351
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Abstract
Sudden unexpected deaths have been reported with antipsychotic use since the early 1960s. In some cases the antipsychotic may be unrelated to death, but in others it appears to be a causal factor. Antipsychotics can cause sudden death by several mechanisms, but particular interest has centred on torsade de pointes (TdP), a polymorphic ventricular arrhythmia that can progress to ventricular fibrillation and sudden death. The QTc interval is a heart rate-corrected value that represents the time between the onset of electrical depolarisation of the ventricles and the end of repolarisation. Prolongation of the QTc interval is a surrogate marker for the ability of a drug to cause TdP. In individual patients an absolute QTc interval of >500 msec or an increase of 60 msec from baseline is regarded as indicating an increased risk of TdP. However, TdP can occur with lower QTc values or changes. Concern about a relationship between QTc prolongation, TdP and sudden death applies to a wide range of drugs and has led to the withdrawal or restricted labelling of several. Among antipsychotics available in the UK, sertindole was voluntarily suspended, droperidol was withdrawn, and restricted labelling introduced for thioridazine and pimozide. The degree of QTc prolongation is dose dependent and varies between antipsychotics reflecting their different capacity to block cardiac ion channels. Significant prolongation is not a class effect. Among currently available agents, thioridazine and ziprasidone are associated with the greatest QTc prolongation. Virtually all drugs known to cause TdP block the rapidly activating component of the delayed rectifier potassium current (I(kr)). Arrhythmias are more likely to occur if drug-induced QTc prolongation coexists with other risk factors, such as individual susceptibility, presence of congenital long QT syndromes, heart failure, bradycardia, electrolyte imbalance, overdose of a QTc prolonging drug, female sex, restraint, old age, hepatic or renal impairment, and slow metaboliser status. Pharmacodynamic and pharmacokinetic interactions can also increase the risk of arrhythmias. Further research is needed to quantify the risk of sudden death with antipsychotics. The risk should be viewed in the context of the overall risks and benefits of antipsychotic treatment. It seems prudent, where possible, to select antipsychotics that are not associated with marked QTc prolongation. If use of a QTc-prolonging drug is warranted, then measures to reduce the risk should be adopted.
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Affiliation(s)
- Peter M Haddad
- Bolton, Salford and Trafford Mental Health Partnership, Eccles, Salford, UK
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352
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Abstract
OBJECTIVE To review the production of cardiac arrhythmia by thioridazine, and consider the role of government regulation in light of antipsychotic prescribing trends in New Zealand. METHODS We conducted a focused literature review on psychotropic-induced cardiotoxicity, including mechanisms and incidence. In addition, we considered trends in antipsychotic prescription in New Zealand and decisions made by regulatory bodies in Australia, North America and the United Kingdom regarding restrictions on the prescription of thioridazine. RESULTS In general, the cardiotoxicity of antipsychotics, including thioridazine, relates to the ability of these drugs to antagonize voltage-sensitive potassium channels, and thereby prolong the QT interval. This action can lead to malignant arrhythmias in a very small proportion (< < 1%) of patients; the risk may be increased by other drugs or factors which prolong QT or inhibit the metabolism of thioridazine. A review of prescription doses and volumes in New Zealand indicates that thioridazine is prescribed mainly in low doses by non-specialists, and its use has been waning significantly over the past 2 years. These trends predate recent publicity regarding cardiotoxicity. CONCLUSION Recommendations regarding thioridazine use are presented. Although new patients should not receive this drug, existing patients benefiting from modest doses should not be denied access unless clear-cut risk factors for cardiotoxicity are evident.
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Affiliation(s)
- David B Menkes
- Psychological Medicine, University of Wales Academic Unit, Wrescam LL13 7YP, UK.
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353
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Davies SJC, Cooke LB, Moore AG, Potokar J. Discontinuation of thioridazine in patients with learning disabilities: balancing cardiovascular toxicity with adverse consequences of changing drugs. BMJ 2002; 324:1519-21. [PMID: 12077046 PMCID: PMC1123452 DOI: 10.1136/bmj.324.7352.1519] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Simon J C Davies
- Psychopharmacology Unit, School of Medical Sciences, Bristol BS8 1TD, UK.
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354
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Abstract
Schizophrenia is a life shortening illness. Unnatural causes and natural causes are put forward as reasons for this excess mortality. In terms of the latter, a host of different physical disorders occur with increased frequency in schizophrenia. When taken together, some of these illnesses such as type 2 diabetes mellitus and cardiovascular disorders constitute the Metabolic Syndrome; a characteristic phenotype of those with this syndrome is excessive visceral fat distribution. The exact reasons why this particular syndrome occurs in schizophrenia is as yet unclear though factors such as life style, poor diet and lack of exercise may contribute to it's development. Alternatively, overactivity of the hypothalamic-pituitary-adrenal axis leading to hypercortisolaemia can also result in excessive visceral fat accumulation. This minireview aims to explore the potential role of these issues and medication in terms of the increased morbidity and mortality observed in schizophrenia.
