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Ouchi R, Nagao M, Suzuki S, Yamagata T, Chiba M, Kurata N, Usui K, Watanabe T, Koyama K, Okada K. A case with a trend of QT interval prolongation due to the introduction of methadone to a pancreatic cancer patient on levofloxacin. J Pharm Health Care Sci 2024; 10:4. [PMID: 38167143 PMCID: PMC10763223 DOI: 10.1186/s40780-023-00322-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/24/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND As methadone can prevent the development of opioid resistance, it has application in alleviating cancer-related pain that proves challenging to manage with other opioids. QT interval prolongation is a serious side effect of methadone treatment, with some reported deaths. In particular, owing to the increased risk of QT interval prolongation, caution should be exercised when using it in combination with drugs that also prolong the QT interval. CASE PRESENTATION This study presents a case in which methadone was introduced to a patient (a man in his 60s) already using levofloxacin, which could prolong the QT interval-a serious side effect of methadone treatment-and whose QTc value tended to increase. Given that levofloxacin can increase the risk of QT interval prolongation, we considered switching to other antibacterial agents before introducing methadone. However, because the neurosurgeon judged that controlling a brain abscess was a priority, low-dose methadone was introduced with continuing levofloxacin. Owing to the risks, we performed frequent electrocardiograms. Consequently, we responded before the QTc increased enough to meet the diagnostic criteria for QT interval prolongation. Consequently, we prevented the occurrence of drug-induced long QT syndrome. CONCLUSIONS When considering the use of methadone for intractable cancer pain, it is important to eliminate possible risk factors for QT interval prolongation. However, as it may be difficult to discontinue concomitant drugs owing to comorbidities, there could be cases in which the risk of QT interval prolongation could increase, even with the introduction of low-dose methadone. In such cases, frequent monitoring, even with simple measurements such as those used in this case, is likely to prevent progression to more serious conditions.
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Affiliation(s)
- Ryusuke Ouchi
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan.
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan.
| | - Munenori Nagao
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Shinju Suzuki
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Toshihiro Yamagata
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Mie Chiba
- Department of Nursing, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Naoko Kurata
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kensuke Usui
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Takashi Watanabe
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kaori Koyama
- Department of Supportive Medicine and Care for Cancer, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Kouji Okada
- Division of Clinical Pharmaceutics and Pharmacy Practice, Faculty of Pharmaceutical Sciences, Tohoku Medical and Pharmaceutical University, Sendai, Miyagi, Japan
- Department of Pharmacy, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
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Gotta V, Bachmann S, Pfister M, Donner B. Characterizing Associations of QTc Interval with Nocturnal Glycemic Control in Children with Type 1 Diabetes. J Clin Pharmacol 2023; 63:1147-1155. [PMID: 37409493 DOI: 10.1002/jcph.2301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023]
Abstract
An association between QT prolongation (Bazett's corrected QT interval, QTcB) of 7 milliseconds and nocturnal hypoglycemia, compared with euglycemia, has been observed in children with type 1 diabetes (T1D). The objective of this pharmacometric analysis was to understand this association and other sources of QTc variability quantitatively. Data originate from a prospective observational study (25 cardiac healthy children with T1D, aged 8.1-17.6 years) with continuous subcutaneous glucose and electrocardiogram measurements for 5 consecutive nights. Mixed-effect modeling was used to compare QTcB with individual heart-rate correction (QTcI). Covariate models accounting for circadian variation, age, and sex were evaluated, followed by an investigation of glucose-QTc relationships (with univariable and combined adjusted analysis). Factors potentially modifying sensitivity to QTc lengthening were explored. Random inter-individual variability was reduced in the QTcI versus QTcB model (±12.6 vs 14.1 milliseconds), and was further reduced in the adjusted covariate model (±9.7 milliseconds), accounting for the significantly (P < .01) shortened QTc in adolescent boys (-14.6 milliseconds), circadian variation (amplitude, 19.2 milliseconds; shift, 2.9 hours), and linear glucose-QTc relationship (delay rate, 0.56-h ; slope, 0.76 milliseconds [95%CI 0.67- 0.85 milliseconds] per 1 mmol/L decrease in glucose). Differing sensitivity was suggested to depend upon hemoglobin A1c (HbA1c), T1D duration, and time spent in nocturnal hypoglycemia. In conclusion, a clinically mild association of QTc prolongation with nocturnal hypoglycemia was confirmed and quantified in this pharmacometric analysis, and the longest QTc interval was around 03:00 a.m. The characterized delayed association with glucose highlights the relevance of both the extent and the duration of hypoglycemia. Further clinical studies are warranted to investigate whether these factors contribute to increased risk of hypoglycemia-associated cardiac arrhythmia in children with T1D.
