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This article was downloaded by: [ULPGC. Biblioteca] On: 16 May 2014, At: 09:43 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Substance Abuse Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wsub20 A Descriptive Study of Adverse Events from Clenbuterol Misuse and Abuse for Weight Loss and Bodybuilding a b c Henry A. Spiller MS, DABAT, FAACT , Kyla J. James PharmD , Steven Scholzen BS & Douglas J. Borys PharmD, DABAT c a Central Ohio Poison Center, Columbus, Ohio, USA; and Department of Pediatrics, College of Medicine , Ohio State University , Columbus , Ohio , USA b School of Pharmacy , Sullivan University , Louisville , Kentucky , USA c School of Pharmacy , Concordia University Wisconsin , Mequon , Wisconsin , USA Accepted author version posted online: 12 Feb 2013.Published online: 11 Jul 2013. To cite this article: Henry A. Spiller MS, DABAT, FAACT , Kyla J. James PharmD , Steven Scholzen BS & Douglas J. Borys PharmD, DABAT (2013) A Descriptive Study of Adverse Events from Clenbuterol Misuse and Abuse for Weight Loss and Bodybuilding, Substance Abuse, 34:3, 306-312, DOI: 10.1080/08897077.2013.772083 To link to this article: http://dx.doi.org/10.1080/08897077.2013.772083 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. 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Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions SUBSTANCE ABUSE, 34: 306–312, 2013 C Taylor & Francis Group, LLC Copyright ISSN: 0889-7077 print / 1547-0164 online DOI: 10.1080/08897077.2013.772083 CASE STUDY A Descriptive Study of Adverse Events from Clenbuterol Misuse and Abuse for Weight Loss and Bodybuilding Henry A. Spiller, MS, DABAT, FAACT Downloaded by [ULPGC. Biblioteca] at 09:43 16 May 2014 Central Ohio Poison Center, Columbus, Ohio, USA; and Department of Pediatrics, College of Medicine, Ohio State University, Columbus, Ohio, USA Kyla J. James, PharmD School of Pharmacy, Sullivan University, Louisville, Kentucky, USA Steven Scholzen, BS and Douglas J. Borys, PharmD, DABAT School of Pharmacy, Concordia University Wisconsin, Mequon, Wisconsin, USA ABSTRACT. Background: Clenbuterol is a β 2 -agonist approved in the United States for veterinary use in nonfood animals. Clenbuterol use is emerging among bodybuilders and fitness enthusiasts attracted to the hypertrophic and lipolytic effects. Cases: This was a retrospective chart review of clenbuterol exposures reported to 2 poison control centers. Misuse of clenbuterol for weight loss and bodybuilding was reported in 11 of 13 clenbuterol users. Reported clinical effects included tachycardia, widened pulse pressure, tachypnea, hypokalemia, hyperglycemia, ST changes on electrocardiogram (ECG), elevated troponin, elevated creatine phosphokinase (CPK), palpitations, chest pain, and tremor. Measured serum clenbuterol concentration was 2983 pg/mL post 4.5 mg ingestion. Coingestants included T3 and anabolic steroids. Treatments included activated charcoal, benzodiazepines, β-blockers, potassium replacement, and intravenous (IV) fluid. Conclusions: There is an increasing use of the Internet for illicit drug use for bodybuilding and weight loss purposes. These patients may not present as the stereotype of illicit drug abusers, but as healthy athletic low-risk patients. Clinical effects persisted greater than 24 hours with evidence of myocardial injury in 2 patients. Clenbuterol is increasingly being abused within the bodybuilding subculture. These cases illustrate the hidden dangers of clenbuterol abuse among bodybuilders and fitness enthusiasts. Keywords: Clenbuterol, abuse, bodybuilding, weight loss INTRODUCTION Research conception and design HS, KJ. Collection of data HS, KJ, Analysis HS, KJ, SS and DB, Interpretation of results HS, KJ, SS and DB, Writing HS, KJ, DB, SS, Revision HS, KJ. Correspondence should be addressed to Henry A. Spiller, MS, DABAT, FAACT, Director, Central Ohio Poison Center, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA. E-mail: [email protected] Clenbuterol hydrochloride is a β 2 -adrenergic agonist with sympathomimetic properties consistent with those found within its pharmacological class. Compared with other βadrenergic agonists, clenbuterol has greater potency, an extended half-life (25–40 hours), and is more readily absorbed (70–80%) from the gastrointestinal tract (1, 2). Sympathomimetic effects from β 2 -receptor stimulation include tachycardia, supraventricular tachycardia, atrial fibrillation, Downloaded by [ULPGC. Biblioteca] at 09:43 16 May 