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Affiliation(s)
- Martina C M Ryan
- Neuroscience Centre, St. Vincent's Hospital, Richmond Rd, Fairview, Dublin 3, Ireland
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355
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LLerena A, Berecz R, de la Rubia A, Dorado P. QTc interval lengthening and debrisoquine metabolic ratio in psychiatric patients treated with oral haloperidol monotherapy. Eur J Clin Pharmacol 2002; 58:223-24. [PMID: 12162273 DOI: 10.1007/s00228-002-0452-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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356
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Abstract
For at least the past 30 years it has been known that people with schizophrenia have higher death rates, particularly from cardiovascular causes, than would be expected on the basis of demographics (Allebeck & Wistedt, 1986; Mortensen & Juel, 1990; Newman & Bland, 1991; Walker et al, 1997). Initially, suspicion focused upon lifestyle factors, such as ubiquitous smoking and poor self-care, and perhaps upon a direct effect of the disease. However, some of the suspicion began to shift to the drugs used to treat the disease, fuelled both by the accumulation of case reports among antipsychotic users of serious ventricular arrhythmias and sudden unexpected deaths (Liberatore & Robinson, 1984; Kriwisky et al, 1990; Mehtonen et al, 1991; Donatini et al, 1992; Thomas, 1994; Jackson et al, 1997; Ravin & Levenson, 1997; Zarate et al, 1997; Dickinson, 2000), as well as advancing understanding of the electrophysiological properties of these drugs (Thomas, 1994; Suessbrich et al, 1997; Drici et al, 1998; Rampe et al, 1998; Shader & Greenblatt, 1998; Studenik et al, 1998; Reilly et al, 2000).
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357
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Reilly JG, Ayis SA, Ferrier IN, Jones SJ, Thomas SHL. Thioridazine and sudden unexplained death in psychiatric in-patients. Br J Psychiatry 2002; 180:515-22. [PMID: 12042230 DOI: 10.1192/bjp.180.6.515] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sudden death has been linked to antipsychotic therapy, but the relative risk associated with specific drugs is unknown. AIMS To assess the risk of sudden unexplained death associated with antipsychotic drug therapy and its relation to drug dose and individual agents. METHOD A case-control study of psychiatric in-patients dying suddenly in five hospitals in the north-east of England and surviving controls matched for age, gender and mental disorder. Logistic regression analysis was used to identify significant risk factors, and odds ratios were calculated. RESULTS Sixty-nine case-control clusters were identified. Probable sudden unexplained death was significantly associated with hypertension, ischaemic heart disease and current treatment with thioridazine (adjusted odds ratio=5.3, 95% CI 1.7-16.2, P=0.004). There was no significant association with other individual antipsychotic drugs. CONCLUSIONS Thioridazine alone was associated with sudden unexplained death, the likely mechanism being drug-induced arrhythmia.
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Affiliation(s)
- J G Reilly
- Academic Department of Psychiatry, University of Newcastle upon Tyne
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358
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McAllister-Williams RH, Ferrier IN. Rapid tranquillisation: time for a reappraisal of options for parenteral therapy. Br J Psychiatry 2002; 180:485-9. [PMID: 12042225 DOI: 10.1192/bjp.180.6.485] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND When parenteral treatments are indicated for acutely disturbed behaviour, previous guidelines have recommended droperidol or haloperidol in combination with benzodiazepines. However, there has been recent concern over cardiotoxicity and sudden death associated with some antipsychotic medication and droperidol has now been withdrawn. AIMS To ascertain what alternatives can be recommended to replace intramuscular droperidol. METHOD Selective review of current guidelines and the literature pertaining to rapid parenteral tranquillisation. RESULTS Current guidelines recommend haloperidol as an alternative to droperidol. There is evidence of cardiotoxicity with haloperidol and it has a propensity to cause extrapyramidal side-effects that may exacerbate disturbed behaviour and reduce longer-term compliance. The rapid-acting intramuscular formulations of atypical antipsychotic agents show promise. CONCLUSIONS It is recommended that the mainstay of pharmacological rapid tranquillisation should be parenteral benzodiazepines used with due care.
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359
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Gluais P, Bastide M, Caron J, Adamantidis M. Risperidone prolongs cardiac action potential through reduction of K+ currents in rabbit myocytes. Eur J Pharmacol 2002; 444:123-32. [PMID: 12063072 DOI: 10.1016/s0014-2999(02)01626-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Prolongation of QT interval by antipsychotic drugs is an unwanted side effect that may lead to ventricular arrhythmias. The antipsychotic agent risperidone has been shown to cause QT prolongation, especially in case of overdosage. We investigated risperidone effects on action potentials recorded from rabbit Purkinje fibers and ventricular myocardium and on potassium currents recorded from atrial and ventricular rabbit isolated myocytes. The results showed that (1) risperidone (0.1-3 microM) exerted potent lengthening effects on action potential duration in both tissues with higher potency in Purkinje fibers and caused the development of early afterdepolarizations at low stimulation rate; (2) risperidone (0.03-0.3 microM) reduced significantly the current density of the delayed rectifier current and at 30 microM decreased the transient outward and the inward rectifier currents. This study might explain QT prolongation observed in some patients treated with risperidone and gives enlightenment on the risk of cardiac adverse events.
