Profile picture
Chilla
@ChillaPharmD
, 7 tweets, 4 min read Read on Twitter
Part 5 #Tramadont #tweetorial
(in which #Tramadont remains a hilariously accurate descriptor of tramadol!)
@NarouzeMD @EMARIANOMD @toby_ashken @DavidJuurlink

CYP2D6 & tramadol is not overrated at all.
Here is a picture of the tramadol metabolism pathway (PMID 11454734) (1/7)
We can agree that M1 is the metabolite which provides opioid analgesic effects. (PMID 10961373) (2/7)
M1 is metabolized by CYP3A4 & CYP2B6 (not CYP2D6 as you suggested) to M5. (PMID 24849324) (3/7)
CYP2D6 is responsible for the vast majority of the conversion of tramadol to M1, so yes, it is quite sensitive to CYP2D6 polymorphisms. (PMID 24849324) (4/7)
While the parent compound, tramadol, is significantly less potent than other opioids, in ultrarapid metabolizers the metabolism to M1 can skyrocket, (5/7)
leading to fatal respiratory depression, significant enough to prompt an update to the package insert from the FDA with a warning for ultra-rapid metabolizers. (6/7)
...#pharmacogenomics, it’s the future!
Thanks again for the lively debate.
(7/7)
Missing some Tweet in this thread?
You can try to force a refresh.

Like this thread? Get email updates or save it to PDF!

Subscribe to Chilla
Profile picture

Get real-time email alerts when new unrolls are available from this author!

This content may be removed anytime!

Twitter may remove this content at anytime, convert it as a PDF, save and print for later use!

Try unrolling a thread yourself!

how to unroll video

1) Follow Thread Reader App on Twitter so you can easily mention us!

2) Go to a Twitter thread (series of Tweets by the same owner) and mention us with a keyword "unroll" @threadreaderapp unroll

You can practice here first or read more on our help page!

Related hashtags

#Tramadont #tweetorial #pharmacogenomics

More from @ChillaPharmD see all

Profile picture
Chilla
@ChillaPharmD
“#Tramadont”, a #tweetorial

In response to the last #pharmacyeducationboard about tramadol- some are still doubting whether it has earned the moniker “Tramadont”. Points have been made that as tramadol is metabolized by CYP2D6 in the liver, so are other drugs. Should we (1/11)
just not prescribe anyone anything metabolized in the liver? Touché. The problem with CYP2D6 specifically is that it happens to have the most polymorphisms of all the CYPs enzymes. What does this mean? It means it has the greatest potential variability in activity (2/11)
from one person to another. Not only this, but unlike the other CYPs, it’s expression can vary from being absolutely nonfunctional to being an ultrarapid metabolizer because of the very unique ability of it to be duplicated! No other CYP enzyme does this!! (3/11)
Read 11 tweets
Profile picture
Chilla
@ChillaPharmD
#Tramadol, a game of analgesic roulette, will it work or won’t it? Will your patient obtain analgesic effects or will they have a seizure, respiratory depression, or various other side effects...🤷🏼‍♀️that’s why it’s been nicknamed #Tramadont! Its variable effects are (1/3)
attributable to hepatic enzyme CYP2D6;unless you know your pt’s CYP2D6 genetic polymorphism (which I haven’t come across anyone who does)AND a comprehensive list of all of their home meds, don’t prescribe it!🙅🏼‍♀️
#pharmacyeducationboard #twitterx #medtwitter #pharmacogenomics (2/3)
Thank you to our #pharmacyresident for putting this one up, and to @DavidJuurlink & @ToxAndHound for the inspiration. 🙂💡 (3/3)
Read 4 tweets