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Affiliation(s)
- Verena Gotta
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
- Pediatric Clinical Pharmacy, University of Basel Children's Hospital, Basel, Switzerland
| | - Sara Bachmann
- Pediatric Endocrinology and Diabetology, University of Basel Children's Hospital, Basel, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Birgit Donner
- Pediatric Cardiology, University of Basel Children's Hospital, Basel, Switzerland
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Poole J, Ray D. The Role of Circadian Clock Genes in Critical Illness: The Potential Role of Translational Clock Gene Therapies for Targeting Inflammation, Mitochondrial Function, and Muscle Mass in Intensive Care. J Biol Rhythms 2022; 37:385-402. [PMID: 35880253 PMCID: PMC9326790 DOI: 10.1177/07487304221092727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The Earth's 24-h planetary rotation, with predictable light and heat cycles, has driven profound evolutionary adaptation, with prominent impacts on physiological mechanisms important for surviving critical illness. Pathways of interest include inflammation, mitochondrial function, energy metabolism, hypoxic signaling, apoptosis, and defenses against reactive oxygen species. Regulation of these by the cellular circadian clock (BMAL-1 and its network) has an important influence on pulmonary inflammation; ventilator-associated lung injury; septic shock; brain injury, including vasospasm; and overall mortality in both animals and humans. Whether it is cytokines, the inflammasome, or mitochondrial biogenesis, circadian medicine represents exciting opportunities for translational therapy in intensive care, which is currently lacking. Circadian medicine also represents a link to metabolic determinants of outcome, such as diabetes and cardiovascular disease. More than ever, we are appreciating the problem of circadian desynchrony in intensive care. This review explores the rationale and evidence for the importance of the circadian clock in surviving critical illness.
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Affiliation(s)
- Joanna Poole
- Anaesthetics and Critical Care, Gloucestershire Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - David Ray
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
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4
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Thomas L, Birangal SR, Ray R, Sekhar Miraj S, Munisamy M, Varma M, S V CS, Banerjee M, Shenoy GG, Rao M. Prediction of potential drug interactions between repurposed COVID-19 and antitubercular drugs: an integrational approach of drug information software and computational techniques data. Ther Adv Drug Saf 2021; 12:20420986211041277. [PMID: 34471515 PMCID: PMC8404633 DOI: 10.1177/20420986211041277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 07/24/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction: Tuberculosis is a major respiratory disease globally with a higher prevalence in Asian and African countries than rest of the world. With a larger population of tuberculosis patients anticipated to be co-infected with COVID-19 infection, an ongoing pandemic, identifying, preventing and managing drug–drug interactions is inevitable for maximizing patient benefits for the current repurposed COVID-19 and antitubercular drugs. Methods: We assessed the potential drug–drug interactions between repurposed COVID-19 drugs and antitubercular drugs using the drug interaction checker of IBM Micromedex®. Extensive computational studies were performed at a molecular level to validate and understand the drug–drug interactions found from the Micromedex drug interaction checker database at a molecular level. The integrated knowledge derived from Micromedex and computational data was collated and curated for predicting potential drug–drug interactions between repurposed COVID-19 and antitubercular drugs. Results: A total of 91 potential drug–drug interactions along with their severity and level of documentation were identified from Micromedex between repurposed COVID-19 drugs and antitubercular drugs. We identified 47 pharmacodynamic, 42 pharmacokinetic and 2 unknown DDIs. The majority of our molecular modelling results were in line with drug–drug interaction data obtained from the drug information software. QT prolongation was identified as the most common type of pharmacodynamic drug–drug interaction, whereas drug–drug interactions associated with cytochrome P450 3A4 (CYP3A4) and P-glycoprotein (P-gp) inhibition and induction were identified as the frequent pharmacokinetic drug–drug interactions. The results suggest antitubercular drugs, particularly rifampin and second-line agents, warrant high alert and monitoring while prescribing with the repurposed COVID-19 drugs. Conclusion: Predicting these potential drug–drug interactions, particularly related to CYP3A4, P-gp and the human Ether-à-go-go-Related Gene proteins, could be used in clinical settings for screening and management of drug–drug interactions for delivering safer chemotherapeutic tuberculosis and COVID-19 care. The current study provides an initial propulsion for further well-designed pharmacokinetic-pharmacodynamic-based drug–drug interaction studies. Plain Language Summary
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Affiliation(s)
- Levin Thomas
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Sumit Raosaheb Birangal