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Affiliation(s)
- Pascale Gluais
- Laboratoire de Pharmacologie, Faculté de Médecine Henri Warembourg, Pole Recherche, 1 place de Verdun, 59045 Lille Cedex, France.
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360
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Feinstein RE. Cardiovascular effects of novel antipsychotic medications. HEART DISEASE (HAGERSTOWN, MD.) 2002; 4:184-90. [PMID: 12028604 DOI: 10.1097/00132580-200205000-00009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This article reviews current knowledge of cardiovascular effects and drug interactions of the most commonly used novel antipsychotics, including clozapine and the atypical antipsychotics. The literature was reviewed through MEDLINE and PSYCINFO searches of articles published from 1980 to 2001. Materials were located using search terms such as antipsychotics and atypical antipsychotics, matched with the terms cardiovascular disease, coronary artery disease, cardiac risk factor, cardiovascular effects, and cardiac effects. Individual drug names were also searched and their 2001 package inserts were reviewed. Drug compendiums from 1998 to 2001 and some psychopharmacology texts were also used for this review. This article focuses on direct cardiovascular effects of these medications and the most common interactions between the antipsychotic and cardiovascular medications.
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Affiliation(s)
- Robert E Feinstein
- Department of Psychiatry, New York Medical College, Westchester Medical Center, Valhalla, NY 10905, USA
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361
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Sander GE, Guillory GS, Giles TD. Noncardiac drugs and QTc interval prolongation: an often unrecognized risk factor for adverse cardiovascular outcomes. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2002; 11:197-202. [PMID: 11986537 DOI: 10.1111/j.1076-7460.2002.00882.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Gary E Sander
- Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
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362
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Feinstein RE, Khawaja IS, Nurenberg JR, Frishman WH. Cardiovascular effects of psychotropic drugs. Curr Probl Cardiol 2002; 27:190-240. [PMID: 12060825 DOI: 10.1067/mcd.2002.125053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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363
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Titier K, Déridet E, Moore N. In vivo and in vitro myocardial binding of risperidone and 9-hydroxyrisperidone. Toxicol Appl Pharmacol 2002; 180:145-9. [PMID: 11969382 DOI: 10.1006/taap.2002.9383] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Antipsychotic drugs have been found to prolong the QT interval, a phenomenon that, when severe, may facilitate the occurrence of complex ventricular arrhythmia such as torsade de pointes. Concentration-dependent QT prolongation has been demonstrated in vitro with such recent drugs as risperidone on Purkinje fibers and in isolated feline hearts. In vivo, there appears to be a relationship between plasma levels and QTc prolongation. This study was designed to estimate cardiac levels in vivo during treatment. For that purpose, we examined both in vivo and in vitro the ratio between plasma and cardiac tissue concentrations of risperidone and its active metabolite 9-hydroxyrisperidone. Binding parameters for different concentrations were determined in vitro by equilibrium dialysis. In vivo, they were determined by intraperitoneal administration of three doses in the guinea pig. Drug concentrations were determined by a high-performance liquid chromatography method with UV detection developed for that purpose. For risperidone, plasma protein binding varied from 67 to 43% and cardiac homogenate binding varied from 90 to 78%. 9-Hydroxyrisperidone values were lower. Tissue levels were 4.5-fold higher than plasma levels. Binding parameters were similar both in vivo and in vitro. From this model, the relevance of in vitro electrophysiological studies to clinical plasma concentrations can be approached.
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Affiliation(s)
- Karine Titier
- Department of Pharmacology and Toxicology, EA 525, University Victor Segalen, Place Amélie Raba-Léon, 33076 Bordeaux Cedex, France
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364
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Francis PD. Effects of psychotropic medications on the pediatric electrocardiogram and recommendations for monitoring. Curr Opin Pediatr 2002; 14:224-30. [PMID: 11981295 DOI: 10.1097/00008480-200204000-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reports of sudden unexpected death in pediatric patients taking selected psychotropic drugs have raised the possibility of ventricular dysrhythmias as the cause of these deaths. The use of psychotropic drugs in the pediatric population has increased significantly in recent years with increasing reports of electrocardiogram abnormalities, particularly prolongation of the corrected QT interval. Many factors affect the susceptibility of the heart to conduction abnormalities and sudden ventricular dysrhythmias in pediatric patients taking psychotropic drugs. These complex relations include genetic predisposition, structural cardiac disease, drug-drug interactions, drug dosage, and drug metabolism and clearance. Many specific psychotropic drugs have been reported to prolong the QTc interval and increase the risk of ventricular dysrhythmias and sudden death. This article discusses the various factors that may influence the electrocardiogram in pediatric patients taking psychotropic drugs and recommendations for monitoring these patients.
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Affiliation(s)
- Paul D Francis
- Department of Pediatrics, Janet Weis Children's Hospital, Geisinger Medical Center, Danville, Pennsylvania 17822, USA.
