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Geurts S, Tilly MJ, Kors JA, Deckers JW, Stricker BHC, de Groot NMS, Ikram MA, Kavousi M. Electrocardiographic parameters and the risk of new-onset atrial fibrillation in the general population: the Rotterdam Study. Europace 2023; 25:euad164. [PMID: 37369558 PMCID: PMC10299895 DOI: 10.1093/europace/euad164] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/14/2023] [Indexed: 06/29/2023] Open
Abstract
AIMS We aimed to assess the (shape of the) association and sex differences in the link between electrocardiographic parameters and new-onset atrial fibrillation (AF). METHODS AND RESULTS A total of 12 212 participants free of AF at baseline from the population-based Rotterdam Study were included. Up to five repeated measurements of electrocardiographic parameters including PR, QRS, QT, QT corrected for heart rate (QTc), JT, RR interval, and heart rate were assessed at baseline and follow-up examinations. Cox proportional hazards- and joint models, adjusted for cardiovascular risk factors, were used to determine the (shape of the) association between baseline and longitudinal electrocardiographic parameters with new-onset AF. Additionally, we evaluated potential sex differences. During a median follow-up of 9.3 years, 1282 incident AF cases occurred among 12 212 participants (mean age 64.9 years, 58.2% women). Penalized cubic splines revealed that associations between baseline electrocardiographic measures and risk of new-onset AF were generally U- and N-shaped. Sex differences in terms of the shape of the various associations were most apparent for baseline PR, QT, QTc, RR interval, and heart rate in relation to new-onset AF. Longitudinal measures of higher PR interval [fully adjusted hazard ratio (HR), 95% confidence interval (CI), 1.43, 1.02-2.04, P = 0.0393] and higher QTc interval (fully adjusted HR, 95% CI, 5.23, 2.18-12.45, P = 0.0002) were significantly associated with new-onset AF, in particular in men. CONCLUSION Associations of baseline electrocardiographic measures and risk of new-onset AF were mostly U- and N-shaped. Longitudinal electrocardiographic measures of PR and QTc interval were significantly associated with new-onset AF, in particular among men.
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Affiliation(s)
- Sven Geurts
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Martijn J Tilly
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jan A Kors
- Department of Medical Informatics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jaap W Deckers
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Bruno H C Stricker
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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Muylle KM, van Laere S, Pannone L, Coenen S, de Asmundis C, Dupont AG, Cornu P. Added value of patient- and drug-related factors to stratify drug-drug interaction alerts for risk of QT prolongation: Development and validation of a risk prediction model. Br J Clin Pharmacol 2023; 89:1374-1385. [PMID: 36321834 DOI: 10.1111/bcp.15580] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 09/14/2022] [Accepted: 10/30/2022] [Indexed: 11/24/2022] Open
Abstract
AIMS Many clinical decision support systems trigger warning alerts for drug-drug interactions potentially leading to QT prolongation and torsades de pointes (QT-DDIs). Unfortunately, there is overalerting and underalerting because stratification is only based on a fixed QT-DDI severity level. We aimed to improve QT-DDI alerting by developing and validating a risk prediction model considering patient- and drug-related factors. METHODS We fitted 31 predictor candidates to a stepwise linear regression for 1000 bootstrap samples and selected the predictors present in 95% of the 1000 models. A final linear regression model with those variables was fitted on the original development sample (350 QT-DDIs). This model was validated on an external dataset (143 QT-DDIs). Both true QTc and predicted QTc were stratified into three risk levels (low, moderate and high). Stratification of QT-DDIs could be appropriate (predicted risk = true risk), acceptable (one risk level difference) or inappropriate (two risk levels difference). RESULTS The final model included 11 predictors with the three most important being use of antiarrhythmics, age and baseline QTc. Comparing current practice to the prediction model, appropriate stratification increased significantly from 37% to 54% appropriate QT-DDIs (increase of 17.5% on average [95% CI +5.4% to +29.6%], padj = 0.006) and inappropriate stratification decreased significantly from 13% to 1% inappropriate QT-DDIs (decrease of 11.2% on average [95% CI -17.7% to -4.7%], padj ≤ 0.001). CONCLUSION The prediction model including patient- and drug-related factors outperformed QT alerting based on QT-DDI severity alone and therefore is a promising strategy to improve DDI alerting.