2014 CASE STUDY palpitations, hypotension, vomiting, hyperglycemia, and hypokalemia (3, 4). The approved use of clenbuterol in the United States is limited to equine use as a bronchodilator (Ventipulmin) (5, 6). Clenbuterol is available in Europe and Latin America as a bronchodilator in humans, with a recommended dose of 20 to 40 μg orally, twice daily. However, clenbuterol has been a popular performance-enhancing substance due to its anthropometric altering effects and has subsequently been banned by the World Anti-Doping Agency and the International Olympic Committee (7). Animal and human studies have demonstrated that clenbuterol enhances lipolysis, glycolytic capacity, and minimizes protein degradation (8, 9). β 3 -Receptors within skeletal muscle fibers are thought to account for the anabolic properties of clenbuterol (10). Additionally, clenbuterol is readily available through Internet commerce and has proliferated a trend of abuse among bodybuilders, for weight loss, and by fitness enthusiasts attracted to the hypertrophic and lipolytic effects (5, 11, 12). The risks associated with these behaviors are compounded by supratherapeutic dosing and coingestion of additional agents such as anabolic steroids and nonprescription supplements. Significant cardiotoxic effects after misuse/abuse of clenbuterol for bodybuilding and sports-related purposes have been reported, including myocardial ischemia, evidence of myocardial injury and/or infarction, coronary artery vasospasm, and ventricular dysrhythmias (4, 13, 20, 29, 30). We conducted a retrospective chart review of clenbuterol exposures in humans reported to 2 regional poison control centers between October 2006 and January 2012. METHODS This was a retrospective review of poison center databases from 2 regional poison centers for human exposures to clenbuterol. Data collected after individual chart review, including review of individual case notes fields, included demographics, substances involved including coingestatants if known, reason for exposure/use of clenbuterol, dose, clinical effects and laboratory results reported, and medical outcome. Case notes were reviewed for source of purchase of clenbuterol if noted in the history. Additionally the National Poison Data System (NPDS) was queried for number of cases reported by year from January 2007 through November 2012. NPDS represents all cases reported to US poison control centers. NPDS does not provide case notes so these data were used to track annual trends, if any. The American Association of Poison Control Centers (AAPCC) maintains the national database of information logged by the country’s poison control centers (PCCs). Case records in this database are from self-reported calls: they reflect only information provided when the public or health care professionals report an actual or potential exposure to a substance (e.g., an ingestion, inhalation, or topical exposure, etc.), or request information/educational materials. Exposures do not necessarily represent a poisoning or 307 overdose. The AAPCC is not able to completely verify the accuracy of every report made to member centers. Additional exposures may go unreported to PCCs and data referenced from the AAPCC should not be construed to represent the complete incidence of national exposures to any substance(s). CASE PRESENTATION Thirteen cases of clenbuterol were located at the 2 regional poison centers. All cases are summarized in Table 1. The mean and median age was 29 and 25 years, respectively. Eleven patients (85%) were male. Six of 13 adult patients provided a quantifiable dose estimate. The ingested dose ranged from 300 to 4500 μg (mean = 2600 μg). The single child patient ingested his mother’s clenbuterol, who had obtained the drug via the Internet for weight loss. Eight patients were treated and released from the emergency department, with 3 patients admitted to the hospital (cases 3, 5, 6) and 2 lost to follow-up (cases 4, 13). In 12 of the patients, the clenbuterol was purchased via the Internet for “bodybuilding” or “weight loss.” In one patient (a 46-year-old veterinary worker), an unintentional exposure occurred to an equine bronchodilator Ventipulmin syrup (75 μg/mL) while he was at work. Reported clinical effects in the thirteen cases included tachycardia (n = 10; maximum heart rate [HR] = 118–170), widened pulse pressure (n = 6; 65–90 mm Hg), tachypnea (n = 3; 20–44 respirations per minute), hypokalemia (n = 3; 2.7–3.1 mEq/L), hyperglycemia (n = 3; maximum blood glucose 159–334 mg/dL), ST changes on