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365
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Abstract
Risperidone is one of the newer atypical antipsychotic agents, which combines potent serotonin and dopamine receptor antagonism. It shows efficacy against the positive and negative symptoms of schizophrenic psychoses and other psychotic conditions, and has a low propensity to cause extrapyramidal side effects. The aim of these case reports in elderly patients is to provide the benefit of personal experience with risperidone to the body of published literature and to demonstrate the types of patients that may benefit from treatment. These cases were compiled retrospectively from data collected on referral and during routine hospital appointments. This series covers four main areas of concern when treating the elderly: low-maintenance dosing minimising the likelihood of adverse events; successful treatment of patients previously uncontrolled and experiencing side effects with other antipsychotics; the possibility of intermittent rather than continuous treatment; and the benefits to patients, carers and the health services. At low doses, risperidone is an effective and well-tolerated treatment for psychoses in elderly patients that improves the quality of life for both patients and their caregivers.
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Affiliation(s)
- R Bullock
- Kingshill Research Centre, Victoria Hospital, Okus Road, Swindon, Wiltshire SN1 4JU, UK
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366
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Fraser GL, Riker R. Advances and Controversies in Adult ICU Sedation, Part 3: Evolving Pharmacological Treatment Issues. Hosp Pharm 2002. [DOI: 10.1177/001857870203700404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This feature examines the impact of pharmacologic interventions on the treatment of the critically ill patient—an area of health care that has become increasingly complex. It will review recent advances (including evolving and controversial data) in drug therapy for adult ICU patients and assess these new modalities in terms of clinical, humanistic, and economic outcomes.
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367
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Bertino JS, Owens RC, Carnes TD, Iannini PB. Gatifloxacin-associated corrected QT interval prolongation, torsades de pointes, and ventricular fibrillation in patients with known risk factors. Clin Infect Dis 2002; 34:861-3. [PMID: 11830802 DOI: 10.1086/339075] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2001] [Revised: 10/15/2001] [Indexed: 11/03/2022] Open
Abstract
Drugs not commonly considered to be cardioactive agents have been reported to cause prolongation of the corrected QT interval with resultant torsades de pointes or ventricular fibrillation. We report 4 cases of gatifloxacin-associated cardiac toxicity in patients with known risk factors for this adverse event.
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Affiliation(s)
- Joseph S Bertino
- Departments of Pharmacy Services and Medicine, Division of Clinical Pharmacology, Bassett Healthcare, Cooperstown, NY, 13326, USA.
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368
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Witchel HJ, Pabbathi VK, Hofmann G, Paul AA, Hancox JC. Inhibitory actions of the selective serotonin re-uptake inhibitor citalopram on HERG and ventricular L-type calcium currents. FEBS Lett 2002; 512:59-66. [PMID: 11852052 DOI: 10.1016/s0014-5793(01)03320-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Using whole-cell patch clamp recording of heterologous HERG-mediated currents in transfected mammalian cells, we observed that the selective serotonin re-uptake inhibitor citalopram blocks HERG with an IC(50) of 3.97 microM. This is slightly less potent than fluoxetine in our system (IC(50) of 1.50 microM). In isolated guinea pig ventricular cardiomyocytes citalopram inhibited L-type calcium current (I(Ca,L)). The voltage dependence of I(Ca,L) inactivation in the presence of 100 microM citalopram was shifted significantly leftward. As a result, the I(Ca,L) 'window' in citalopram was found to be (a) smaller and (b) leftward-shifted compared to control. The effects of citalopram on both calcium current amplitude and the I(Ca,L) 'window' may help to explain citalopram's good cardiac safety profile, given its propensity to block HERG at excessive dosages.
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Affiliation(s)
- Harry J Witchel
- Cardiovascular Research Laboratories and Department of Physiology, School of Medical Sciences, Bristol, UK.
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369
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Furst BA, Champion KM, Pierre JM, Wirshing DA, Wirshing WC. Possible association of QTc interval prolongation with co-administration of quetiapine and lovastatin. Biol Psychiatry 2002; 51:264-5. [PMID: 11839370 DOI: 10.1016/s0006-3223(01)01333-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND QTc interval prolongation can occur as a result of treatment with both conventional and novel antipsychotic medications and is of clinical concern because of its association with the potentially fatal ventricular arrhythmia, torsade de pointes. METHODS One case is described in which a patient with schizophrenia, who was being treated for dyslipidemia, developed a prolonged QTc interval while taking quetiapine and lovastatin. RESULTS QTc returned to baseline when the lovastatin dose was reduced. CONCLUSIONS QTc prolongation associated with antipsychotic medication occurs in a dose-dependent manner. We therefore hypothesize that the addition of lovastatin caused an increase in plasma quetiapine levels through competitive inhibition of the cytochrome P(450) (CYP) isoenzyme 3A4. Our case highlights the potential for a drug interaction between quetiapine and lovastatin leading to QTc prolongation during the management of dysipidemia in patients with schizophrenia.