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Affiliation(s)
- Katoo M Muylle
- Department of Pharmaceutical and Pharmacological Sciences, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, 1090, Belgium
| | - Sven van Laere
- Department of Public Health, Research Group of Biostatistics and Medical Informatics, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, 1090, Belgium
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Samuel Coenen
- Department of Family Medicine and Population Health, Faculty of Medicine and Health Sciences, Campus Drie Eiken, Gouverneur Kinsbergencentrum, University of Antwerp, Doornstraat 331, Antwerp, 2610, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, European Reference Networks Guard-Heart, Universitair Ziekenhuis Brussel - Vrije Universiteit Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium
| | - Alain G Dupont
- Department of Pharmaceutical and Pharmacological Sciences, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, 1090, Belgium
| | - Pieter Cornu
- Department of Pharmaceutical and Pharmacological Sciences, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, Brussels, 1090, Belgium.,Department of Medical Informatics, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussels, 1090, Belgium
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3
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Andric T, Winckel K, Tanzer TD, Hollingworth S, Smith L, Isoardi K, Tan O, Siskind D. Estimation of cardiac QTc intervals in people prescribed antipsychotics: a comparison of correction factors. Ther Adv Psychopharmacol 2022; 12:20451253221104947. [PMID: 35747226 PMCID: PMC9210090 DOI: 10.1177/20451253221104947] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/16/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A prolonged electrocardiogram (ECG) QT interval is associated with cardiac events and increased mortality. Antipsychotics can prolong the QT interval. The QT interval requires correction (QTc) for heart rate using a formula or QT-nomogram. The QT and QTc can be calculated automatically by the ECG machine or manually; however, machine-measured QT(c) intervals may be inaccurate. OBJECTIVE We aimed to investigate the mean QTc and proportion of prolonged QTc intervals in people taking antipsychotic medicines. METHODS We conducted an observational retrospective chart review and data analysis of all consecutive patients taking antipsychotics, with an ECG record, admitted to the psychiatric unit of a large tertiary hospital in Brisbane, Australia, between 1 January 2017 and 30 January 2019. We investigated the mean QTc of people taking antipsychotics to determine differences using (a) machine versus manual QT interval measurement and (b) QTc correction formulae (Bazett, Fridericia, Framingham, Hodges and Rautaharju) and the QT-nomogram. We also determined the number of people with a prolonged QTc using different methods and compared rates of prolonged QTc with antipsychotic monotherapy and polypharmacy. RESULTS Of 920 included people, the mean (±SD) machine-measured, Bazett-corrected QT interval (recorded from the ECG) was 435 ms (±27), significantly longer (p < 0.001) than the mean manually measured corrected QT intervals with Fridericia 394 ms (±24), Framingham 395 ms (±22), Hodges 398 ms (±22) and Rautaharju 400 ms (±24) formulae. There were significantly more people with a prolonged QTc using machine-measured QT and the Bazett formula (12.0%, 110/920) when compared with manually measured QT and the Fridericia formula (2.2%, 20/920) or QT-nomogram (0.7%, 6/920). Rates of QTc prolongation did not differ between people taking antipsychotic polypharmacy compared with monotherapy. CONCLUSION Machine-measured QTc using the Bazett formula overestimates the QTc interval length and number of people with a prolonged QTc, compared with other formulae and the QT-nomogram. We recommend manually measuring the QT and correcting with the Fridericia formula or QT-nomogram prior to modifying antipsychotic therapies.
