https://orcid.org/0000-0002-3628-0601
To the Editor,
Recently, Lurie et al. reported an outbreak of severe coagulopathy and life-threatening bleeding among 98 users of inhaled illicit synthetic cannabinoids laced with brodifacoum, a potent, long-acting anticoagulant rodenticide (LAAR), in northern Israel [Citation1]. To date, four victims have died. Despite facile access to free medical care in Israel, the majority of these patients did not show up for follow-up clinic visits nor adhered to prescribed long-term (one to three months), high dose (60 mg daily) oral vitamin K1 therapy once discharged from the hospital. This, in turn, led to recurrent severe coagulopathy, bleeding, and hospitalization in a large proportion of patients [Citation1].
Similar widespread non-adherence with post-discharge, long-term (several months), high-dose (20 tablets; 100 mg daily) oral vitamin K1 therapy leading to recalcitrant coagulopathy and bleeding has been reported in two earlier outbreaks in the US involving patients who inhaled illicit synthetic cannabinoids laced with LAARs, that involved, in some cases, a mixture of brodifacoum, bromadiolone, and difenacoum [Citation2–5]. However, the reasons underlying non-adherence with post-hospitalization long-term, high-dose oral vitamin K1 therapy provided free of charge to poisoned patients in the US and Israel have not been reported by the authors [Citation1–4].
To that end, in both US outbreaks, adequate, free of charge supply of vitamin K1 tablets was not readily available at retail pharmacies for victims once discharged from the hospital [Citation1–3]. In addition, appropriate public health assets, such as widely available national public health laboratories certified to quantify circulating LARRs and public health professionals experienced in combating rare mass poisoning events, were not deployed in a timely fashion to facilitate long-term follow-up of victims in the community [Citation5–8].
Given our own experience with patient nonadherence during the 2018 outbreak in Chicago, Illinois [Citation9] and similar experiences reported during recent LAAR poisoning outbreaks in northern Israel and Florida [Citation1, Citation4], we propose that public health authorities worldwide should now address these shortcomings by building a multifaceted, community-based public health infrastructure in preparation for possible similar outbreaks in the future. These measures should include but are not limited to establishing a nationwide certified clinical laboratories network to quantify plasma LAAR concentrations rapidly, stockpiling adequate supplies of vitamin K1 tablets with rapid deployment and distribution to medical facilities and pharmacies treating LAAR poisoning victims, and developing safe and effective adjunctive countermeasures that will appreciably reduce the duration of high dose oral vitamin K1 therapy post-hospitalization by accelerating elimination of LAARs from poisoned victims, such as bile acid sequestrants [Citation8, Citation10].
Acknowledgements
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
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References
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