- Department of Pharmaceutical Chemistry, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Rajdeep Ray
- Department of Pharmaceutical Chemistry, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Sonal Sekhar Miraj
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Murali Munisamy
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Muralidhar Varma
- Department of Infectious Diseases, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | | | - Mithu Banerjee
- Department of Biochemistry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Gautham G Shenoy
- Department of Pharmaceutical Chemistry, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, India
| | - Mahadev Rao
- Professor and Head, Department of Pharmacy Practice, Coordinator, Centre for Translational Research, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, Karnataka, India
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5
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Kim Y, Kim A, Chung JY. Population pharmacokinetic/pharmacodynamic modeling of delayed effect of escitalopram-induced QT prolongation. J Affect Disord 2021; 285:120-126. [PMID: 33647579 DOI: 10.1016/j.jad.2021.02.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND A thorough QT study identified that escitalopram-induced QT prolongation was delayed. This study thus aimed to develop a population pharmacokinetic (PK)/pharmacodynamic (PD) model to characterize the relationship between escitalopram concentrations and the delayed effect on QT prolongation. METHODS The data of completed subjects who had placebo (n=36) and a single dose of 20 mg escitalopram (n=33) from a previous thorough QT study were used. Population PK/PD analysis was performed by nonlinear mixed-effects modeling. A escitalopram concentration-drug effect model was developed with estimated individual PK and baseline QT parameters. To explain the relationship between escitalopram concentrations and QT prolongation delay, an effect compartment model was utilized. RESULTS A two-compartment model with first-order absorption and lag time and first-order elimination adequately described the PK of escitalopram. The circadian rhythm of baseline QT interval was best explained by two harmonic cosine functions. A linear model properly characterized escitalopram-induced QT prolongation. The average estimated maximal QT prolongation was 5.4 ms (range: 1.9-7.6 ms). The equilibrium half-life of delayed QT prolongation was 1.9 h. The drug effect of QTc change compared with that at baseline remained relatively constant from 1.3 to 3.5 ms over 24 h, and the maximum QTc change occurred with a 3-h delay after the time to the maximum plasma concentration. LIMITATIONS We did not include genetic polymorphisms, such as CYP2C19, as potential covariates owing to limited information. CONCLUSIONS These results may provide useful information on when to monitor electrocardiogram in patients who require intensive care after drug administration.
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Affiliation(s)
- Yun Kim
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Anhye Kim
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Jae-Yong Chung
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Bundang Hospital, Seongnam, Republic of Korea.
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6
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Wiśniowska B, Bielecka ZM, Polak S. How circadian variability of the heart rate and plasma electrolytes concentration influence the cardiac electrophysiology - model-based case study. J Pharmacokinet Pharmacodyn 2021; 48:387-399. [PMID: 33666801 PMCID: PMC8144092 DOI: 10.1007/s10928-021-09744-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/24/2021] [Indexed: 11/24/2022]
Abstract
The circadian rhythm of cardiac electrophysiology is dependent on many physiological and biochemical factors. Provided, that models describing the circadian patterns of cardiac activity and/or electrophysiology which have been verified to the acceptable level, modeling and simulation can give answers to many of heart chronotherapy questions. The aim of the study was to assess the performance of the circadian models implemented in Cardiac Safety Simulator v 2.2 (Certara, Sheffield, UK) (CSS), as well as investigate the influence ofcircadian rhythms on the simulation results in terms of cardiac safety. The simulations which were run in CSS accounted for inter-individual and intra-individual variability. Firstly, the diurnal variations in QT interval length in a healthy population were simulated accounting for heart rate (HR) circadian changes alone, or with concomitant diurnal variations of plasma ion concentrations. Next, tolterodine was chosen as an exemplary drug for PKPD modelling exercise to assess the role of circadian rhythmicity in the prediction of drug effects on QT interval. The results of the simulations were in line with clinical observations, what can serve as a verification of the circadian models implemented in CSS. Moreover, the results have suggested that the circadian variability of the electrolytes balance is the main factor influencing QT circadian pattern. The fluctuation of ion concentration increases the intra-subject variability of predicted drug-triggered QT corrected for HR (QTc) prolongation effect and, in case of modest drug effect on QTc interval length, allows to capture this effect.
