Agranulocytosis is a serious, potentially life-threatening disorder that frequently occurs as an adverse reaction to drugs. Carbamazepine is a known culprit and a very common drug used as an anti-epileptic. The case is reported of a 49-year-old epileptic woman on long-term carbamazepine treatment who developed agranulocytosis following bariatric surgery (sleeve gastrectomy), likely due to carbamazepine-altered oral exposure resulting in high plasma levels. A reduction in the drug dose resulted in normalization of carbamazepine levels and improvement of the neutrophil count without the use of granulocyte colony-stimulating factor (GCSF). This observation could explain a dose-dependent drug-induced cytopenia rather than an idiosyncratic effect. This is the first case of drug-induced agranulocytosis following bariatric surgery, which illustrates the need for careful postoperative monitoring of specific drugs. A literature search of the use of GCSF in agranulocytosis and the status of drug absorption following bariatric surgery was also performed.
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References
1.
AndrèsE, KurtzJE, MaloiselF. Non-chemotherapy drug-induced agranulocytosis: experience of the Strasbourg teaching hospital (1985–2000) and review of the literature. Clin Lab Haematol, 2002; 24:99–106.
BénichouC, Solal-CelignyP. Standardization of definitions and criteria for causality assessment of adverse drug reactions. Drug induced blood cytopenias: report of an international consensus meeting. Nouv Rev Fr Hematol, 1991; 33:257–262.
4.
AndrèsE, ZimmerJ, AffenbergerS, FedericiL, AltM, MaloiselF. Idiosyncratic drug-induced agranulocytosis: update of an old disorder. Eur J Intern Med, 2006; 17:529–535.
5.
SadockBJ, SadockVA. Synopsis of Psychiatry, ninth ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002:508–511, 1036–1037.
6.
SobotkaJL, AlexanderB, CookBL. A review of carbamazepine's hematologic reactions and monitoring recommendations. DICP, 1990; 24:1214–1219.
7.
TohenM, CastilloJ, BaldessariniRJ, ZarateCJr, KandoJC. Blood dyscrasias with carbamazepine and valproate: a pharmacoepidemiological study of 2,228 patients at risk. Am J Psychiatry, 1995; 152:413–418.
OlcayL, PekcanS, YalnizoğluD, BüyükpamukçuM, YalazK. Fatal agranulocytosis developed in the course of carbamazepine therapy. A case report and review of the literature. Turk J Pediatr, 1995; 37:73–77.
10.
OwensCW, ParkerNE, NunnPP, DaviesJ. Agranulocytosis associated with carbamazepine, and a positive reaction with anti-lymphoid leukaemia antiserum during recovery. Postgrad Med J, 1980; 56:665–668.
11.
PattonWN, DuffullSB. Idiosyncratic drug-induced haematological abnormalities: incidence, pathogenosis, management and avoidance. Drug Safety, 1994; 11:445–462.
12.
JuliaA, OlonaM, BuenoJ, et al.Drug induced agranulocytosis: prognostic factors in a series of 168 episodes. Br J Haematol, 1991; 79:366–372.
SawayaRA, JaffeJ, FriedenbergL, FriedenbergFK. Vitamin, mineral, and drug absorption following bariatric surgery. Curr Drug Metab, 2012; 13:1345–1355.
15.
The British Obesity and Metabolic Surgery Society. GP Guidance: Management of Nutrition Following Bariatric Surgery. London, BOMSS, 2014
16.
PadwalRS, et al.A systematic review of drug absorption following bariatric surgery and its theoretical implications. International Association for the Study of Obesity. Obes Rev, 2009; 11:41–50.
17.
SkottheimIB, StormarkK, ChristensenH, JakobsenGS. Significantly altered systemic exposure to atorvastatin acid following gastric bypass surgery in morbidly obese patients. Clin Pharmacol Ther, 2009; 86:311–318.
18.
JakobsenGS, SkottheimIB, SandbuR, et al.Long-term effects of gastric bypass and duodenal switch on systemic exposure of atorvastatin. Surg Endosc, 2013; 27:2094–2101.
19.
RoerigJL, SteffenK, ZimmermanC, MitchellJE, CrosbyRD, CaoL. Preliminary comparison of sertraline levels in postbariatric surgery patients versus matched nonsurgical cohort. Surg Obes Relat Dis, 2012; 8:62–66.
20.
RogersCC, AllowayRR, AlexanderJW, CardiM, TrofeJ, VinksAA. Pharmacokinetics of mycophenolic acid, tacrolimus and sirolimus after gastric bypass surgery in end-stage renal disease and transplant patients: a pilot study. Clin Transpl, 2008; 22:281–291.
21.
RubioI, GalrãoA, SantoM, ZaniniA, Medeiros-NetoG. Levothyroxine absorption in morbidly obese patients before and after Roux-en-Y gastric bypass (RYGB) surgery. Obes Surg, 2012; 22:253–258.
22.
MillerA, SmithK. Medication and nutrient administration considerations after bariatric surgery. Am J Health Syst Pharm, 2006; 63:1852–1857.
23.
BrocksDR, Ben-EltrikiM, GabrRQ, PadwalRS. The effects of gastric bypass surgery on drug absorption and pharmacokinetics. Expert Opin Drug Metab Toxicol, 2012; 8:1505–1519.
24.
KimS, ÖstörAJ, NisarMK. Interleukin-6 and cytochrome-P450, reason for concern?. Rheumatol Int, 2012; 32:2601–2604.
25.
MetcalfD, NicolaNA. Proliferative effects of purified granulocyte colony-stimulating factor (G-CSF) on normal mouse hemopoietic cells. J Clin Pathol, 1983; 116:198–206.
26.
CzygierM, DakowiczL, SzmitkowskiM. The effect of granulocyte colony stimulating factor on neutrophil function in children with neutropenia after chemotherapy in the course of neoplasm. Adv Medi Sci, 2007; 52:143–146.
27.
AndrèsE, MaloiselF, ZimmerJ. The role of haematopoietic growth factors granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor in the management of drug-induced agranulocytosis. Br J Haematol, 2010; 150:3–8.
28.
LichtmanMA, WilliamsWJ. Williams Hematology, seventh ed. New York: McGraw-Hill, 2007.