Related threads

Profile picture
Pauli Ohukainen
@POhukainen
#Tweetorial time! 🚨 Looks like there’s another misconception about #cholesterol and #atherosclerosis making rounds again. This one has to do with the process of #LDL particles entering the arterial wall. So gather round friends and let me science the s*it out of this 🤓 (1/24)
For background, here’s a widely cited series of figures by Nakashima et al. (2007). They performed autopsies on 38 people aged 7-49, who died of non-#cardiovascular causes (2/24)
ncbi.nlm.nih.gov/pubmed/17303781
Nakashima et al. looked for atherosclerotic lesions at different stages, according to a previously published morphological classification scheme. They found them, took slices, stained them to find #lipids and #macrophages and organized them nicely (3/24)
Read 25 tweets
Profile picture
Steven Chen
@DrStevenTChen
1/
 #Dermatology #tweetorial time! Let's spend some time on the autoimmune blistering diseases. There are many, so this will be a broad overview of the approach to a the bullous disease patient.
#dermtwitter #FOAMed #medtwitter #medstudenttwitter #MedEd @healourskin pc:@dermnetnz
2/
 The first ? we usually ask: "What is the level of the split?" That helps to distinguish between the #pemphigus group of diseases where the desmosome is involved in the epidermis, and the #pemphigoid group where the hemi-desmosome is involved at the basement membrane zone.
3/
This correlates with the exam! Higher up in the epidermis means a thinner walled blister that's more fragile. So these are usually flaccid bullae. Deeper down means tense bullae. Photo 1 is pemphigus - see how droopy the bulla is? Vs photo 2 of pemphigoid, which stands up.
Read 17 tweets
Profile picture
Anand Patel
@Anand_88_Patel
#Tweetorial Just finished 4 weeks on the leukemia service at @UCCancerCenter. We saw a number of patients present with a new diagnosis of acute leukemia and hyperleukocytosis, our index of concern for the development of leukostasis was dependent on if they had AML or ALL.
In 1982 Lichtman et al wrote about hyperleukocytic leukemias. The leukocrit (packed WBC volume) was described in AML, ALL, and CLL. Due to the larger mean cell volume of myeloblasts, a higher leukocrit was observed in AML compared to ALL and CLL.
The pathophysiology of leukostasis is thought to be driven in part by blood viscosity. A higher leukocrit and hematocrit correlates with a higher blood viscosity.
Read 11 tweets
Profile picture
Jonathan Afilalo
@FrailtyMD
#Tweetorial PIONEER-HF Trial: Angiotensin–Neprilysin Inhibition in Acute Decompensated Heart Failure pubmed.com/30415601
▶️ Double-blind RCT at 129 US hospitals, ITT analysis
🅿️ N=881 hospitalized patients
- Primary Dx of ADHF (1/3 new Dx)
- LVEF ≤40%
- NTproBNP ≥1600 or BNP ≥400
- GFR ≥30
- SBP ≥100
- No IV nitro or increase in IV diuretics within 6h
- Age IQR 51-71
- Day of enrolment IQR 2-4
Read 9 tweets
Profile picture
Lucas Kimmig
@Lucas_Kimmig
#Tweetorial on hypoxemic #respiratoryfailure. #FITSurvivalGuide #FOAMed
1️⃣ Shunt
2️⃣ V/Q mismatch
3️⃣ Low FiO2/low O2 tension
4️⃣ Alveolar hypoventilation
5️⃣ Diffusion limitation
6️⃣ Venous admixture
#CriticalCare
1️⃣Shunt - can be intra or extrapulmonary. No V, only Q. Does not respond to O2 - shunt fraction not exposed to o2. Inflamm alveolar dz (eg PNA) can p/w shunt (imp. vasoconstr.) Think abt PFO w R➡️L shunt in PE, ARDS (elevation in R sided pressures), check bubble study. Aa grad ⬆️
2️⃣V/Q mismatch. More Q than V but regions with low V not entirely excluded from gas exchange. Can improve w increasing FiO2. Probably 75-90% of hypoxemia cases. Wide Aa gradient.
Read 7 tweets
Profile picture
Jonathan H Chen
@jonc101x
#Tweetorial on #Diagnostics and #Screening interpretation.
An otherwise healthy 40 year old woman comes to you after reading on the internet about a terrible disease that one in a thousand women get, and a highly accurate test that can save her life.
The test is over 99% accurate in people with the disease. For those without disease, the test is only wrong 5% of the time.

You order this test and it comes back positive. The woman anxiously asks you, do I have the disease? What is the chance this woman has the disease?
Assuming they weren't immediately fooled by the "test is only wrong 5 % of the time," most I've asked correctly recognize the stats provided are Sensitivity = 99% and Specificity = 95%, and that the objective is to determine the Positive Predictive Value.
Read 21 tweets

Trending hashtags

#pathtweetorial #airtravel #causalinference #dermatology #granuloma #tweetorial #forces #RCT #EndoTwitter #atherosclerosis #Tweetorial #FAME #ASEchoJC #pathology #ChiefResidents #pemphigoid #angiography #bias #necrosis #AntibioticResistant #modern #TWEETORIAL #RHC #cardiovascular #EchoFirst
Follow Us on Twitter!

Did Thread Reader help you today?

Support us! We are indie developers!

This site is made by just three indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3.00/month or $30.00/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!