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Affiliation(s)
- Teodora Andric
- School of Pharmacy, The University of Queensland, 20 Cornwall Street, Woolloongabba, Brisbane, QLD 4102, Australia
| | - Karl Winckel
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | | | | | - Lesley Smith
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Katherine Isoardi
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Olivier Tan
- School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Newell B, Wirick N, Rigelsky F, Migal K. Implementation of a Pharmacist Monitoring Process for Patients on QTc Prolonging Antibiotics: A Pilot Study. Hosp Pharm 2021; 56:772-776. [PMID: 34732937 DOI: 10.1177/0018578720965429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: The purpose of this pilot study was to implement a pharmacist monitoring process for 4 antimicrobials; azithromycin, ciprofloxacin, levofloxacin, and fluconazole. This pilot study was a patient safety initiative to screen patients and engage providers about therapies at risk for QT prolongation. Methodology: A concurrent chart review was performed at a single center from January 6, to February 22, 2020, of adult patients ≥ 18 years of age initiated on azithromycin, ciprofloxacin, levofloxacin, and fluconazole. Patient risk factors assessed: age, female sex, loop diuretic use, potassium ≤ 3.5 mEq/L, QTc ≥ 450 ms, acute myocardial infarction (MI) or heart failure, 1 or more QTc prolonging agents, and sepsis. The primary endpoint was successful implementation of the QTc monitoring process by pharmacists. Secondary endpoints were the interventions made by pharmacists. Results: From January 6, to February 22, 2020, there were a total of 412 orders for one of the target antimicrobials that resulted in 157 documented pharmacist reviews (38.1%). Of the 157 evaluations, 100 of these represented patients in our high risk group (84 moderate, 16 high risk). Successful implementation was observed through documentation of assessment on all patients with moderate or high risk scores in the 100 person cohort. Conclusion: The pilot study demonstrated a successful implementation of a QTc monitoring process by pharmacists since all patients had documented reviews. Further steps include investigating how to improve efficiency, as well as ways for continued success in monitoring.
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Affiliation(s)
- Benjamin Newell
- PGY1 Clinical Pharmacy Resident at Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
| | - Nathan Wirick
- Infectious Disease Clinical Specialist at Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
| | - Frank Rigelsky
- Cardiology Clinical Specialist at Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
| | - Kimberly Migal
- Clinical Pharmacist at Cleveland Clinic Hillcrest Hospital, Mayfield Heights, OH, USA
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5
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Mangona E, Sandonato E, Brothers TN, Pawasauskas J. Drug-Induced QTc Prolongation: What We Know and Where We Are Going. Curr Drug Saf 2021; 17:100-113. [PMID: 34551700 DOI: 10.2174/1574886316666210922153059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/17/2021] [Accepted: 08/29/2021] [Indexed: 11/22/2022]
Abstract
Drug-induced QTc prolongation is a concerning electrocardiogram (ECG) abnormality. This cardiac disturbance carries a 10% risk of sudden cardiac death due to the malignant arrhythmia, Torsades de Pointes. The Arizona Center for Education and Research on Therapeutics (AzCERT) has classified QTc prolonging therapeutic classes such as antiarrhythmics, antipsychotics, anti-infectives, and others. AzCERT criteria categorizes medications into three risk categories: "known," "possible," and "conditional risk" of QTc prolongation and Torsades de Pointes. The list of QTc prolonging medications continues to expand as new drug classes are approved and studied. Risk factors for QTc prolongation can be delineated into modifiable or non-modifiable. A validated risk scoring tool may be utilized to predict the likelihood of prolongation in patients receiving AzCERT classified medication. The resultant risk score may be applied to a clinical decision support system which offers mitigation strategies. Mitigation strategies including discontinuation of possible offending agents with selection of an alternative agent, assessment of potential drug interactions or dose adjustments through pharmacokinetic and pharmacodynamic monitoring, and initiation of both ECG and electrolyte monitoring are essential to prevent a drug-induced arrhythmia. The challenges presented by the COVID-19 pandemic have led to the development of innovative continuous monitoring technology, increasing protection for both patients and healthcare workers. Early intervention strategies may reduce adverse events and improve clinical outcomes in patients identified to be at risk of QTc prolongation.