electrocardiogram (ECG; n = 2), elevated troponin (n = 2; 0.86–36.3 mcg/L), elevated creatine phosphokinase (CPK; n = 2; 256–1549 IU/L), palpitations (n = 2), chest pain (n = 3), tremor (n = 4), nausea (n = 4), and vomiting (n = 2). Coingestants are listed in Table 1. NPDS From January 2007 through November 2012, a total of 426 human exposure cases of clenbuterol exposure were reported to NPDS. However, 58 of these 462 cases involved contaminated heroin, 19 contaminated cocaine, and 9 cases of other street drugs. These reported cases of drugs of abuse contaminated with clenbuterol primarily occurred in 2007 to 2009 and in these cases the use of clenbuterol was not intended by the individual but was a contaminant of the heroin or cocaine. There were 341 clenbuterol cases unrelated to drugs of abuse (80%), reported by year in Figure 1. Case 3 A 30-year-old male presented with tremor and tinnitus and complains of feeling “shaky and fluttery” after ingesting 3000 μg of clenbuterol (15 mL of 200 μg/mL syrup). He reported obtaining clenbuterol “over-the-counter” for weight 308 SUBSTANCE ABUSE TABLE 1 Case Summary Downloaded by [ULPGC. Biblioteca] at 09:43 16 May 2014 Case Age M/F Ingested dose (μg) Peak Peak Nadir Pulse HR SBP DBP pressure 1 2 3 46 25 30 M M M Drop Unknown 3000 72 118 170 153 — 143 88 — 53 65 — 90 4 5 21 25 M M Unknown 4500 — 160 — 140 — 33 — 75 6 25 M Unknown 140 114 49 65 7 8 9 10 11 19 2 37 21 36 M M M M M 1000 100–200 1000 4000 Unknown 130 165 108 139 140 170 128 90 57 80 70 12 37 F Unknown 140 13 28 F Unknown — — — — Management Observation Observation Fluids β-BlockersPotassium replacement Lost to follow-up AC Fluids β-Blockers Benzodiazepines β-Blockers Benzodiazepines Odansetron Ibuprofen Observation Benzodiazepine Potassium supplementation Benzodiazepine Potassium supplementation Benzodiazepine Lost to follow-up Duration of effect (hours) Coingestants <8 <8 >24, <72 n/a n/a n/a n/a >24, <72 <8 24 <8 <8 <12 n/a Proanabolic boladrol Clomiphene citrate Phreak Liothyronine Beastdrol Levothyronine n/a n/a n/a n/a <12 n/a n/a Liothyronine >72, <90 Other Serum clenbuterol: 2.983 ng/mL Serum T3 : 7.5 pg/mL Temp: 102◦ F M/F = male or female; HR = heart rate; bpm = beats per minute; SBP = systolic blood pressure (mm Hg); DBP = diastolic blood pressure (mm Hg); PP = pulse pressure (mm Hg); AC = activated charcoal; n/a = not available—no coingestants were mentioned in the history or no information available on duration of effects in patient lost to follow-up. loss purposes. In the emergency department 5 hours post ingestion, vital signs were blood pressure 126/53 mm Hg, variable heart rate ranging from 126 to 170 bpm, and respiratory rate 18 breaths per minute. He was admitted to the critical care unit where tachycardia persisted at 127 bpm, with peak systolic blood pressure 143 mm Hg, widened pulse pres- FIGURE 1 sure 90 mm Hg, and maximum respiratory rate 20 breaths per minute. Pertinent laboratory measures included potassium 2.7 mEq/L and glucose 334 mg/dL. Telemetry yielded nonspecific inferolateral ST changes; however, corresponding troponin measures were insignificant (<0.03 ng/mL) approximately 8 hours after ingestion. The patient was treated Clenbuterol exposures reported to US poison centers by year (Color figure available online). CASE STUDY supportively with intravenous fluids and β-blockers, and potassium replacement. He remained tachycardic for approximately 24 hours in the range of 100 bpm, but normal sinus rhythm had been restored. Follow-up laboratory measures included potassium 3.9 mEq/L and glucose 107 mg/dL. Downloaded by [ULPGC. Biblioteca] at 09:43 16 May 2014 Case 5 A 25-year-old male arrived in the emergency department with a history of ingesting 4500 μg of clenbuterol (22.5 mL of 200 μg/mL syrup) approximately 45 minutes prior to arrival. The patient admitted to “chronic use” of clenbuterol that he obtained from the Internet. Additionally, he reported use of proanabolic boladrol within last 2 weeks, use of a supplement known as Phreak (Phantom Laboratories), and had recently begun using clomiphene citrate—all of which were obtained from the Internet. The patient was agitated, anxious with a heart rate of 160 bpm and complained of headache. The patient was administered a single dose of activated charcoal and admitted to critical care services. Pertinent laboratory measures on arrival included potassium, 2.7 mEq/L; glucose, 247 mg/dL; creatine phosphokinase, 247 ng/mL; and troponin, <0.01 ng/mL, with no evidence of abnormal corresponding telemetry