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Pilunthanakul T, Ting MQJ, Lee J, Gupta B. The impact of adjunctive aripiprazole on QT interval: A 12-week open label study in patients on olanzapine, clozapine or risperidone. Hum Psychopharmacol 2023; 38:e2863. [PMID: 36810742 DOI: 10.1002/hup.2863] [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: 10/03/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To evaluate the effect of adjunct aripiprazole on QT of patients clinically stabilized on atypical antipsychotics. METHODS The dataset was from an open-label 12-week prospective trial that evaluated adjunctive use of 5 mg/day of aripiprazole on metabolic profile in patients with schizophrenia, or schizoaffective disorder stabilized on olanzapine, clozapine, or risperidone. Bazett-corrected QT (QTc) was manually calculated from ECGs measured at baseline (before aripiprazole) and week 12, by two doctors blind to the diagnosis and atypical antipsychotic. The change in QTc (∆QTc: baseline QTc-week 12 QTc) and the number of participants in normal, borderline, prolonged, and pathological groups after 12 weeks were analyzed. RESULTS Fifty-five participants, mean age of 39.3 (SD 8.2) years, were analyzed. The ∆QTc after 12 weeks was 5.9 ms (p = 0.143) for the whole sample; 16.4 ms (p = 0.762), 3.7 ms (p = 0.480) and 0.5 ms (p = 0.449), for the clozapine, risperidone and olanzapine group, respectively. There was no significant statistical difference comparing the change in QTc overall, and between atypical antipsychotic groups, when evaluating from baseline to endpoint. However, stratifying the sample based on sex-dependent QTc cut-offs showed a 45% decrease in abnormal QTc readings (p = 0.049) after aripiprazole initiation; 20 subjects had abnormal QTc at baseline, while only 11 subjects had abnormal QTc at 12 weeks. 25.5% of participants showed a reduction in at least one QTc severity group, while 65.5% had no change and 9.0% worsened in QTc group, after 12 weeks of adjunct aripiprazole. CONCLUSION Low-dose adjunctive aripiprazole did not prolong QTc in patients stabilized on either olanzapine, risperidone, or clozapine. More controlled studies evaluating the QTc effect of adjunctive aripiprazole should be done to confirm and support these findings.
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Affiliation(s)
- Thanita Pilunthanakul
- Department of Emergency and Crisis Care, Institute of Mental Health, Singapore, Singapore
| | - Mable Quek Jing Ting
- Department of Emergency and Crisis Care, Institute of Mental Health, Singapore, Singapore
| | - Jimmy Lee
- Department of Psychosis and Research Division, Institute of Mental Health, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Bhanu Gupta
- Department of Emergency and Crisis Care, Institute of Mental Health, Singapore, Singapore
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Abstract
Objective: To review the use of aripiprazole in children and adolescents. Methods: Medline and Embase databases were systematically searched using the keywords aripiprazole and child or adolescent over the period from 2000 to 2019. The initial screen yielded 163 publications, from which 99 studies were reviewed. Results: Aripiprazole is one of the most widely prescribed atypical antipsychotics. Like others, its use in children and adolescents is becoming commonplace and occurs in off-label indications. Aripiprazole has proven efficacy for several indications in children and adolescents, including schizophrenia, bipolar disorder, Tourette's syndrome, and behavioral impairments associated with autism and intellectual disability. Adverse effects are more important in children and adolescents than adults, particularly weight gain, drowsiness, extrapyramidal effects, and metabolic effects, even though the latter may appear less important than with other atypical antipsychotics. Severe adverse effects often occur in multiple-prescription settings. At present, postprescription monitoring is very poor. Conclusion: Aripiprazole has proven efficacy for several indications in children and adolescents. However, its use requires clinical and paraclinical monitoring to assess the occurrence of adverse events that may challenge the benefit/risk ratio. In addition, off-label prescriptions should be limited, as they appear to account for a significant proportion of aripiprazole use worldwide.