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Affiliation(s)
- Erinn Mangona
- Department of Pharmacy Practice, University of Rhode Island, Kingston. United States
| | - Elisa Sandonato
- Department of Pharmacy Practice, University of Rhode Island, Kingston. United States
| | - Todd N Brothers
- Department of Pharmacy Practice, University of Rhode Island, Kingston. United States
| | - Jayne Pawasauskas
- Department of Pharmacy Practice, University of Rhode Island, Kingston. United States
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6
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Then MI, Andrikyan W, Maas R, Fromm MF. The CredibleMeds ® list: Usage of QT interval prolonging drugs in Germany and discordances with prescribing information. Br J Clin Pharmacol 2021; 88:226-236. [PMID: 34156728 DOI: 10.1111/bcp.14951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/02/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS A substantial number of Summaries of Product Characteristics (SmPCs)/Prescribing Information (PI) have warnings or contraindications on QT interval prolongation. The goal of this work was to quantify usage of QT interval prolonging drugs according to the CredibleMeds® database of the German outpatient drug prescription market and to evaluate discrepancies between German SmPCs/US PI and CredibleMeds® . METHODS Drugs listed on CredibleMeds® with known, possible or conditional risk for torsade de pointes were evaluated from 2000 to 2020. The German drug prescription report was used as source for defined daily dose- (DDD-) based prescriptions of the German outpatient drug prescription market of the public health insurance system. German SmPCs and US PI of 253 CredibleMeds® -listed drugs were evaluated for contents regarding QT interval prolongation. RESULTS Of the drugs currently listed on CredibleMeds® , 59.7% (95% confidence interval [CI] 53.5-65.5%) were listed after 2012. Due to newly listed drugs, the proportion of DDDs of CredibleMeds® drugs among all prescriptions increased from 4.6% in 2013 to 21.1% in 2019. DDD-based usage of the CredibleMeds® drugs already listed in 2013 was similar in 2019. Among the drugs with known QT risk according to CredibleMeds® , 7.5% (95% CI 2.6-19.9%) of German SmPCs and 21.1% (95% CI 11.1-36.3%) of US PI had no mention of QT issues whatsoever. CONCLUSION A significant proportion of all drugs prescribed in the outpatient sector is associated with QT risks according to CredibleMeds® . SmPCs and PI should systematically be evaluated for concordance with the widely used CredibleMeds® database to increase medication safety.
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Affiliation(s)
- Melanie I Then
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Wahram Andrikyan
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Renke Maas
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Martin F Fromm
- Institute of Experimental and Clinical Pharmacology and Toxicology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Schjøtt J, Schjøtt P, Assmus J. Analysis of consensus among drug interaction databases with regard to combinations of psychotropics. Basic Clin Pharmacol Toxicol 2019; 126:126-132. [PMID: 31468698 DOI: 10.1111/bcpt.13312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/19/2019] [Indexed: 11/28/2022]
Abstract
Drug interaction databases are important tools in today's clinical decision support. However, there is great variation with regard to classification and presentation of interactions among databases. The present study aimed to investigate consensus among databases with regard to combinations of psychotropics. A database integrated in Norwegian computerised clinical decision support systems and three international recommended subscription databases were compared. Combinations of psychotropics (two or more) prescribed to patients 65 years or older on a single day from three nursing homes in Bergen, Norway 16 years apart (2000 and 2016) were studied. The databases were compared in a common analysis with the following questions: interaction (no, not contraindicated or contraindicated), type (pharmacodynamic or pharmacokinetic), the total number of interactions, and the first ranked interaction among several in each patient. Consensus among the four drug interaction databases was associated with pharmacokinetic interactions involving mainly older psychotropics in the common analysis. The qualities that best characterised interactions with consensus was primarily the evidence including a description of manageability. There was a surprising lack of consensus with regard to contraindicated interactions, even when older psychotropics were involved. Lack of consensus decreased with the number of psychotropics in the combinations. This was mainly because the highest ranked interactions in the respective databases involved different drugs. We propose evidence and manageability as core factors when ranking and presenting interactions in clinical decision support.