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Affiliation(s)
- Barbara Wiśniowska
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland.
| | - Zofia M Bielecka
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
| | - Sebastian Polak
- Faculty of Pharmacy, Jagiellonian University Medical College, Medyczna 9 Street, 30-688, Kraków, Poland
- Simcyp Division, Certara UK Limited, Level 2-Acero, 1 Concourse Way, Sheffield, S1 2BJ, UK
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7
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The power of modelling pulsatile profiles. J Pharmacokinet Pharmacodyn 2021; 48:439-444. [PMID: 33660229 PMCID: PMC8144129 DOI: 10.1007/s10928-021-09743-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/12/2021] [Indexed: 11/30/2022]
Abstract
The quantitative description of individual observations in non-linear mixed effects models over time is complicated when the studied biomarker has a pulsatile release (e.g. insulin, growth hormone, luteinizing hormone). Unfortunately, standard non-linear mixed effects population pharmacodynamic models such as turnover and precursor response models (with or without a cosinor component) are unable to quantify these complex secretion profiles over time. In this study, the statistical power of standard statistical methodology such as 6 post-dose measurements or the area under the curve from 0 to 12 h post-dose on simulated dense concentration–time profiles of growth hormone was compared to a deconvolution-analysis-informed modelling approach in different simulated scenarios. The statistical power of the deconvolution-analysis-informed approach was determined with a Monte-Carlo Mapped Power analysis. Due to the high level of intra- and inter-individual variability in growth hormone concentrations over time, regardless of the simulated effect size, only the deconvolution-analysis informed approach reached a statistical power of more than 80% with a sample size of less than 200 subjects per cohort. Furthermore, the use of this deconvolution-analysis-informed modelling approach improved the description of the observations on an individual level and enabled the quantification of a drug effect to be used for subsequent clinical trial simulations.
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Pooled Multicenter Analysis of Cardiovascular Safety and Population Pharmacokinetic Properties of Piperaquine in African Patients with Uncomplicated Falciparum Malaria. Antimicrob Agents Chemother 2020; 64:AAC.01848-19. [PMID: 32312783 PMCID: PMC7318010 DOI: 10.1128/aac.01848-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/08/2020] [Indexed: 01/08/2023] Open
Abstract
Dihydroartemisinin-piperaquine has shown excellent efficacy and tolerability in malaria treatment. However, concerns have been raised of potentially harmful cardiotoxic effects associated with piperaquine. The population pharmacokinetics and cardiac effects of piperaquine were evaluated in 1,000 patients, mostly children enrolled in a multicenter trial from 10 sites in Africa. A linear relationship described the QTc-prolonging effect of piperaquine, estimating a 5.90-ms mean QTc prolongation per 100-ng/ml increase in piperaquine concentration. Dihydroartemisinin-piperaquine has shown excellent efficacy and tolerability in malaria treatment. However, concerns have been raised of potentially harmful cardiotoxic effects associated with piperaquine. The population pharmacokinetics and cardiac effects of piperaquine were evaluated in 1,000 patients, mostly children enrolled in a multicenter trial from 10 sites in Africa. A linear relationship described the QTc-prolonging effect of piperaquine, estimating a 5.90-ms mean QTc prolongation per 100-ng/ml increase in piperaquine concentration. The effect of piperaquine on absolute QTc interval estimated a mean maximum QTc interval of 456 ms (50% effective concentration of 209 ng/ml). Simulations from the pharmacokinetic-pharmacodynamic models predicted 1.98 to 2.46% risk of having QTc prolongation of >60 ms in all treatment settings. Although piperaquine administration resulted in QTc prolongation, no cardiovascular adverse events were found in these patients. Thus, the use of dihydroartemisinin-piperaquine should not be limited by this concern. (This study has been registered at ClinicalTrials.gov under identifier NCT02199951.)
