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This is an interesting article which provides useful insights for regulators. Unfortunately the authors state: 'DXP toxicity is mainly
due to its long half-life (15–37 hours), and
it can be increased by concomitant use of
alcohol or sedative drugs', quoting 2 rather old references.
We showed that deaths occurred before hospital admission, early in the course of poisoning, and postulated that this was likely due to the arrythmogenic effect of DXP, its main metabolite combined with the respiratory depressant effect the opioid action. This was one of the main reasons this drug was withdrawn in the UK, saving many hundreds of lives since withdrawal here. (Sandilands EA, Bateman DN. Co-proxamol withdrawal has reduced suicide from drugs in Scotland. British Journal of Clinical Pharmacology 2008; 66: 290-293.)