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Affiliation(s)
- Jan Schjøtt
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | | | - Jörg Assmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
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8
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Vandenberk B, Siau C, Vandael E, Puype L, Branders J, Dewolf P, Foulon V, Willems R, Verelst S. A prolonged QTc-interval at the emergency department: Should we always be prepared for the worst? J Cardiovasc Electrophysiol 2019; 30:2041-2050. [PMID: 31402492 DOI: 10.1111/jce.14114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION QTc-interval prolongation is associated with ventricular arrhythmias and mortality in a general population. Bazett's correction formula (QTcB) is routinely used despite its overcorrection at high heart rates. Recently, we proposed a patient-specific QT correcting algorithm (QTcA) resulting in improved rate correction and predictive value in a general population. We hypothesize risk stratification at the Emergency Department (ED) could be improved using QTcA. METHODS AND RESULTS A retrospective case-control study including a randomized age- and sex-matched control population was performed at a tertiary care ED. A total of 1930 patients were included in the analysis (63.0% males, age 71.5 ± 15.6 years). Patient characteristics, history, and test results at the time of the electrocardiogram were collected. QTc was dichotomized as prolonged (>450 millisecond for men, >470 millisecond for women) or severely prolonged (>500 millisecond). Implementation of QTcA would reduce the number of patients considered to have a prolonged QTc by 65.2%, for severely prolonged QTc 79.6%. Multivariate regression was performed for in-hospital mortality, cardiovascular endpoints, and hospital admission. Neither a prolonged QTcB (HR 1.04; 95% CI, 0.64-1.69) nor QTcA (HR 0.76; 95% CI, 0.42-1.38) was an independent predictor of in-hospital mortality. A severely prolonged QTcA (OR, 2.54; 95% CI, 1.04-6.23) was an independent predictor of cardiovascular events. Both a prolonged QTcA (OR, 1.52; 95% CI, 1.06-2.18) and a prolonged QTcB (OR, 1.37; 95% CI, 1.05-1.79) were associated with higher hospitalization rates. CONCLUSIONS QTcA reduced the number of patients considered at risk. Neither QTcB nor QTcA were predictors of in-hospital mortality. A severely prolonged QTcA was associated with cardiovascular events.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Caroline Siau
- Emergency Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Eline Vandael
- Department of Pharmaceutical and Pharmacological Sciences, University of Leuven, Belgium
| | - Laura Puype
- Emergency Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Jordi Branders
- Emergency Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Philippe Dewolf
- Emergency Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Veerle Foulon
- Department of Pharmaceutical and Pharmacological Sciences, University of Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Sandra Verelst
- Emergency Medicine, University Hospital of Leuven, Leuven, Belgium
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9
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A retrospective comparison of inappropriate prescribing of psychotropics in three Norwegian nursing homes in 2000 and 2016 with prescribing quality indicators. BMC Med Inform Decis Mak 2019; 19:102. [PMID: 31142298 PMCID: PMC6542081 DOI: 10.1186/s12911-019-0821-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/14/2019] [Indexed: 11/28/2022] Open
Abstract
Background Inappropriate prescribing of psychotropics is a persistent and prevalent problem in nursing homes. The present study compared inappropriate prescribing of psychotropics in nursing homes 16 years apart with prescribing quality indicators. The purpose was to identify any change in inappropriate prescribing of relevance for medical informatics. Methods Three Norwegian nursing homes were audited in 2000 and 2016 with regard to prescribing quality. Psychotropics among 386 patients in 2000, and 416 patients in 2016, included combinations of antidepressants, antipsychotics, anxiolytics-hypnotics, and antiepileptics. Prescribing quality indicators included psychotropic polypharmacy (defined as concurrent use of three or more psychotropics) and potential inappropriate psychotropic substances or combinations. Furthermore, potential clinically relevant psychotropic interactions were classified as pharmacodynamic or pharmacokinetic using an interaction database. The first ranked (most important) interaction in each patient was selected with the following importance of categories in the database; recommended action > documentation > severity. Three levels (from low to high) within each category were used for ranking. Results From 2000 to 2016, psychotropic polypharmacy increased from 6.2 to 29.6%, potential inappropriate psychotropic substances was reduced from 17.9 to 11.3% and potential inappropriate psychotropic combinations increased from 7.8 to 27.9%. Changes in polypharmacy and combinations were predominantly associated with prescribing of anxiolytics-hypnotics. Sixty-three patients (16.3%) had psychotropic interactions in 2000 increasing to 146 patients (35.1%) in 2016. The increase in interactions was associated with prescribing of antidepressants. First ranked interactions, more than 60% of all interactions in both years, were increasingly pharmacodynamic, from 69.9 to 91.0%. Interactions in 2016 were associated with a lower level of recommended action and documentation, but not severity compared to 2000. The inappropriate prescribing of antipsychotics and antiepileptics was reduced in 2016 compared to 2000. Conclusions Using prescribing quality indicators we observed the importance of antidepressants and anxiolytics-hypnotics for inappropriate prescribing in 2016 while the role of antipsychotics and antiepileptics were reduced compared to 2000. A change to mainly pharmacodynamic interactions that lack good documentation was also observed. The present findings can be used for medical informatics-based approaches to address specific problems with prescribing, and prescribing quality indicators, in Norwegian nursing homes.