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Affiliation(s)
- Benjamin A Furst
- Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles School of Medicine, Los Angeles, California, USA
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370
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Bauer M, Whybrow PC, Angst J, Versiani M, Möller HJ. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Unipolar Depressive Disorders, Part 1: Acute and continuation treatment of major depressive disorder. World J Biol Psychiatry 2002; 3:5-43. [PMID: 12479086 DOI: 10.3109/15622970209150599] [Citation(s) in RCA: 262] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of unipolar depressive disorders, as well as the management of the acute and continuation-phase treatment. These guidelines are primarily concerned with the biological treatment (including antidepressants, other psychopharmacological and hormonal medications, electroconvulsive therapy, light therapy, adjunctive and novel therapeutic strategies) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.
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Affiliation(s)
- Michael Bauer
- Neuropsychiatric Institute & Hospital, Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles (ULCA), 300 UCLA Medical Plaza, Suite 2330, Los Angeles, CA 90095, USA.
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371
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Wang PS, Levin R, Zhao SZ, Avorn J. Urinary antispasmodic use and the risks of ventricular arrhythmia and sudden death in older patients. J Am Geriatr Soc 2002; 50:117-24. [PMID: 12028256 DOI: 10.1046/j.1532-5415.2002.50017.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The introduction of new medications to treat overactive bladder has resulted in a significant increase in the number of individuals with this condition who use medications for symptoms. Formal epidemiological studies of the safety of these medications in typical patient populations are lacking, particularly studies of serious events. We sought to determine whether the use of urinary antispasmodics increases the risk of ventricular arrhythmias or sudden death. DESIGN Retrospective cohort study. SETTING Retrospective analysis of data of participants in community, hospital or nursing home setting. PARTICIPANTS Fourteen thousand six hundred thirty-eight subjects with a diagnosis of urinary incontinence made between January 1, 1991, and June 30, 1995; all were aged 65 and older and enrolled in Medicare and Medicaid or the Pharmacy Assistance for the Aged and Disabled programs of New Jersey. MEASUREMENTS Filled prescriptions for oxybutynin (Ditropan), flavoxate (Urispas), hyoscyamine (Cystospas), and hyoscyamine sulfate (Cystospas-M) were used to define days of exposure to these drugs. We also identified all use of nonsedating antihistamines and cytochrome P450 3A4 inhibitors, and their concurrent use, to serve as a positive control exposure. Two outcomes were then defined: a new diagnosis of ventricular arrhythmia combined with initiation of an antiarrhythmic medication and sudden death. Other covariates, including clinical, demographic, medication use, and healthcare utilization variables, were also assessed. Adjusted risk ratios of ventricular arrhythmia and sudden death were derived from multivariable Cox proportional hazards models. RESULTS There was no significant association between periods of use of urinary antispasmodics and the development of ventricular arrhythmias (adjusted risk ratio (RR) = 1.23, 95 confidence interval (CI) = 0.87-1.75) or sudden death (adjusted RR = 0.70, 95% CI = 0.28-1.74). A significantly increased risk of ventricular arrhythmia was observed for the positive control regimen, concurrent use of nonsedating antihistamines and cytochrome P450 3A4 inhibitors (adjusted RR = 5.47; 95% CI = 1.34-22.26), but not for use of either drug group alone. Concurrent use of nonsedating antihistamines and cytochrome P450 3A4 inhibitors was also associated with a significant increase in the risk of sudden death (adjusted RR = 21.50, 95% CI = 5.23-88.37). Other variables significantly associated with ventricular arrhythmia included ischemic heart disease and congestive heart failure, whereas nursing home use before the index date was associated with a decreased likelihood of receiving a diagnosis of and treatment for ventricular arrhythmia. Other variables significantly associated with sudden death included male gender, black race, and congestive heart failure. CONCLUSIONS Antimuscarinic urinary antispasmodics available before 1996 were not associated with an increased risk of ventricular arrhythmias and sudden death. Additional study will be required to confirm these results, exclude the possibility of unmeasured confounders contributing to any lack of an observed relationship, and extend these findings to newer agents such as tolterodine.
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Affiliation(s)
- Philip S Wang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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372
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373
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Street JS, Clark WS, Kadam DL, Mitan SJ, Juliar BE, Feldman PD, Breier A. Long-term efficacy of olanzapine in the control of psychotic and behavioral symptoms in nursing home patients with Alzheimer's dementia. Int J Geriatr Psychiatry 2001; 16 Suppl 1:S62-70. [PMID: 11748789 DOI: 10.1002/1099-1166(200112)16:1+<::aid-gps569>3.0.co;2-j] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Psychotic symptoms and behavioral disturbances are a leading cause of institutionalization in elderly patients with Alzheimer's disease (AD). OBJECTIVES Elderly nursing home patients (n=105) with possible or probable AD were entered into a multicenter study to determine the long-term efficacy and safety of olanzapine in treatment of psychotic symptoms and behavioral disturbances due to AD. METHODS Following a double-blind, 6-week exposure to fixed-dose olanzapine (5, 10, or 15 mg/d), patients entered an additional 18-week, open-label, flexible-dose treatment. Baseline was defined from the start of the extension phase. RESULTS Patients improved significantly on the primary efficacy measure, defined a priori, which consisted of the sum of the Agitation/Aggression, Delusions, and Hallucinations items ('Core':) of the NPI/NH. Olanzapine also significantly improved scores for the NPI/NH total and the Core item-associated Occupational Disruptiveness of the NPI/NH, as well as the BPRS total and CGI Severity-of-Alzheimer's scores. Barnes Akathasia scores improved significantly from baseline, while Simpson-Angus and AIMS scores were not significantly changed. Treatment-emergent symptoms included somnolence, accidental injury, and rash. No significant changes were seen in ECGs, including QT(c) interval, nor in weight or vital signs, including orthostasis. CONCLUSIONS Low-dose olanzapine appears to be effective and well tolerated for treatment of behavioral disturbances and psychotic symptoms due to AD in elderly patients.
