A young woman has abused Doloxene (dextropropoxyphene) and Distalgesic (dextropropoxyphen and parac

Fråga: A young woman has abused Doloxene (dextropropoxyphene) and Distalgesic (dextropropoxyphen and paracetamol) in large quantities for many years. Laboratory values have earlier shown a decrease in platelets and leucocytes. Recently the haemoglobin value decreased and the mean corpuscular volume (MCV) increased. The patient is also treated with Antabus (disulfiram) due to alcohol abuse.<br><br>Could this be caused by dextropropoxyphene and/or paracetamol?

Sammanfattning: Different kinds of anemia, including leucopenia and trombocytopenia have been reported in connection with both dextropropoxyphen and paracetamol treatment but appear to be very rare considering the wide use of these drugs.

Svar: Treatment with paracetamol is known to cause anemia, neutropenia, pancytopenia, aplastic anemia and haemolytic anemia, although the risk of developing a significant anemia is extremely low considering the wide use of paracetamol (1,2).<br><br>The files of the Swedish Adverse Drug Reactions Advisory Committee contain six cases of trombocytopenia, four cases of agranulocytosis, three cases of haemolytic anemia, two cases each of leucopenia and megaloblastic anemia, and one case of neutropenia connected to paracetamol treatment. All cases were judged possible except one case of trombocytopenia judged probable, which concerned a 68-year-old woman who took 500 mg paracetamol daily for three days for a cold.<br><br>Dextropropoxyphen has also been reported to cause haemolytic anemia (3). A few cases of leucopenia, neutropenia and trombocytopenia have previously been reported and dealt with in Drugline (4). A case report concerned a previously healthy elderly woman who developed macrocytic anemia (haemoglobin 91 g/l, MCV 129 fl, white cell count and platelets within the normal range). The patient had a daily intake of 4 to 8 tablets of dextropropoxyphene 32.5 mg and paracetamol 325 mg, which is the same content as in Distalgesic. Withdrawal of treatment cured the anemia (4).<br><br>The files of the Swedish Adverse Drug Reactions Advisory Committee contain eight cases of trombocytopenia, four cases of agranulocytosis, three cases of haemolytic anemia, two cases each of anemia and leucopenia, and one case of neutropenia, all judged as possibly connected to dextropropoxyphen treatment. In total, four of the cases are the same as those reported for paracetamol.<br><br>In the present case, alcohol abuse and/or other causes appear to be more probable causes of macrocytic anemia than the drug intake but such a relationship can, however, not be fully excluded.<div id="referenser" style="display:none;">1 Drugline nr 05742 (year 1987)<br>2 Drugline nr 07118 (year 1989)<br>3 Meyler´s, Side effects of drugs. ED by MNG Dukes, Elsevier, Amsterdam.<br>4 Fulton JD, McGonigal G: Steroid responsive haemolytic anaemia due to dextropropoxyphene paracetamol combination. J R Soc Med 1989; 82: 228</div>