{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,28]],"date-time":"2025-08-28T00:04:47Z","timestamp":1756339487694,"version":"3.44.0"},"reference-count":22,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2025,1,2]],"date-time":"2025-01-02T00:00:00Z","timestamp":1735776000000},"content-version":"unspecified","delay-in-days":1,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2024,12,8]]},"published-print":{"date-parts":[[2025,1]]},"abstract":"<jats:p>Cardiogenic shock with bradycardia due to beta-blockers is well-documented; however, this condition in association with arotinolol is unreported. We present a case of cardiogenic shock resulting from delayed arotinolol clearance caused by bile duct obstruction. A man in his 60s presented to our hospital with jaundice. We suspected acute obstructive suppurative cholangitis; however, the patient did not exhibit fever or abdominal symptoms. Based on the physical examination results, we concluded the patient was in cardiogenic shock as a consequence of delayed arotinolol elimination. We attempted to maintain organ perfusion using norepinephrine and dopamine, with minimal response. On initiating isoproterenol, the heart rate stabilised. After tapering off isoproterenol, endoscopic retrograde cholangiopancreatography (ERCP) was performed. Subsequent serum arotinolol level measurement revealed a significant reduction in the elimination half-life before and after ERCP. In cases of cardiogenic shock associated with arotinolol, presumably eliminated via the bile duct, it is crucial to consider potential delayed elimination and to appropriately time ERCP.<\/jats:p>","DOI":"10.1136\/bcr-2024-262234","type":"journal-article","created":{"date-parts":[[2025,1,3]],"date-time":"2025-01-03T01:30:22Z","timestamp":1735867822000},"page":"e262234","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Cholestasis due to biliary obstruction can cause cardiogenic shock with bradycardia by delaying the elimination of arotinolol"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0009-0007-0698-1101","authenticated-orcid":false,"given":"Yuki","family":"Iizuka","sequence":"first","affiliation":[{"name":"Critical Care Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yasunori","family":"Urayama","sequence":"additional","affiliation":[{"name":"Department of Pharmacy, Metropolitan Bokutoh Hospital, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Takeo","family":"Yasu","sequence":"additional","affiliation":[{"name":"Department of Medicinal Therapy Research, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan"},{"name":"Bokutoh Hospital-Meiji Pharmaceutical University Joint Research Center, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jun","family":"Makino","sequence":"additional","affiliation":[{"name":"Critical Care Medicine, Metropolitan Bokutoh Hospital, Tokyo, Japan"},{"name":"Bokutoh Hospital-Meiji Pharmaceutical University Joint Research Center, Tokyo, Japan"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,1,2]]},"reference":[{"key":"2025082708103912000_18.1.e262234.1","doi-asserted-by":"crossref","DOI":"10.1136\/bmj.f55","article-title":"Benefits of \u03b2 blockers in patients with heart failure and reduced ejection fraction: network meta-analysis","volume":"346","author":"Chatterjee","year":"2013","journal-title":"BMJ"},{"key":"2025082708103912000_18.1.e262234.2","doi-asserted-by":"crossref","DOI":"10.3389\/fcvm.2022.1071387","article-title":"Effect of arotinolol on chronic heart failure: A systematic review and meta-analysis of randomized controlled trials","volume":"9","author":"Huang","year":"2022","journal-title":"Front Cardiovasc Med"},{"key":"2025082708103912000_18.1.e262234.3","doi-asserted-by":"publisher","DOI":"10.1016\/S1353-8020(03)00029-4"},{"key":"2025082708103912000_18.1.e262234.4","article-title":"A Case Report of BRASH (Bradycardia, Renal Failure, Atrioventricular (AV) Blockage, Shock, and Hyperkalemia) Syndrome With a Challenging Diagnosis and Management Dilemma","volume":"15","author":"Ghallab","year":"2023","journal-title":"Cureus"},{"key":"2025082708103912000_18.1.e262234.5","article-title":"A Combination of Beta-Blockade and Calcium Channel Blockade Leading to Bradycardia, Renal Failure, Atrioventricular Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Case Report","volume":"15","author":"Patel","year":"2023","journal-title":"Cureus"},{"key":"2025082708103912000_18.1.e262234.6","unstructured":"Arotinolol hydrochloride tablet prescribing information. 