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Affiliation(s)
- J S Street
- Lilly Research Laboratories, Indianapolis, IN 46285, USA
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374
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Abstract
The atypical antipsychotics have a low incidence of extrapyramidal side effects (EPS), have improved tardive dyskinesia profiles, and have a broad range of therapeutic efficacy. These agents offer important therapeutic advantages that extend beyond their initial regulatory approval in several conditions and patient groups. The use of atypical antipsychotics is most relevant in the treatment of mood disorders, where these medications are being used increasingly for acute mood stabilization and in patients who are resistant to other treatments. Similar circumstances and clinical advantages pertain to the use of atypical antipsychotics in the treatment of behavioral disturbances in patients with dementia and in the management of personality disorders-both circumstances where conventional antipsychotics were initially poorly tolerated because of EPS. The low incidence of EPS associated with atypical antipsychotics is highly beneficial in several neuropsychiatric conditions. The extent to which endocrine and metabolic dysregulations associated with atypical antipsychotics will influence antipsychotics' role remains to be determined. As therapeutic opportunities evolve and diversify, atypical antipsychotics, because of favorable adverse-effect profiles, will have enhanced patient tolerability and use in nonpsychiatric conditions.
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Affiliation(s)
- P F Buckley
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Augusta 30912, USA
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375
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Abstract
Much of the individual variation in drug response is due to genetic drug metabolic polymorphisms. Clinically relevant examples include acetylator status; cytochrome P450 2D6, 2C9 and 2C19 polymorphisms; and thiopurine methyltransferase deficiency. It is important to be aware of which drugs are subject to pharmacogenetic variability. In the future, population-based pharmacogenetic testing will allow more individualized drug treatment and will avoid the current empiricism.
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Affiliation(s)
- P I Pillans
- Department of Clinical Pharmacology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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376
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Abstract
Since the introduction of clozapine, several novel antipsychotic agents have been introduced and more are in Phase II/III studies. Because these agents are used clinically as first-line treatment, we need to be more familiar with their side-effect profiles. This manuscript reviews the cardiovascular side effects of currently available novel antipsychotics. The medications reviewed include clozapine, risperidone, olanzapine, quetiapine, and ziprasidone. Guidelines are suggested for the use of these medications in clinical practice.
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Affiliation(s)
- S Gupta
- Department of Psychiatry, Olean General Hospital, Olean, NY, USA.
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377
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Abstract
Treatment-refractory schizophrenia is common. Refinements in pharmacologic and psychosocial treatments of schizophrenia offer the expectation of superior outcomes for this disadvantaged patient group. This article critically reviews those articles that were published during the year 2000 that address this treatment-refractory population.
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Affiliation(s)
- P F Buckley
- Department of Psychiatry, Medical College of Georgia, 1515 Pope Avenue, Augusta, GA 30912-3800, USA.
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378
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Wright N. Removal of thioridazine from primary care formulary will result in prescribing vacuum. BMJ (CLINICAL RESEARCH ED.) 2001; 323:695. [PMID: 11566843 PMCID: PMC1121250 DOI: 10.1136/bmj.323.7314.695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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379
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Meehan K, Zhang F, David S, Tohen M, Janicak P, Small J, Koch M, Rizk R, Walker D, Tran P, Breier A. A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating acutely agitated patients diagnosed with bipolar mania. J Clin Psychopharmacol 2001; 21:389-97. [PMID: 11476123 DOI: 10.1097/00004714-200108000-00006] [Citation(s) in RCA: 186] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
There are no rapid-acting intramuscular formulations of atypical antipsychotics available for quickly calming an agitated patient with bipolar disorder. In this study, 201 agitated patients with bipolar mania were randomly assigned to receive one to three injections of the atypical antipsychotic olanzapine (10 mg, first two injections; 5 mg, third injection), the benzodiazepine lorazepam (2 mg, first two injections; 1 mg, third injection), or placebo (placebo, first two injections; olanzapine, 10 mg, third injection) within a 24-hour period. Agitation was measured at baseline, every 30 minutes for the first 2 hours, and at 24 hours after the first injection using the Positive and Negative Syndrome Scale-Excited Component subscale and two additional agitation scales. At 2 hours after the first injection, patients treated with olanzapine showed a significantly greater reduction in scores on all agitation scales compared with patients treated with either placebo or lorazepam. At 24 hours after the first injection, olanzapine remained statistically superior to placebo in reducing agitation in patients with acute mania, whereas patients treated with lorazepam were not significantly different from those treated with placebo or olanzapine. Furthermore, no significant differences among the three treatment groups were observed in safety measures, including treatment-emergent extrapyramidal symptoms, the incidence of acute dystonia, or QTc interval changes. These findings suggest that intramuscular olanzapine is a safe and effective treatment for reducing acute agitation in patients with bipolar mania.