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Affiliation(s)
- Nicolas Coustals
- Department of Child and Adolescent Psychiatry, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Marie-Line Ménard
- Department of Child and Adolescent Psychiatry, Children's Hospitals of Nice CHU-Lenval, Nice, France.,CoBTek, EA7276, University of Côte d'Azur, Nice, France
| | - David Cohen
- Department of Child and Adolescent Psychiatry, APHP, Groupe Hospitalier Pitié-Salpêtrière, Université Sorbonne, Paris, France.,Institut des Systèmes Intelligents et Robotiques, CNRS UMR 7222, Université Sorbonne, Paris, France
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Cicala G, Barbieri MA, Santoro V, Tata C, Colucci PV, Vanadia F, Drago F, Russo C, Cutroneo PM, Gagliano A, Spina E, Germanò E. Safety and Tolerability of Antipsychotic Drugs in Pediatric Patients: Data From a 1-Year Naturalistic Study. Front Psychiatry 2020; 11:152. [PMID: 32265749 PMCID: PMC7108128 DOI: 10.3389/fpsyt.2020.00152] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/18/2020] [Indexed: 01/07/2023] Open
Abstract
Background: Antipsychotic drugs (APs) are increasingly used to treat a variety of psychiatric disorders in children and adolescents. However, their safety and tolerability profiles, when used in a developmental age context, show different characteristics from the ones observed in adult patients. Treatment with APs in pediatric patients is often long-term. However, the tolerability data regarding these patients mostly derive from short-term studies. Methods: Starting from April 2017, for a 1-year period, patients between 4 and 18 years of age followed by five units of developmental age neuropsychiatry, who initiated a treatment with at least an AP (ATC class N05A) were included into the study. Patient-related data have been collected at baseline and regularly thereafter, as allowed by the clinical routine. Changes to continuous variables over time have been analyzed using a linear mixed model in subsamples of our population treated with risperidone or aripiprazole. Results: During the observation period, 158 patients were initially enrolled, but only 116 completed 12 months of therapy with an AP. Risperidone was the most used AP (n = 52) followed by aripiprazole (n = 44) and olanzapine (n = 7). For both the aripiprazole and risperidone groups, the mean body mass index (BMI) (P < 0.001 for both groups) and heart rate (P = 0.026 for aripiprazole group and P < 0.001 for the risperidone one) values significantly increased over time. The mean prolactin concentration value significantly increased over time only in the risperidone group (P = 0.04). Eighty-six patients experienced at least one adverse drug reaction (ADR), accounting for a total of 238 specific reactions, with the most frequent being weight gain (n = 34), increased serum prolactin levels (n = 21), hyperphagia (n = 20), and hypercholesterolemia (n = 14). Among these, only 24 ADRs were classifiable as serious. Conclusions: The results of this study confirm that risperidone and aripiprazole are relatively well-tolerated therapeutic options for the treatment of a variety of psychiatric disorders in pediatric patients. However, in findings such as statistically significant increments of BMI and heart rate mean values, the variations over time in prolactin levels observed with risperidone and the differences between the two drugs remark the necessity of systematic monitoring.
