We've all seen firsthand how well opioids can work when first given. But they are at their pharmacologic best in the initial days of treatment.

Continue them for weeks, months, or years and the calculus becomes progressively less favourable.

Join us for UofT Therapeutics Day November 1st

- drug interactions
- NSAID allergy
- within-class safety differences
- complex polypharmacy
- pharmacogenetics
- SGLT2 inhibitors
- buprenorphine

Register here: eventbrite.com/e/the-drugs-we…

Toronto-area MDs and pharmacists: Join us for Therapeutics Day 2025

- Relevant topics
- Great speakers (but also me)
- You will be fed
- You will get CE credits

Register here: tinyurl.com/mr447y5n

Every time I hear someone mention tramadol

In the second group, I start mero or erta early

It's conceptually similar to early alkalinization for ASA toxicity

/12

The second is people *expected* to get sick, generally those who ingest >300-400 mg/kg

/11

The first is easy: the sickest of the sick

If you're contemplating hemo, you should be contemplating mero or erta

As I wrote:

/10

A few case reports describe using mero or erta for VPA toxicity, like this one

www.sciencedirect.com/science/arti...

/8

What's missing from that depiction is the reversibility of the lowermost pathway

Normally, the dominant metabolite (VPA glucuronide) is back-converted to VPA by acyl peptide hydrolase (APEH)

/6

We now know why this happens. It relates to how VPA is metabolized, which is generally represented like this:

/5

In 1997, Japanese doctors reported 3 children whose VPA levels plummeted after treatment with panipenem

/4

journals.lww.com/drug-monitor...

Worth reading Roald Dahl’s account of the death of his daughter Olivia, age 7

No

If only OxyContin worked as well as people seem to think

This was a weird one casereports.bmj.com/content/2014...

Explained: toxandhound.com/toxhound/tra...