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10
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Turner JR, Rodriguez I, Mantovani E, Gintant G, Kowey PR, Klotzbaugh RJ, Prasad K, Sager PT, Stockbridge N, Strnadova C. Drug-induced Proarrhythmia and Torsade de Pointes: A Primer for Students and Practitioners of Medicine and Pharmacy. J Clin Pharmacol 2018; 58:997-1012. [PMID: 29672845 DOI: 10.1002/jcph.1129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
Multiple marketing withdrawals due to proarrhythmic concerns occurred in the United States, Canada, and the United Kingdom in the late 1980s to early 2000s. This primer reviews the clinical implications of a drug's identified proarrhythmic liability, the issues associated with these safety-related withdrawals, and the actions taken by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and by regulatory agencies in terms of changing drug development practices and introducing new nonclinical and clinical tests to asses proarrhythmic liability. ICH Guidelines S7B and E14 were released in 2005. Since then, they have been adopted by many regional regulatory authorities and have guided nonclinical and clinical proarrhythmic cardiac safety assessments during drug development. While this regulatory paradigm has been successful in preventing drugs with unanticipated potential for inducing the rare but potentially fatal polymorphic ventricular arrhythmia torsade de pointes from entering the market, it has led to the termination of drug development programs for other potentially useful medicines because of isolated results from studies with limited predictive value. Research efforts are now exploring alternative approaches to better predict potential proarrhythmic liabilities. For example, in the domain of human electrocardiographic assessments, concentration-response modeling conducted during phase 1 clinical development has recently become an accepted alternate primary methodology to the ICH E14 "thorough QT/QTc" study for defining a drug's corrected QT interval prolongation liability under certain conditions. When a drug's therapeutic benefit is considered important at a public health level but there is also an identified proarrhythmic liability that may result from administration of the single drug in certain individuals and/or drug-drug interactions, marketing approval will be accompanied by appropriate directions in the drug's prescribing information. Health-care professionals in the fields of medicine and pharmacy need to consider the prescribing information in conjunction with individual patients' clinical characteristics and concomitant medications when prescribing and dispensing such drugs.
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Affiliation(s)
- J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Emily Mantovani
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA, USA
| | - Ralph J Klotzbaugh
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Philip T Sager
- Sager Consulting and Stanford University, San Francisco, CA, USA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Colette Strnadova
- Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada
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Meid AD, Bighelli I, Mächler S, Mikus G, Carrà G, Castellazzi M, Lucii C, Martinotti G, Nosè M, Ostuzzi G, Barbui C, Haefeli WE. Combinations of QTc-prolonging drugs: towards disentangling pharmacokinetic and pharmacodynamic effects in their potentially additive nature. Ther Adv Psychopharmacol 2017; 7:251-264. [PMID: 29201344 PMCID: PMC5676495 DOI: 10.1177/2045125317721662] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/08/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Whether arrhythmia risks will increase if drugs with electrocardiographic (ECG) QT-prolonging properties are combined is generally supposed but not well studied. Based on available evidence, the Arizona Center for Education and Research on Therapeutics (AZCERT) classification defines the risk of QT prolongation for exposure to single drugs. We aimed to investigate how combining AZCERT drug categories impacts QT duration and how relative drug exposure affects the extent of pharmacodynamic drug-drug interactions. METHODS In a cohort of 2558 psychiatric inpatients and outpatients, we modeled whether AZCERT class and number of coprescribed QT-prolonging drugs correlates with observed rate-corrected QT duration (QTc) while also considering age, sex, inpatient status, and other QTc-prolonging risk factors. We concurrently considered administered drug doses and pharmacokinetic interactions modulating drug clearance to calculate individual weights of relative exposure with AZCERT drugs. Because QTc duration is concentration-dependent, we estimated individual drug exposure with these drugs and included this information as weights in weighted regression analyses. RESULTS Drugs attributing a 'known' risk for clinical consequences were associated with the largest QTc prolongations. However, the presence of at least two versus one QTc-prolonging drug yielded nonsignificant prolongations [exposure-weighted parameter estimates with 95% confidence intervals for 'known' risk drugs + 0.93 ms (-8.88;10.75)]. Estimates for the 'conditional' risk class increased upon refinement with relative drug exposure and co-administration of a 'known' risk drug as a further risk factor. CONCLUSIONS These observations indicate that indiscriminate combinations of QTc-prolonging drugs do not necessarily result in additive QTc prolongation and suggest that QT prolongation caused by drug combinations strongly depends on the nature of the combination partners and individual drug exposure. Concurrently, it stresses the value of the AZCERT classification also for the risk prediction of combination therapies with QT-prolonging drugs.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Irene Bighelli