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Affiliation(s)
- Giuseppe Cicala
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Maria A Barbieri
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenza Santoro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmela Tata
- Childhood and Adolescence Neuropsychiatry, Azienda Sanitaria Provinciale 8, Syracuse, Italy
| | - Pia V Colucci
- Complex Operative Unit of Neurology for Mental Retardation, IRCCS Oasi Maria SS, Enna, Italy
| | - Francesca Vanadia
- Childhood Neuropsychiatry, Arnas Civico di Cristina Benfratelli, Palermo, Italy
| | - Flavia Drago
- Childhood Neuropsychiatry, Arnas Civico di Cristina Benfratelli, Palermo, Italy
| | - Carmelita Russo
- Childhood Neuropsychiatry, S. Marta and S. Venera Hospital, Azienda Sanitaria Provinciale 3, Catania, Italy
| | - Paola M Cutroneo
- Regional Pharmacovigilance Center, Siciliy, AOU Policlinico G. Martino, Messina, Italy
| | - Antonella Gagliano
- Child and Adolescent Neuropsychiatry, Department of Biomedical Sciences, University of Cagliari and "G. Brotzu" Hospital Trust, Cagliari, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.,Regional Pharmacovigilance Center, Siciliy, AOU Policlinico G. Martino, Messina, Italy
| | - Eva Germanò
- Department of Adulthood and Developmental Age Human Pathology "Gaetano Barresi", University of Messina, Messina, Italy
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Pillay J, Boylan K, Newton A, Hartling L, Vandermeer B, Nuspl M, MacGregor T, Featherstone R, Carrey N. Harms of Antipsychotics in Children and Young Adults: A Systematic Review Update. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:661-678. [PMID: 29865900 PMCID: PMC6187435 DOI: 10.1177/0706743718779950] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To update and extend our previous systematic review on first- (FGAs) and second-generation antipsychotics (SGAs) for treatment of psychiatric and behavioral conditions in children, adolescents, and young adults (aged ≤24 years). This article focuses on the evidence for harms. METHOD We searched (to April 2016) 8 databases, gray literature, trial registries, Food and Drug Administration reports, and reference lists. Two reviewers conducted study screening and selection independently, with consensus for selection. One reviewer extracted and another verified all data; 2 reviewers independently assessed risk of bias. We conducted meta-analyses when appropriate and network meta-analysis across conditions for changes in body composition. Two reviewers reached consensus for ratings on the strength of evidence for prespecified outcomes. RESULTS A total of 135 studies (95 trials and 40 observational) were included, and 126 reported on harms. FGAs caused slightly less weight gain and more extrapyramidal symptoms than SGAs. SGAs as a class caused adverse effects, including weight gain, high triglyceride levels, extrapyramidal symptoms, sedation, and somnolence. They appeared to increase the risk for high cholesterol levels and type 2 diabetes. Many outcomes for individual drug comparisons were of low or insufficient strength of evidence. Olanzapine caused more short-term gains in weight and body mass index than several other SGAs. The dose of SGAs may not make a difference over the short term for some outcomes. CONCLUSIONS Clinicians need to weigh carefully the benefit-to-harm ratio when using antipsychotics, especially when treatment alternatives exist. More evidence is needed on the comparative harms between antipsychotics over the longer term.
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Affiliation(s)
- Jennifer Pillay
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Khrista Boylan
- 2 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Newton
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada.,3 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada.,3 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ben Vandermeer
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Megan Nuspl
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Tara MacGregor
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Robin Featherstone
- 1 University of Alberta Evidence-based Practice Center, Edmonton, Alberta, Canada
| | - Normand Carrey
- 4 Douglas Research Institute and IWK Health Centre, Halifax, Nova Scotia, Canada.,5 Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
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Aronow WS, Shamliyan TA. Effects of atypical antipsychotic drugs on QT interval in patients with mental disorders. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:147. [PMID: 29862236 DOI: 10.21037/atm.2018.03.17] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Drug-induced QT prolongation is associated with higher risk of cardiac arrhythmias and cardiovascular mortality. We investigated the effects of atypical antipsychotic drugs on QT interval in children and adults with mental disorders. Methods We conducted random-effects direct frequentist meta-analyses of aggregate data from randomized controlled trials (RCT) and appraised the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our search in PubMed, EMBASE, the Cochrane Library, clinicaltrials.gov, and PharmaPendium up to October 2017 identified studies that examined aripiprazole, quetiapine, risperidone, olanzapine, ziprasidone and brexpiprazole. Results Low quality evidence suggests that aripiprazole (four meta-analyses and twelve RCTs), brexpiprazole (one systematic review and four RCTs) or olanzapine (five meta-analyses and twenty RCTs) do not increase QT interval. Low quality evidence suggests that ziprasidone (five meta-analyses and 11 RCTs) increases QT interval and the rates of QT prolongation while risperidone (four meta-analyses, 70 RCTs) and quetiapine (two meta-analyses and seven RCTs) are associated with QT prolongation and greater odds of torsades de pointes ventricular tachycardia especially in cases of drug overdose. Conclusions The main conclusion of our study is that in people with mental disorders and under treatment with atypical antipsychotic drugs, in order to avoid QT prolongation and reduce the risk of ventricular tachycardia clinicians may recommend aripiprazole, brexpiprazole or olanzapine in licensed doses. Long-term comparative safety needs to be established.
