are
no randomized controlled trials for the treatment and prevention of
MDMA related hepatoxicity. Rat studies, however, have shown
beneficial effects of ascorbic acid and N-acetylcysteine (Carvalho
et al.)
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