measures. Tachycardia was managed with an esmolol intravenous infusion titrated to maintain systolic blood pressure (SBP) levels above 90 mm Hg. Additional therapies included potassium replacement, intravenous fluids, benzodiazepines for agitation, and acetaminophen for headache. Follow-up laboratory measures after 4 hours included potassium, 3.1 mEq/L, glucose, 262 mg/dL, CPK, 195 ng/mL. Troponin levels increased to 0.02 ng/mL with a peak of 0.86 ng/mL at 22 hours post exposure. Measured serum clenbuterol concentration was 2.983 ng/mL. Within 3 hours of admission, SBP and heart rate (HR) decreased to 140 mm Hg and 134 bpm, respectively. Despite normalization of SBP and HR, diastolic blood pressure continued to decrease, rendering a peak pulse pressure of 75 mm Hg. Esmolol infusion was continued until approximately 36 hours post exposure and patient’s vital signs were stable within 48 hours. Case 6 A 25-year-old male presented to emergency services with chest pain and palpitations after ingesting an unknown quantity of clenbuterol, liothyronine sodium (50 μg), and an anabolic agent “beastdrol” within the last 12 hours. He reported a 4-day history of using liothyronine sodium (25 μg × 3 days, 50 μg × 1 day), but clenbuterol was recently added to his regimen for “weight loss and fat burning.” His mother gave additional history of a 100-pound weight loss in the patient over the last few months due to “working out.” Upon arrival, he was agitated with a heart rate of 140 bpm; pulse pressure 64 mm Hg; troponin 5 ng/mL; and creatine kinase 700 ng/mL. Telemetry revealed “diffuse ST-segment changes,” but was not deemed to be a myocardial infarction. The patient contin- 309 ued to deteriorate and had acute respiratory distress syndrome and myocarditis within 10 hours of admission. The patient received steroids and mechanical ventilation for adult respiratory distress syndrome (ARDS). Follow-up troponin levels were 36.3 ng/mL at 14 hours and 5.87 ng/dL at 72 hours after initial presentation. The serum T3 measurement, 7.5 pg/mL, was consistent with use of concomitant liothyronine. The patient was discharged on hospital day 4. Case 8 A mother reported finding her normally healthy, 2-year-old son with a “bottle of pills” she had purchased from the Internet for weight loss. She reported having stopped taking the clenbuterol after losing a pregnancy while using them for weight loss. The dose ingested by the child was unknown. The bottle initially contained 80 × 20-μg tablets, with 61 tablets remaining plus a few “crushed or wet.” Based upon the information reported, ingestion was in the range of 100 to 200 μg (5 to 10 tablets). The child was seen in the local emergency department and transferred to a tertiary children’s health care facility for observation. Clinical effects reported were vomiting, fever, agitation hypokalemia (K = 3.3 mEq/L), and tachycardia. Effects resolved by 18 to 20 hours post ingestion. DISCUSSION Clenbuterol is available in Europe and Latin America as bronchodilator in humans, with a recommended dose of 20 to 40 μg orally, twice daily. In the United States, clenbuterol is available for veterinary use only (6). However, it is the unique β 3 -adrenergic effects of clenbuterol, unrelated to its brochodialating effects, that has brought this drug to the attention of illicit users. Research in humans and animals has shown increased skeletal and cardiac muscle growth. In humans, doses of 60 μg, twice daily (2 μg/kg/day), were effective in producing muscle hypertrophy and increased muscle strength (9, 13). Ranchers have abused clenbuterol in cattle to increase lean muscle mass in their herds (14, 15). Clenbuterol abuse in humans for muscle growth has been documented in bodybuilding and professional sports (4, 16–19). Additionally, clenbuterol is being marketed on the Internet as a slimming agent and has been abused/misused for weight loss purposes (12, 18). Intentional illicit use was the reason in 11 of the 13 reported cases of clenbuterol exposure. However, these cases represent a different paradigm to previous reports related to clenbuterol-tainted heroin use (20–23). The Internet has further enabled this subculture with additional routes of access to illicit drugs in the pursuit of their bodybuilding ideals. This population distinguishes themselves from other drugusing populations and uses terms such as “supplements” or “medicines” in attempt to normalize abnormal behavior (24). 