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Affiliation(s)
- Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Tatyana A Shamliyan
- Quality Assurance, Evidence-Based Medicine Center, Elsevier, Philadelphia, PA, USA
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Change and dispersion of QT interval during treatment with quetiapine extended release versus aripiprazole in children and adolescents with first-episode psychosis: results from the TEA trial. Psychopharmacology (Berl) 2018; 235:681-693. [PMID: 29185022 DOI: 10.1007/s00213-017-4784-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effect of quetiapine extended release (ER) versus aripiprazole on corrected QT interval (QTc) and QT dispersion (QTd) in youths with first-episode psychosis. METHODS Youths 12-17 years were randomized to quetiapine ER (daily dose range = 50 to 800 mg) or aripiprazole (daily dose range = 2.5 to 30 mg) in a 12-week double-blinded trial and examined at weeks 0, 4, and 12. Primary outcome was QTc change using Hodges formula (QTcH); secondary outcomes included QTcH > 450 ms, QTcH > 500 ms, QTcH change > 60 ms, QTd, and heart rate (HR). RESULTS Among 113 randomized youths, follow-up ECG was available for 93 patients (82.3%) (age = 15.8 ± 1.3 years, males = 34.4%, schizophrenia = 67.7%). Quetiapine ER treatment (n = 47) was associated with a significant increase in QTcH of + 6.8 ± 20.2 ms (p = 0.025), while the change from baseline in patients receiving aripiprazole (n = 46) was non-significant (- 3.4 ± 18.9 ms, p = 0.225). One patient in the quetiapine ER group had a QTcH change of + 62.3 ms. Age, sex, smoking, body mass index, and concomitant medication were not significantly associated with QTcH change, but higher baseline potassium was correlated to higher QTcH change in the quetiapine ER group. The HR increased significantly with quetiapine ER (+ 11.0 ± 14.2 bpm, p < 0.001) but not with aripiprazole (- 0.8 ± 12.0 bpm, p = 0.643). QTd did not significantly change with quetiapine ER or aripiprazole. CONCLUSION QTcH and HR increased significantly with quetiapine ER, although changes were small and likely not clinically significant in otherwise healthy patients. QTcH and HR were unchanged with aripiprazole. No significant change in QTd was seen. ClinicalTrials.gov: NCT01119014, EudraCT: 2009-016715-38.
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Risperidone and Cardiometabolic Risk in Children and Adolescents: Clinical and Instrumental Issues. J Clin Psychopharmacol 2017; 37:302-309. [PMID: 28338545 DOI: 10.1097/jcp.0000000000000688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Although second-generation antipsychotics are used to treat and manage symptoms for several psychiatric disorders, data about their adverse effects in developmental age are limited. The aim of this prospective observational study was to verify the cardiovascular and metabolic risk in a sample of antipsychotic-naive children/adolescent patients starting risperidone therapy. METHODS Twenty-two patients, younger than 18 years, were recruited. The assessment included anthropometric data, cardiovascular parameters, blood tests, and ultrasonographic abdominal study. RESULTS After an average follow-up period of 7.6 months, statistically significant increases in mean values of waist circumference, body mass index (BMI), BMI percentile, BMI z score, total cholesterol, and prolactin were found. Other cardiometabolic parameters showed an upward trend in time. Subjects in pubertal/postpubertal stage and female patients were more susceptible to developing cardiometabolic changes. Moreover, significant correlations between changes in anthropometric and several metabolic parameters were found. A tendency to change in constitution of the liver parenchyma and distribution of the abdominal fat mass with ultrasonographic abdominal study was also evident. CONCLUSIONS In our sample, several metabolic parameters showed a sensitivity to risperidone treatment. Because most of these parameters are age dependent, metabolic syndrome criteria used for adults were inappropriate in children and adolescents. Periodic clinical and instrumental evaluations and guidelines for monitoring of any metabolic, laboratory, and instrumental complications are necessary in the perspective of even long-time second-generation antipsychotics treatment in children and adolescents.