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Shojaei L, Ruzbahani M, Khajavian S, Shahsavari S, Tamasoki N, Rajabian M, Moradi F, Shahbazi F. Analysis of QTc Interval during Levofloxacin Prescription in Cardiac Patients with Pneumonia. Curr Drug Saf 2020; 15:111-116. [DOI: 10.2174/1574886315666200213112702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/22/2022]
Abstract
Background:
Medications induced QT prolongation could cause ventricular arrhythmia,
torsade de pointes, and death.
Objective:
The purpose of this study was to evaluate the magnitude of QTc interval prolongation as
a result of levofloxacin treatment in patients admitted to cardiology wards.
Methods:
This was a cross-sectional study conducted in the coronary care units and general wards
of the Imam Ali Heart Hospital in Kermanshah, Iran. The QTc interval was determined at baseline
and after 72 hours of levofloxacin administration. Changes in the QTc interval before and after the
levofloxacin prescription were determined.
Results:
The mean age of recruited patients was 63.26 ± 14.56 years. More than 80% of patients
who received levofloxacin experienced QTc prolongation. The QTc interval was increased significantly
after levofloxacin administration (15.68 ± 26.84 milliseconds) (p<0.001). These changes remained
significant after excluding medications with QTc lengthening properties (p<0.001).
Conclusion:
Treatment with levofloxacin in patients with heart disease increases the risk of QT
prolongation.
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Affiliation(s)
- Lida Shojaei
- Pharmaceutical Sciences Research Center, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Ruzbahani
- Imam Ali cardiovascular Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shiva Khajavian
- Imam Ali cardiovascular Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Soodeh Shahsavari
- School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Negin Tamasoki
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mina Rajabian
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Farzaneh Moradi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Foroud Shahbazi
- Pharmaceutical Sciences Research Center, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Measurement and Management of QT Interval Prolongation for General Physicians. J Gen Intern Med 2020; 35:865-873. [PMID: 31654357 PMCID: PMC7080915 DOI: 10.1007/s11606-019-05477-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/24/2019] [Accepted: 10/02/2019] [Indexed: 02/08/2023]
Abstract
One of the more challenging aspects of ECG interpretation is measurement and interpretation of the QT interval. This interval represents the time taken for the ventricles to completely repolarise after activation. Abnormal prolongation of the QT interval can lead to torsades de pointes, a form of potentially life-threatening polymorphic ventricular tachycardia (VT). Detection of a prolonged QT interval is essential as this can be a reversible problem, particularly in the context of the use of a variety of commonly prescribed medications in the hospital setting. Automated ECG printouts cannot be relied upon to diagnose QT interval prolongation; thus, the onus is on the clinician to identify it. This is a difficult task, as the normal QT interval is typically measured relative to the heart rate. Therefore, the QT interval often requires "correction" for the current heart rate, in order to correctly stratify the risk of torsades de pointes. A wealth of correctional formulae have been derived, but none has proven superior. We present an approach to the ECG in this context, and a step-by-step guide to manually measuring and correcting the QT interval, and an approach to management in common hospital-based clinical scenarios.
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11
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Huh Y, Chen D, Riley S, Chang C, Nicholas T. Evaluation of QT Liability for PF-05251749 in the Presence of Potential Circadian Rhythm Modification. CPT Pharmacometrics Syst Pharmacol 2020; 9:60-69. [PMID: 31749321 PMCID: PMC6966184 DOI: 10.1002/psp4.12483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 11/04/2019] [Indexed: 12/16/2022] Open
Abstract
PF-05251749 is a dual inhibitor of casein kinase 1 δ/ε, key regulators of circadian rhythm. As a result of its mechanism of action, PF-05251749 may also change the heart rate corrected QT (QTc) circadian rhythm, which may confound detection of drug-induced QTc prolongation. In this analysis, a nonlinear mixed effect model including a multioscillator function was developed in addition to fitting the prespecified linear mixed effect concentration-QTc model, to identify QTc liability of PF-05251749 in the presence of potential circadian rhythm change. The modeling results suggested lack of clinically meaningful QTc prolongation (upper bound of 90% confidence interval for ∆∆QTc < 10 milliseconds) and that the drug-induced QTc circadian rhythm change was not present. However, simulation results indicated that inference of drug-induced QTc prolongation could be misleading if the drug effect on QTc circadian rhythm is not properly addressed. The modeling and simulation results suggest that prespecification of the concentration-QTc model should be reconsidered for drugs with circadian rhythm modulation potential.
