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35th AM (2025) - Poster Session
The Use of Aripiprazole and Mirtazapine in the Man ...
The Use of Aripiprazole and Mirtazapine in the Management of Xylazine Toxicity
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This case report discusses the novel use of aripiprazole and mirtazapine in managing xylazine toxicity in a 42-year-old male with severe opioid and sedative use disorders, as well as other comorbidities. Xylazine, a veterinary sedative acting as a central α2-agonist, inhibits norepinephrine and epinephrine release, causing symptoms like lethargy, analgesia, respiratory depression, bradycardia, and hypotension. Its growing abuse as an opioid adulterant presents a public health challenge, but literature on managing toxicity is sparse.<br /><br />The patient had a 15-year history of intravenous heroin and fentanyl use, frequently combined with xylazine. He presented with encephalopathy, ataxia, seizures, tachycardia, hypertension, and agitation. Despite naloxone administration for opioid overdose, the patient's degree of somnolence and neurological impairment was inconsistent with opioid effects alone, raising suspicion of xylazine toxicity.<br /><br />Initial supportive measures included lacosamide for seizures and intensive monitoring. The consult team introduced low-dose aripiprazole and nightly mirtazapine, noting significant improvement in alertness, orientation, and neurological function within 24 hours. Upon a second presentation with unresponsiveness and seizures, re-initiation and titration of these medications alongside buprenorphine for opioid use disorder led to clinical improvement.<br /><br />Mirtazapine, an α2-antagonist, likely counteracts xylazine’s receptor activity, while aripiprazole's activating properties may mitigate central nervous system depression caused by xylazine. Importantly, other α2-agonists like clonidine were avoided to prevent additive effects. The case highlights the necessity of high suspicion for xylazine toxicity, especially when opioid reversal agents fail, and presents this pharmacologic combination as a promising treatment approach.<br /><br />In summary, aripiprazole and mirtazapine may offer effective management of xylazine intoxication, warranting further study given the rise of xylazine adulteration in opioids and limited existing treatment guidelines.
Keywords
xylazine toxicity
aripiprazole
mirtazapine
opioid use disorder
sedative use disorder
α2-agonist
naloxone resistance
buprenorphine
central nervous system depression
veterinary sedative abuse
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