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Karpuz D, Hallioglu O, Toros F, Tasdelen B. The effect of metilpheniydate, risperidone and combination therapy on ECG in children with attention-deficit hyperactivity disorder. J Electrocardiol 2017; 50:410-415. [PMID: 28274540 DOI: 10.1016/j.jelectrocard.2017.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION This study is to investigate ventricular repolarization on electrocardiogram (ECG) in a pediatric population receiving methylphenidate (MPH), risperidone (RIS) and combined therapy. METHODS A total of 215 patients between 6 and 12years with ADHD/conduct disorder receiving methylphenidate, risperidone and combined therapy for minimum 3months and an untreated ADHD group (n=76) was consecutively included in the study. Twelve lead ECG parameters including mean QT, QTc, T-peak to T-end (TpTe) intervals, TpTe dispersion and TpTe/QT ratio were compared. RESULTS QT interval, and QTc, TpTe interval, TpTe dispersion and TpTe/QTc ratio values for groups receiving RIS, MPH and combined therapy were found to be significantly higher than other groups. Moreover, in the combined therapy group TpTe and TpTe/QTc values were higher than the single drug administration groups (p<0.05). TpTe and TpTe/QT ratio was significantly higher in the RIS group compared to that of the MPH group. CONCLUSION These results suggested that combined therapy of these drugs had a more prominent impact on the T wave and RIS could be strongly associated with it.
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Affiliation(s)
- Derya Karpuz
- Mersin University, Faculty of Medicine, Department of Pediatric Cardiology, TR, Mersin, Turkey.
| | - Olgu Hallioglu
- Mersin University, Faculty of Medicine, Department of Pediatric Cardiology, TR, Mersin, Turkey
| | - Fevziye Toros
- Mersin University, Faculty of Medicine, Department of Child and Adolescent Psychiatry, TR, Mersin, Turkey
| | - Bahar Tasdelen
- Mersin University, Faculty of Medicine, Department of Biostatistics and Medical Informatics, TR, Mersin, Turkey
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Prevalence and Risk Factors of Prolonged Corrected QT Interval Among Children and Adolescents Treated With Antipsychotic Medications: A Long-Term Follow-Up in a Real-World Population. J Clin Psychopharmacol 2017; 37:78-83. [PMID: 27930499 DOI: 10.1097/jcp.0000000000000639] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE This study aimed to describe the prevalence of corrected QT (QTc) interval disorders and the possible predisposing factors in children and adolescents treated with antipsychotic (AP) medications in a real-world population with a long-term follow-up. METHODS Data were obtained from the SafEty of NeurolepTics in Infancy and Adolescence (SENTIA) registry (https://sentia.es). The SENTIA includes patients younger than 18 years who are currently taking or initiating treatment with AP medications and have agreed to participate in the registry. The SENTIA's follow-up includes an electrocardiogram (ECG) assessment before starting treatment and at 1, 3, and 6 months after treatment initiation or after any changes in the patient's AP medication treatment. Thereafter, all participants undergo an ECG every 6 months. A QTc interval more than 450 milliseconds, increases in QTc interval of 60 milliseconds or more, or QTc dispersion more than 100 milliseconds were considered abnormal. RESULTS Since January 1, 2011, 101 patients have been enrolled in SENTIA and have had at least 1 ECG assessment. The mean age at inclusion was 11.5 years; 75% of the patients were men. The mean follow-up time was 20.0 ± 15.1 months. The most frequently prescribed AP medications were risperidone (52.2%) and aripiprazole (45.5%). Seven patients (6.9%) had abnormal changes in QTc. No patient had a QTc interval more than 500 milliseconds. All patients were asymptomatic. The QTc changes were observed at different times of exposure, with a range of 1 to 39 months after beginning AP treatment. Concomitant use of attention deficit and hyperactivity disorder drugs seemed a possible factor associated with QTc disorders. CONCLUSIONS Patients should undergo a baseline ECG assessment before starting AP medication treatment, particularly patients with concomitant use of attention deficit and hyperactivity disorder drugs or a family/personal history of heart disease.
