David Juurlink

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.

Opioid prescribing in Canada: a continued retreat from God’s own medicine [See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.250670][1] Key points In this issue’s research article, Rebić and colleagues show that rates of opioid prescribing across 6 Canadian provin...

Canadian MDs are relying less on opioids. That is a good thing. New commentary from me in @cmaj.ca

www.cmaj.ca/content/197/...

PSA: When a naturopath recommends chelation “to remove the metal from your body,” that is exactly what you should not do.

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…

Funded Research - PSI Foundation List of projects funded by PSI Foundation.

Drs. Jessica Kent ‪Rice @jessicakentrice.bsky.social ‬& David Juurlink @davidjuurlink.bsky.social study on trends in opioid agonist therapy retention after non-fatal #OpioidOverdose: www.psifoundation.org/funded-resea... #InternationalOverdoseAwarenessDay #IOAD2025 @sunnybrookhsc.bsky.social

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

I'm not saying these "ivermectin cured my cancer" testimonials are entirely fabricated but THEORETICALLY if someone:

1) no longer had a medical license, and
2) profited from pushing ivermectin, and
3) had no qualms about lying to desperate people ...

Just putting this out there

YouTube video by Therapeutics Initiative Dr. David Juurlink: Relieving pain in the era of fentanyl

🚨 ICYMI - #Opioids prescribing webinar recording featuring pharmacologist @davidjuurlink.bsky.social 🚨

💊 What have we learned about #prescribing?
💊 How should we treat pain when opioids overdoses have become an intractable epidemic?
👉🏽 ti.ubc.ca/juurlink-ana...

#pain #MedEd #medsafety

Every time I hear someone mention tramadol

To sum up:

- Carbapenems lower VPA concentrations abruptly and dramatically

- They do this by tinkering with VPA metabolism

- Consider carbapenems in patients with severe VPA toxicity and those you expect to develop it

/end

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

BPS Publications Severe valproic acid (VPA) overdose is characterized by coma (sometimes with cerebral oedema), respiratory depression, hypotension and metabolic abnormalities. Traditional management of VPA poisoning...

I wrote this review on the topic. It's not open access so I'll unpack the two scenarios where I think carbapenems should be considered.

/9
bpspubs.onlinelibrary.wiley.com/doi/abs/10.1...

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

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

/8

What carbapenems so is inhibit APEH, abruptly and irreversibly

The net effect?

- a dramatic INCREASE in VPA-glucuronide (which is inert and eliminated by the kidney)

- a dramatic DECREASE in VPA concentrations

/7

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...

Traditional management of VPA overdose?

- GI decontamination (mainly charcoal)
- L-carnitine for ↑NH₃
- Hemodialysis in the sickest of the sick

/3

Most VPA overdoses manifest as just lethargy. But large ones (>400 mg/kg) get sick, with

- coma ± cerebral edema
- respiratory depression
- hypotension
- multiorgan dysfunction
- HAGMA
- hyperammonemia

And sometimes they die

/2

Let's talk about using carbapenem antibiotics in patients with valproic acid (VPA) poisoning

/1🧵

Returning home from an international medical conference in Vancouver. In 25 years of attending these meeting I have *never* heard so many American physicians talk so openly about possibly moving to Canada.

Not me

It takes a unique kind of genius to fuck up the US-Canada relationship.

Identification and Treatment of Alcohol Use Disorder | NEJM Several clinical and biologic methods are available to identify alcohol use disorder. Pharmacologic treatment is available, but it is underused.

So important. Glad NEJM has made this open access. www.nejm.org/doi/full/10....

Not starting a detox today because I have a liver and kidneys

For those contemplating a detox or cleanse in the new year, here’s a toxicologist’s explanation of how they work:

They don’t

I don’t know who needs to hear this but short, focused progress notes are better than long, detailed progress notes. By a mile.

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