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Affiliation(s)
- K Meehan
- Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana 46285, USA
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380
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Cohen H, Loewenthal U, Matar M, Kotler M. Association of autonomic dysfunction and clozapine. Heart rate variability and risk for sudden death in patients with schizophrenia on long-term psychotropic medication. Br J Psychiatry 2001; 179:167-71. [PMID: 11483480 DOI: 10.1192/bjp.179.2.167] [Citation(s) in RCA: 102] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Antipsychotic medications cause a wide range of adverse effects and have been associated with sudden death in psychiatric patients. AIMS To supply power spectral analysis of heart rate variability as a tool to examine the arrythmogenic effects of neuroleptics. METHOD Heart rate analysis was carried out in patients with schizophrenia on standard doses of neuroleptic monotherapy -- 21 were on clozapine, 18 on haloperidol and 17 on olanzapine -- and in 53 healthy subjects. RESULTS Patients with schizophrenia on clozapine had significantly higher heart rate, lower heart rate variability and lower high-frequency and higher low-frequency components compared with patients on haloperidol or olanzapine and matched control subjects. Prolonged QTc intervals were more common in patients than controls. CONCLUSIONS Patients treated with neuroleptic medications, especially clozapine, showed autonomic dysregulation and cardiac repolarisation changes. Physicians should be aware of this adverse reaction.
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Affiliation(s)
- H Cohen
- Anxiety and Stress Research Unit, Ministry of Health Mental Health Center, Faculty of Health-Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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381
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Rodriguez de la Torre B, Dreher J, Malevany I, Bagli M, Kolbinger M, Omran H, Lüderitz B, Rao ML. Serum levels and cardiovascular effects of tricyclic antidepressants and selective serotonin reuptake inhibitors in depressed patients. Ther Drug Monit 2001; 23:435-40. [PMID: 11477329 DOI: 10.1097/00007691-200108000-00019] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) are used to treat depression. Whereas cardiovascular effects have occasionally been reported during controlled studies with SSRIs, TCA treatment poses a well-known problem in this respect. To investigate the putative correlation between antidepressant dose or serum levels and adverse effects, the authors devised a naturalistic study to evaluate the tricyclic antidepressants' and SSRIs' effect on the cardiovascular system. The authors also compared antidepressant serum levels to adverse effects. Inpatients treated with TCAs or SSRIs were included; an electrocardiogram (ECG) and a Schellong test were carried out on the day patients entered the hospital and during steady-state treatment with antidepressant drugs when blood was drawn for therapeutic drug monitoring. The patient population consisted of 114 acutely depressed patients; 81 patients were treated with TCAs and 33 with SSRIs. The TCAs comprised amitriptyline (n = 43), clomipramine (n = 11), doxepin (n = 19) and imipramine (n = 8); the SSRIs comprised fluvoxamine (n = 14) and paroxetine (n = 19). In TCA-treated patients, the authors observed the same type of abnormalities in conduction and orthostatic hypotension as had been observed earlier. The authors also observed cases of first-degree atrioventricular block, prolonged QTc interval, and orthostatic hypotension in SSRI-treated patients. Thus SSRIs also appear to affect the cardiovascular system, which might pose a problem for patients with preexisting conduction disease. The authors observed a strong correlation between the decrease in systolic pressure and antidepressant serum concentration (except for clomipramine and paroxetine), suggesting that antidepressant serum level is a better correlate than dose.
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382
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Hoehns JD, Stanford RH, Geraets DR, Skelly KS, Lee HC, Gaul BL. Torsades de pointes associated with chlorpromazine: case report and review of associated ventricular arrhythmias. Pharmacotherapy 2001; 21:871-83. [PMID: 11444585 DOI: 10.1592/phco.21.9.871.34565] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE To present a case of chlorpromazine-associated torsades de pointes, review established cases of ventricular arrhythmias associated with chlorpromazine, and describe the proarrhythmic characteristics of this drug. DATA SOURCES Articles identified through a search of MEDLINE and IDIS from January 1966-November 2000 and thorough review of the article bibliographies. Patient cases also were identified from a search of the Food and Drug Administration's Adverse Event Reporting System database (November 1997-March 2001). Cases involving intentional overdoses of chlorpromazine were excluded. RESULTS In addition to the case reported herein, 12 cases of documented, chlorpromazine-associated ventricular arrhythmias were identified; five had characteristic features of torsades de pointes. Chlorpromazine delayed repolarization and produced electrocardiographic abnormalities; although, whether chlorpromazine induced torsades de pointes through a mechanism of early afterdepolarizations is unclear. Similar to other instances of drug-induced torsades de pointes, concurrent factors such as electrolyte deficiencies may place the patient at increased risk for arrhythmia. CONCLUSIONS Chlorpromazine can delay repolarization and produce electrocardiographic abnormalities. These can result infrequently in ventricular arrhythmias and torsades de pointes, particularly in patients with confounding factors.