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Vo LC, Snyder C, McCracken C, McDougle CJ, McCracken JT, Aman MG, Tierney E, Arnold LE, Levi D, Kelleman M, Carroll D, Morrissey J, Vitiello B, Scahill L. No Apparent Cardiac Conduction Effects of Acute Treatment with Risperidone in Children with Autism Spectrum Disorder. J Child Adolesc Psychopharmacol 2016; 26:900-908. [PMID: 27726426 PMCID: PMC5178011 DOI: 10.1089/cap.2016.0090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Risperidone is approved for the treatment of serious behavioral problems in children with autism spectrum disorder (ASD). This study examined the effects of risperidone on cardiac conduction in children with ASD. METHODS Data were collected from an 8-week, five-site trial conducted by the Research Units on Pediatric Psychopharmacology Autism Network. Children (age 5-17 years) were randomly assigned to risperidone (n = 49) or placebo (n = 52) under double-blind conditions. Risperidone was superior to placebo in reducing serious behavioral problems. A standard 12-lead, electrocardiogram (ECG) was obtained in most subjects at screening and week 8. A pediatric electrophysiologist blind to treatment assignment reviewed all available ECGs for readability, abnormalities, and cardiac conduction parameters, including QTc. The electrophysiologist measurements were compared to machine readings. A second blinded electrophysiologist examined all available ECGs for abnormalities and a 20% random sample for QTc. RESULTS Of the 101 randomized subjects in the trial, complete pretreatment and week 8 data were available on 65 subjects (placebo n = 30; risperidone n = 35). The electrophysiologist did not identify any cardiac conduction adverse effects of risperidone and there was no difference in mean change on the QTc compared to placebo. The Bland-Altman plot showed a systematic bias in QTc measurements by the electrophysiologist and machine. Machine readings produced higher values than the electrophysiologist for shorter QTc intervals and machine scoring was lower than electrophysiologist readings for longer QTc values (p = 0.001). Two electrophysiologists had overall percent agreements of 82.9% (95% CI: 76.3 to 89.6) on qualitative assessment and 88.6% (95% CI: 79.3 to 98.0) on QTc interval. CONCLUSION Using conventional doses during acute treatment in children with ASD and serious behavioral problems, there was no difference in the mean change in QTc between risperidone and placebo. Compared to the electrophysiologist, the machine readings may miss elevated QTc measurements.
