1207 - Over-the-counter overdose: a case of loperamide abuse and the role of acute inpatient rehabilitation in successful return to home

Case Diagnosis: Debility in the setting of acute-on-chronic loperamide abuse

Case Description: A 28-year-old male with a history of substance abuse disorder presented to the ED for cardiac arrest with ROSC in the setting of massive loperamide ingestion. On admission, he was found to have significantly prolonged QTc and torsades with 2 subsequent arrests and remained sedated and intubated for one week. He was transferred to acute inpatient rehabilitation after a 4-week hospital course complicated by aspiration pneumonia, acute hepatocellular injury, acute metabolic/toxic encephalopathy, megacolon with calcified stool, and withdrawal symptoms. Rehabilitation deficits on admission were dysphagia, moderate cognitive-linguistic deficits, intermittent confusion, impulsivity, and gait instability requiring CGA. In AIR, with a comprehensive rehab program involving PT, OT, and SLP, he improved to independent ambulation and transfers and supervised self-feeding of regular solids and thin liquids.

Discussions: Loperamide, a commonly used OTC anti-diarrheal, can be abused to achieve euphoria and offset withdrawal symptoms through the activation of µ-opioid receptors. Exceeding the recommended daily limit (16 mg/day) can cause systemic effects, including CNS depression and QT prolongation. This patient was reportedly taking up to 280 mg of loperamide daily for years, which likely contributed to cerebral volume loss noted on MRI and facilitated a vulnerability in the patient's brain when the cardiac arrests occurred. This is an important consideration in the rehabilitation process as cognitive deficits can further complicate critical illness debility and delay functional gains and return to independence. The immersive nature of inpatient rehabilitation can mitigate these complications by providing continual reinforcement and redirection which cannot be achieved in the outpatient setting. This case also highlights the need for safeguards for commonly available OTC medications.

Conclusions: Acute inpatient rehabilitation provides structured and multidisciplinary therapy beneficial for patients with acute-on-chronic drug abuse resulting in cognitive and physical deficits requiring prolonged hospitalization for safe home discharge.