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Sarah Mächler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Giuseppe Carrà
- Division of Psychiatry, University College of London, UK Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Mariasole Castellazzi
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Claudio Lucii
- Department of Mental Health, Company Health-ULS7-Siena, Siena, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, University of Chieti, Chieti, Italy
| | - Michela Nosè
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Corrado Barbui
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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12
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Ikram MA, Brusselle GGO, Murad SD, van Duijn CM, Franco OH, Goedegebure A, Klaver CCW, Nijsten TEC, Peeters RP, Stricker BH, Tiemeier H, Uitterlinden AG, Vernooij MW, Hofman A. The Rotterdam Study: 2018 update on objectives, design and main results. Eur J Epidemiol 2017; 32:807-850. [PMID: 29064009 PMCID: PMC5662692 DOI: 10.1007/s10654-017-0321-4] [Citation(s) in RCA: 338] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/06/2017] [Indexed: 02/07/2023]
Abstract
The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1500 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.
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Affiliation(s)
- M Arfan Ikram
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - Guy G O Brusselle
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Respiratory Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sarwa Darwish Murad
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Gastro-Enterology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Cornelia M van Duijn
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - André Goedegebure
- Department of Otolaryngology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Caroline C W Klaver
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tamar E C Nijsten
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robin P Peeters
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Psychiatry, Erasmus Medical Center, Rotterdam, The Netherlands
| | - André G Uitterlinden
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Meike W Vernooij
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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13
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Riad FS, Davis AM, Moranville MP, Beshai JF. Drug-Induced QTc Prolongation. Am J Cardiol 2017; 119:280-283. [PMID: 28126150 DOI: 10.1016/j.amjcard.2016.09.041] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 12/01/2022]
Abstract
QTc prolongation has a high prevalence of and is associated with increased all-cause mortality. Nonetheless, QTc prolonging medications are often used during patient hospitalizations despite baseline prolongation and QTc changes. Data regarding the real-world relative risk of QTc prolongation in the hospital setting are lacking. In this study, we sought to quantify the degree and relative risk of QTc prolongation in patients receiving Arizona Center for Education and Research on Therapeutics (AzCERT) "known risk" medications. Electronic medical records of patients receiving an electrocardiogram at the University of Chicago, admitted in 2011 were analyzed. The longest QTc interval and medications administered within the preceding 24 hours were evaluated. Medications were classified into 4 categories according to the AzCERT classification. Of a total of 14,804 patients, mean QTc intervals were 485 versus 454 ms for men and 469 versus 453 ms for women receiving known risk medications compared with those receiving no risk medications (p <0.001). The rate of QTc prolongation was 71% versus 48% for men and 50% versus 34% for women, respectively. There was no significant increase in QTc prolongation for patients administered multiple QT-relevant medications or for those administered only conditional or possible risk medications. In conclusion, the prevalence of significant QTc prolongation in patients receiving AzCERT known risk medications is high. This may be a reflection of inadequate awareness or overall quality inadequacies.
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Affiliation(s)
- Fady S Riad
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew M Davis
- Department of Internal Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Michael P Moranville
- Department of Internal Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - John F Beshai
- Department of Cardiovascular Diseases, Mayo Clinic Hospital, Phoenix, Arizona.
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14
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Investigating the Additive Interaction of QT-Prolonging Drugs in Older People Using Claims Data. Drug Saf 2016; 40:133-144. [DOI: 10.1007/s40264-016-0477-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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