Hospital Pharmacy - July/August 2019 - 241

828860
other2019

HPXXXX10.1177/0018578719828860Hospital PharmacyMancano et al

ISMP ADR Series

ISMP Adverse Drug Reactions:
Pheochromocytoma Crisis Induced by
Metoclopramide Baclofen Dependence
Following High-Dose Therapy Fatal
Cardiotoxicity Following High-Dose
Cyclophosphamide Acute Anterograde
Amnestic Syndrome Induced by Fentanyl
Ivermectin-Induced Toxic Epidermal
Necrolysis Pembrolizumab-Induced Type
1 Diabetes

Hospital Pharmacy
2019, Vol. 54(4) 241-245
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/0018578719828860
DOI: 10.1177/0018578719828860
journals.sagepub.com/home/hpx

Michael A. Mancano1, Jonathan Lapin1,
and Andrew Paik1
The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of
prevention, and promote reporting of ADRs to the US Food and Drug Administration's (FDA) MedWatch program (800FDA-1088). If you have reported an interesting, preventable ADR to MedWatch, please consider sharing the account with
our readers. E-mail Dr. Mancano at michael.mancano@temple.edu. Your report will be published anonymously unless
otherwise requested. This feature is provided by the Institute for Safe Medication Practices (ISMP) in cooperation with the
FDA's MedWatch program and Temple University School of Pharmacy. ISMP is an FDA MedWatch partner.

Pheochromocytoma Crisis Induced by
Metoclopramide
A 36-year-old woman with past medical history significant
for anxiety and obesity was observed in the emergency
department (ED) with complaints of headaches, nausea, and
vomiting for the preceding 3 days. Her vital signs were normal, apart from a slightly elevated blood pressure (BP) of
134/86 mm Hg, and her physical and neurological examinations were both unremarkable, including a computed tomographic (CT) scan of her head. Metoclopramide 10 mg was
administered intravenously for symptomatic management of
the patient's nausea and headaches. One hour after administration, the patient reported severe agitation and headache,
ranking her pain 9 out of 10 on a pain scale, and the patient's
BP increased to 223/102 mm Hg. Diphenhydramine and
methylprednisolone were administered, after suspecting an
allergy to metoclopramide, and labetalol and hydralazine
were administered to decrease BP. Laboratory findings
drawn after administration of metoclopramide appeared normal, except for leukocytosis (White Blood Cell Count,
14.3K/µL; normal, 4-11K/µL). Severe left-sided chest pain
and diaphoresis manifested two and a half hours later, and a
wide-complex tachycardia with a heart rate of 177 bpm was

observed on electrocardiogram (ECG). Given the new progression of symptoms, aortic dissection was suspected, and
the patient underwent a CT scan of her chest and abdomen,
which showed a large heterogeneous right adrenal mass,
with no other acute findings.
The patient's symptoms further progressed, after completion of the CT scan, to acute respiratory distress with hypoxia
and central cyanosis, with repeated episodes of vomiting; the
patient was later intubated to protect the airway. Metabolic
acidosis with severe acidemia (pH <6.81, normal, 7.357.45), as well as lactic acidosis (16.4 mmol/L, normal, 0.5-1
mmol/L) developed. Progressing acute respiratory distress
syndrome requiring extracorporeal membrane oxygenation
(ECMO) precipitated her transfer to a tertiary care center.
The patient's status further declined, suffering non-ST segment elevation myocardial infarction, cardiogenic shock,
acute liver failure with an aspartate aminotransferase of
1

Temple University School of Pharmacy, Philadelphia, PA, USA

Corresponding Author:
Michael A. Mancano, Chair and Clinical Professor, Department of
Pharmacy Practice, Temple University School of Pharmacy, Philadelphia,
PA 19140, USA.
Email: michael.mancano@temple.edu

https://us.sagepub.com/en-us/journals-permissions https://www.doi.org/10.1177/0018578719828860 http://journals.sagepub.com/home/hpx

Hospital Pharmacy - July/August 2019

Table of Contents for the Digital Edition of Hospital Pharmacy - July/August 2019