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Affiliation(s)
- J D Hoehns
- College of Pharmacy, University of Iowa, Iowa City, USA
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383
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Wilton LV, Heeley EL, Pickering RM, Shakir SA. Comparative study of mortality rates and cardiac dysrhythmias in post-marketing surveillance studies of sertindole and two other atypical antipsychotic drugs, risperidone and olanzapine. J Psychopharmacol 2001; 15:120-6. [PMID: 11448085 DOI: 10.1177/026988110101500212] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sertindole (Serdolect), an atypical antipsychotic, was voluntarily suspended in the European Union in 1998 following regulatory concerns over reports of serious cardiac dysrhythmias and sudden unexpected deaths. The reported causes of death, their frequency, prolongation of the rate corrected QT interval (QTc) and cardiac dysrhythmias in patients prescribed sertindole were compared with those for patients treated with two other atypical antipsychotics. All patients in England, prescribed atypical antipsychotics by general practitioners during each drug's immediate post-marketing period, were identified using an observational cohort technique, prescription-event monitoring. Mortality rates in the sertindole cohort were compared with those in a comparator cohort using standardized mortality ratios and incidence rate ratios. Cardiovascular events were reviewed and followed up to identify cases of prolongation of QTc interval. There was no statistically significant difference in mortality rates between sertindole and the comparator cohort, although confidence intervals (CI) were wide due to small numbers in the sertindole cohort. A much smaller number of patients were prescribed sertindole than the other antipsychotics. Six cases of prolongation of QTc interval were identified in 462 patients (1.3%, 95% CI 0.5-2.8) treated with sertindole and one with unspecified electrocardiogram changes in the comparator cohort of 16,542 patients. This study contributes to the understanding of the occurrence of prolongation of QTc interval during clinical use of sertindole, the incidence of which was similar to that in clinical trials. Although no statistically significant difference was shown in mortality rates between sertindole and comparator cohort, the sertindole cohort was too small to rule out an association between the use of this drug and cardiovascular deaths.
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Affiliation(s)
- L V Wilton
- Drug Safety Research Unit, Bursledon, Southampton, UK.
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384
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Burns MJ. The pharmacology and toxicology of atypical antipsychotic agents. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 39:1-14. [PMID: 11327216 DOI: 10.1081/clt-100102873] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Recently, atypical antipsychotic agents have largely replaced traditional agents as first-line drugs for the treatment of schizophrenia. It is likely that atypical agents will soon account for the majority of poisonings from antipsychotic agents that present to health care facilities in the US. This article reviews the pharmacodynamics, pharmacokinetics, and toxicology of atypical antipsychotic drugs, chiefly clozapine, risperidone, olanzapine, and quetiapine. A descriptive summary of the human overdose experience with these agents is provided. Adverse effect and drug interaction data are reviewed. Based on the available pharmacodynamic, pharmacokinetic, and human overdose data, recommendations on management are provided.
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Affiliation(s)
- M J Burns
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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385
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Abstract
Minor cardiovascular adverse effects from antipsychotic drugs are extremely common. They include effects such as postural hypotension and tachycardia due to anticholinergic or alpha1-adrenoceptor blockade, and may occur in the majority of patients at therapeutic dosages. There are a number of pharmacological effects that are of uncertain clinical significance, such as blockade of calmodulin, sodium and calcium channels and alpha2-adrenoceptors in the central nervous system. The most serious consequences of treatment, arrhythmias and sudden death, are probably uncommon and are most likely to be caused primarily by blockade of cardiac potassium channels such as HERG. Incomplete evidence suggests that arrhythmias and sudden death are a particular problem with certain drugs (thioridazine and droperidol), high risk populations (elderly, pre-existing cardiovascular disease, inherited disorders of cardiac ion channels or of antipsychotic drug metabolism) or people taking interacting drugs (such as drugs that prolong the QT interval, e.g. tricyclic antidepressants, drugs that inhibit antipsychotic drug metabolism, or diuretics). Clozapine may be unique in also causing death from myocarditis and cardiomyopathy. Much further research is required to more clearly identify high risk drugs and the populations that are at risk of sudden death, as well as the mechanisms involved and the extent of the risk.
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Affiliation(s)
- N A Buckley
- Department of Clinical Pharmacology, Royal Adelaide Hospital, South Australia, Australia.
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386
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387
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388
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389
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390
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Appleby L, Thomas S, Ferrier N, Lewis G, Shaw J, Amos T. Sudden unexplained death in psychiatric in-patients. Br J Psychiatry 2000; 176:405-6. [PMID: 10912212 DOI: 10.1192/bjp.176.5.405] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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391
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Current Awareness. Pharmacoepidemiol Drug Saf 2000. [DOI: 10.1002/1099-1557(200009/10)9:5<441::aid-pds491>3.0.co;2-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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