2024. Available: https:\/\/sumitomo-pharma.jp\/product\/arotinolol\/attachment\/interv.html"},{"key":"2025082708103912000_18.1.e262234.7","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1111\/j.1365-2362.1975.tb02309.x","article-title":"Alteration of drug metabolism during cholestasis in man","volume":"5","author":"Carulli","year":"1975","journal-title":"Eur J Clin Invest"},{"key":"2025082708103912000_18.1.e262234.8","doi-asserted-by":"crossref","first-page":"15","DOI":"10.18433\/J3RG6W","article-title":"Pharmacodynamics of rocuronium in cholestatic patients with or without hepatocellular injury: normal onset time of initial dose and prolonged duration time after repeated doses","volume":"11","author":"Yang","year":"2008","journal-title":"J Pharm Pharm Sci"},{"key":"2025082708103912000_18.1.e262234.9","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.90.4.1765"},{"key":"2025082708103912000_18.1.e262234.10","doi-asserted-by":"crossref","unstructured":"Hjalmarson A , Goldstein S , Fagerberg B , et al . n.d. Effects of controlled-release metoprolol on total mortality, hospitalizations, and well-being in patients with heart failure: the Metoprolol CR\/XL Randomized Intervention Trial in congestive heart failure (MERIT-HF). 283:1295\u2013302.","DOI":"10.1001\/jama.283.10.1295"},{"key":"2025082708103912000_18.1.e262234.11","doi-asserted-by":"publisher","DOI":"10.1001\/jama.289.6.712"},{"key":"2025082708103912000_18.1.e262234.12","unstructured":"Farzam K , Blockers JAB . Beta blockers. In: StatPearls. Treasure Island (FL): StatPearls Publishing, 2023."},{"key":"2025082708103912000_18.1.e262234.13","first-page":"4549","article-title":"Pharmacokinetic study of S-596 in mice and rats","volume":"21","author":"Iba","year":"1987","journal-title":"Kiso to Rinsho"},{"key":"2025082708103912000_18.1.e262234.14","first-page":"131","article-title":"Pharmacokinetics and pharmacodynamics of antihypertensive drugs in the elderly","volume":"26","author":"Kuwajima","year":"1989","journal-title":"Nihon Ronen Igakkai Zasshi"},{"key":"2025082708103912000_18.1.e262234.15","doi-asserted-by":"crossref","first-page":"495","DOI":"10.3999\/jscpt.13.495","article-title":"Hemodynamics of a New \u03b1, \u03b2-Blocking agent S-596 in Exercise Loading Test] Atarasii \u03b1,\u03b2 syadanzai S-596 no undohukashiken ni okeru kekkou doutai ni tuite (in Japanese","volume":"13","author":"Nakajima","year":"1982","journal-title":"Jpn J Clin Pharmacol Ther"},{"key":"2025082708103912000_18.1.e262234.16","doi-asserted-by":"crossref","DOI":"10.1186\/s13054-021-03585-7","article-title":"Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup","volume":"25","author":"Bouchard","year":"2021","journal-title":"Crit Care"},{"key":"2025082708103912000_18.1.e262234.17","first-page":"1543","article-title":"Pharmacokinetics and Clinical Effects of Arotinolol in Hemodialysis Patients","volume":"25","author":"Yamamoto","year":"1988","journal-title":"Med Consult & New Rem"},{"key":"2025082708103912000_18.1.e262234.18","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1007\/BF01683062","article-title":"Comparative haemodynamic effects of dobutamine and isoproterenol in man","volume":"3","author":"Rigaud","year":"1977","journal-title":"Intensive Care Med"},{"key":"2025082708103912000_18.1.e262234.19","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9149(75)90079-X"},{"key":"2025082708103912000_18.1.e262234.20","doi-asserted-by":"publisher","DOI":"10.2165\/00139709-200423040-00003"},{"key":"2025082708103912000_18.1.e262234.21","doi-asserted-by":"publisher","DOI":"10.1016\/S0196-0644(89)80324-5"},{"key":"2025082708103912000_18.1.e262234.22","doi-asserted-by":"publisher","DOI":"10.1155\/2016\/3596415"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2024-262234","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,27]],"date-time":"2025-08-27T15:10:48Z","timestamp":1756307448000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2024-262234"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,1]]},"references-count":22,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,1,2]]},"published-print":{"date-parts":[[2025,1]]}},"alternative-id":["10.1136\/bcr-2024-262234"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2024-262234","relation":{},"ISSN":["1757-790X"],"issn-type":[{"type":"electronic","value":"1757-790X"}],"subject":[],"published":{"date-parts":[[2025,1]]}}}