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Affiliation(s)
- Yeamin Huh
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
| | - Danny Chen
- Early Clinical DevelopmentPfizer IncCambridgeMassachusettsUSA
| | - Steve Riley
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
| | - Cheng Chang
- Global Product DevelopmentPfizer IncGrotonConnecticutUSA
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Kervezee L, Kosmadopoulos A, Boivin DB. Metabolic and cardiovascular consequences of shift work: The role of circadian disruption and sleep disturbances. Eur J Neurosci 2018; 51:396-412. [PMID: 30357975 DOI: 10.1111/ejn.14216] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/25/2018] [Accepted: 10/11/2018] [Indexed: 12/26/2022]
Abstract
Shift work, defined as work occurring outside typical daytime working hours, is associated with an increased risk of various non-communicable diseases, including diabetes and cardiovascular disease. Disruption of the internal circadian timing system and concomitant sleep disturbances is thought to play a critical role in the development of these health problems. Indeed, controlled laboratory studies have shown that short-term circadian misalignment and sleep restriction independently impair physiological processes, including insulin sensitivity, energy expenditure, immune function, blood pressure and cardiac modulation by the autonomous nervous system. If allowed to persist, these acute effects may lead to the development of cardiometabolic diseases in the long term. Here, we discuss the evidence for the contributions of circadian disruption and associated sleep disturbances to the risk of metabolic and cardiovascular health problems in shift workers. Improving the understanding of the physiological mechanisms affected by circadian misalignment and sleep disturbance will contribute to the development and implementation of strategies that prevent or mitigate the cardiometabolic impact of shift work.
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Affiliation(s)
- Laura Kervezee
- Centre for Study and Treatment of Circadian Rhythms, Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada
| | - Anastasi Kosmadopoulos
- Centre for Study and Treatment of Circadian Rhythms, Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada
| | - Diane B Boivin
- Centre for Study and Treatment of Circadian Rhythms, Department of Psychiatry, Douglas Mental Health University Institute, McGill University, Montreal, Quebec, Canada
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Kervezee L, Burggraaf J. Response to "Time of the Day and Magnitude of the Effect of a Drug on the QTc Interval". CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2017; 6:284. [PMID: 28194906 PMCID: PMC5445228 DOI: 10.1002/psp4.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/09/2017] [Indexed: 11/06/2022]
Affiliation(s)
- L Kervezee
- Laboratory for Neurophysiology, Department of Molecular Cell Biology, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Human Drug Research, Leiden, The Netherlands
| | - J Burggraaf
- Centre for Human Drug Research, Leiden, The Netherlands
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Täubel J, Fernandes S, Ferber G. Time of the Day and Magnitude of the Effect of a Drug on the QTc Interval. CPT Pharmacometrics Syst Pharmacol 2017; 6:283. [PMID: 28142221 PMCID: PMC5445225 DOI: 10.1002/psp4.12179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/05/2016] [Accepted: 01/18/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- J Täubel
- Richmond Pharmacology Ltd, London, UK
| | | | - G Ferber
- Statistik Georg Ferber GmbH, Riehen, Switzerland
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15
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Garnett C, Johannesen L. Commentary on: "Levofloxacin-Induced QTc Prolongation Depends on the Time of Drug Administration". CPT Pharmacometrics Syst Pharmacol 2016; 5:452-4. [PMID: 27647678 PMCID: PMC5036419 DOI: 10.1002/psp4.12128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/22/2016] [Indexed: 01/03/2023] Open
Abstract
Circadian variations in the corrected QT (QTc) interval have been documented in clinical trials. Animal models show circadian variations in expression of the cardiac ion channels that are necessary to maintain the heart's electrophysiological properties. Can these diurnal rhythms in QTc affect the ability of a drug to delay cardiac repolarization?
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Affiliation(s)
- C Garnett
- Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA.
| | - L Johannesen
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland, USA
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