310 31/M bodybuilder 18/M bodybuilder with history of asthma; no identified risk factors for coronary heart disease; nonsmoker 22/M bodybuilder with unremarkable past medical history; nonsmoker 26/M nonremarkable past medical history; nonsmoker 17/M bodybuilder with nonremarkable past medical history Hutchins et al., J Emerg Med, 2012 (13) Hutchins et al., J Emerg Med, 2012 (13) Goldstein et al, South Med J, 1998 (29) Kierzkowska et al., Circ J, 2005 (30) Age/Gender Daubert et al., J Med Toxicol, 2007 (4) Reference Palpitations; shortness of breath 30 minutes post ingestion Tachycardia, hypokalemia Myocardial ischemia supported by elevated troponins and ECG revealing supraventricular tachycardia with ventricular rate of 254 Sudden onset of shortness of breath; “heart racing” beginning 90 minutes prior, chest pain, N/V, tremor, and diaphoresis Hypokalemia, hyperglycemia ECG: Sinus tachycardia with T-wave inversions, elevated troponin ECHO: mild left ventricular hypertrophy with normal ejection fraction (60%) Palpitations (“heart was racing right out of his chest”), N/V, diaphoresis Initial ECG: sinus tachycardia with evidence of inferolateral ischemia Hypokalemia, hyperglycemia, elevated troponin, depressed thyroid-stimulating hormone (TSH) Dull, central chest pain of 3-hour duration; reported tremors, palpitations, and nervousness over last 2 weeks Myocardial infarct indicated by ECG ST-segment elevation and elevated troponin; mechanism suspected to be coronary spasm Presented with stabbing retrosternal chest pain reported as intermittent tachycardic, febrile, elevated troponins Final diagnosis of “reperfused non-Q MI with possible coronary artery spasm” 108 μg Ventipulmin syrup (72.5 μg/mL) acquired veterinary source. Coingestants: Tamoxifen, citrate flax seed oil, taurine, and multivitamin supplements Amount of ingested clenbuterol unknown Intermittent anabolic steroid use over last 3 years, including intramuscular depot injections of testosterone, propionate, cypionate, and enanthate and oral methandrostenolone and stanozolol Reported finishing 2-week cycle of taking oral clenbuterol (Spiropent: 20 mg; 1 tablet twice daily for 2 days alternated with 2-day break) Reported 30 mg ingestion of clenbuterol 2 hours prior to presenting to emergency services Amount of ingested clenbuterol unknown; attempted to self-manage symptoms with inhaled albuterol prior to presenting to emergency services Clinical presentation Clenbuterol ingestion/coingestants TABLE 2 Summary of Published Case Reports of Clenbuterol Abuse/Misuse Downloaded by [ULPGC. Biblioteca] at 09:43 16 May 2014 Chest pain and heart rate resolved over “several hours” One month: normal exercise test; remained asymptomatic Reported as asymptomatic 2 weeks after discharge Resolved in less than 48 hours, doing “well” and remaining physically active at 1-year follow-up Normal sinus rhythm resumed by 15 hours 3 months: Normal exercise tolerance with no ECG abnormalities Atrial fibrillation persisted for 48 hours until elective cardioversion to sinus rhythm Management Downloaded by [ULPGC. Biblioteca] at 09:43 16 May 2014 CASE STUDY These patients may not view use of clenbuterol as drug abuse or present as the stereotype of illicit drug abusers, but may present as healthy athletic low-risk patients. For example, one patient in our case series rationalized illegal use of clenbuterol “to get buff” rather than for recreational purposes. This trend is not limited to bodybuilders and extreme fitness enthusiasts. An Internet search of “clenbuterol” will generate numerous advertisements disguised as “educational information” (25). Cases 3, 6, and 13 and the mother of case 8 had all obtained the clenbuterol for weight loss purposes rather than muscle building and may illustrate an emerging trend with the mainstream public. The cases presented in this report and the published reports involved healthy and fit individuals under age 30 years (Table 2). However, this should not preclude the possibility of encountering cases involving older adults, particularly females. It would not be unreasonable to surmise that any target of weight loss marketing with Internet access is susceptible to the appeal of clenbuterol. Although a majority of the literature on clenbuterol overdose involves tainted drugs of abuse, the majority of cases reported to poison centers do not involve street drugs. These individuals abusing clenbuterol may overestimate their “knowledge,” which is often acquired anecdotally without full understanding of risks. Additionally frequent coadministration of additional agents such as anabolic steroids or thyroid hormones adds to the risk of serious cardiotoxicity. Two patients reported in our case series were concomitantly abusing agents including anabolic steroids, estrogen antagonists, liothyronine, caffeine, as well as alcoholic beverages. The reported doses used among these patients significantly exceed the therapeutic range of 20 to 40 μg twice daily indicated for asthma; in several of our cases exceeding the dose by several orders of magnitude (26). One patient had a blood clenbuterol level of 2.983 ng/mL following the ingestion of an estimated 4500 μg, which is approximately 100 times the recommended dose. This serum concentration is in the range reported from patients with clenbuterol-contaminated heroin. In a report of clenbuterol in heroin deaths, postmortem blood clenbuterol levels ranged from 6.3 to 76 ng/mL (22). In a series of clenbuterol-contaminated heroin, serum clenbuterol levels were reported in 2 patients: 2.4 and 6 ng/mL, respectively (23). Clinical effects from clenbuterol were primarily cardiovascular and persisted greater than 24 hours in the 3 patients requiring inpatient management. One patient sustained electrocardiograph conduction disturbances within 3 hours of ingesting 3000 μg of clenbuterol alone. Two patients ingesting clenbuterol with other agents presented with evidence of myocardial injury. Clenbuterol toxicity can include supraventricular tachycardia, pulmonary edema, myocardial infarction, elevated troponin and CPK-Mb, ECG changes including ST-wave changes, chest pain, palpitations, wide pulse pressure, muscle spasm, hyperreflexia, elevated CPK, rhabdomyolysis, headache, anxiety, agitation, vomiting, hy- 311 pokalemia, and mydriasis (4, 21, 23, 27–29). These clinical effects, including myocardial injury and infarction, have occurred in otherwise healthy patients with normal coronary arteriograms (28, 29). Several possible mechanisms for the ischemic injury have been suggested, including coronary artery vasospasm, microvascular endothelial injury, and demand ischemia due to prolonged metabolic demand on the myocardium (13, 28, 29). Given that clenbuterol use is extending into the mainstream public, index of suspicion should not be solely limited to those with extreme bodybuilding appearances. Patients and families are often poor historians unable to give an accurate medication history. Thus, when obtaining medication histories, it is important to ascertain all medication use, including “natural” substances and “training aids.” Treatment for clenbuterol toxicity has not been clearly defined. Additionally, use of anabolic steroid and thyroid hormone complicates diagnosis and management due to an independent risk of myocyte toxicity, ventricular arrhythmias, myocardial infarction, and cardiomyopathy (29). Management decisions should be individualized to the patient. In general, goals of management include stabilizing vital signs (hypertension, tachycardia) and symptomatic treatment of anxiety, tremor, or agitation. These goals may be met through a combination of intravenous (IV) fluids, oxygen, β-antagonists, and benzodiazepines. In cases of cardiac ischemia, aspirin may be warranted. Treatment with β-antagonists (esmolol, metoprolol, labetalol) proved successful in our cases and in published reports and is recommended for patients with persistent tachycardia and hypertension (4, 13, 23, 30, 31). Hypokalemia is frequently present due to the β 2 -agonist–induced intracellular shift of potassium and replacement therapy is generally not required. These cases illustrate the hidden dangers of clenbuterol abuse among bodybuilders, fitness enthusiasts, and those seeking a drug for weight loss. These patients do not fit the prototype of a narcotic or amphetamine abuser and may present as “fit and healthy.” An increasing number of patients who are abusing clenbuterol are presenting to emergency departments with adverse or overdose effects. REFERENCES [1] Couet W, Girault J, Reigner BG, et al. Steady-state bioavailability and pharmacokinetics of ambroxol and clenbuterol administered alone and combined in a new oral formulation. Int J Clin Pharmacol Ther Toxicol. 1989;27:467–472. [2] Hida W, Sakurai M, Ichinose M, et al. Effect of clenbuterol on peripheral airway obstruction in bronchial asthma. Curr Med Res Opin. 1985;9:616–625. [3] Whitsett TL, Manion CV, Wilson MF. Cardiac, pulmonary and neuromuscular effects of clenbuterol and terbutaline compared with placebo. Br J Clin Pharmacol. 1981;12:195–200. Downloaded by [ULPGC. 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