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Affiliation(s)
- Lan Chi Vo
- Department of Psychiatry, Emory University School of Medicine, Atlanta, Georgia
| | - Christopher Snyder
- Division of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Courtney McCracken
- Children's Hospital of Atlanta & Emory University School of Medicine, Atlanta, Georgia
| | - Christopher J. McDougle
- Harvard Medical School, Massachusetts General Hospital, Lurie Center for Autism, Boston, Massachusetts
| | - James T. McCracken
- Division of Child Psychiatry, University of California at Los Angeles, Los Angeles, California
| | | | | | | | - Daniel Levi
- Mattel Children's Hospital, University of California at Los Angeles, Los Angeles, California
| | - Michael Kelleman
- Children's Hospital of Atlanta & Emory University School of Medicine, Atlanta, Georgia
| | - Deirdre Carroll
- Yale Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - John Morrissey
- Mattel Children's Hospital, University of California at Los Angeles, Los Angeles, California
| | | | - Lawrence Scahill
- Marcus Autism Center, Emory University School of Medicine, Atlanta, Georgia
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Lamberti M, Siracusano R, Italiano D, Alosi N, Cucinotta F, Di Rosa G, Germanò E, Spina E, Gagliano A. Head-to-Head Comparison of Aripiprazole and Risperidone in the Treatment of ADHD Symptoms in Children with Autistic Spectrum Disorder and ADHD: A Pilot, Open-Label, Randomized Controlled Study. Paediatr Drugs 2016; 18:319-29. [PMID: 27278054 DOI: 10.1007/s40272-016-0183-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are frequently overlapping neurodevelopmental disorders. Individuals in whom the disorders are comorbid show more severe impairment because of deficits in the processing of social situations, adaptive functioning, and executive control than individuals with either disorder alone. OBJECTIVE This open-label pilot study aimed to evaluate and compare the efficacy and tolerability of risperidone and aripiprazole for treating ADHD symptoms in patients with both ASD and ADHD over the course of 24 weeks of treatment. METHODS Patients (n = 44) were randomly assigned to start treatment with risperidone (22 patients) or aripiprazole (22 patients). Children were evaluated before starting treatment (T0), and after 12 weeks (T1) and 24 weeks (T2) of treatment. At each visit, specific psychiatric clinical scales were administered to assess the efficacy of the two drugs. RESULTS The mean age was 8.4 ± 2.9 years in the aripiprazole group and 7.8 ± 2.3 years in the risperidone group. A total of 37 children (29 boys and 8 girls) completed the study (18 in the aripiprazole group and 19 in the risperidone group). Aripiprazole and risperidone appeared to have similar benefits in terms of efficacy and tolerability, although there were slight differences between the two drugs. Both groups showed a significant improvement in ADHD symptoms after 24 weeks of treatment (ADHD Rating Scale, Conners Parent Rating Scale-Hyperactivity, and Clinical Global Improvement-Severity Scale). No significant difference between the two drugs on any parameters at 24 weeks were found. Prolactin levels were decreased in the aripiprazole group. Both drugs were well tolerated, with no serious adverse events detected. CONCLUSIONS Our study confirms the efficacy of both aripiprazole and risperidone in ameliorating ADHD symptoms of children also presenting with ASD.
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Affiliation(s)
- Marco Lamberti
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Policlinico Universitario G. Martino, Via Consolare Valeria 1, 98125, Messina, Italy.
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | | | - Domenico Italiano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Norma Alosi
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Policlinico Universitario G. Martino, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Francesca Cucinotta
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Policlinico Universitario G. Martino, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Gabriella Di Rosa
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Policlinico Universitario G. Martino, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Eva Germanò
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Policlinico Universitario G. Martino, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonella Gagliano
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Policlinico Universitario G. Martino, Via Consolare Valeria 1, 98125, Messina, Italy
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12
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Pisano S, Catone G, Veltri S, Lanzara V, Pozzi M, Clementi E, Iuliano R, Riccio MP, Radice S, Molteni M, Capuano A, Gritti A, Coppola G, Milone A, Bravaccio C, Masi G. Update on the safety of second generation antipsychotics in youths: a call for collaboration among paediatricians and child psychiatrists. Ital J Pediatr 2016; 42:51. [PMID: 27209326 PMCID: PMC4875613 DOI: 10.1186/s13052-016-0259-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/04/2016] [Indexed: 02/08/2023] Open
Abstract
During the past decade, a substantial increase in the use of second generation antipsychotics (SGAs) has occurred for a number of juvenile psychiatric disorders, often as off-label prescriptions. Although they were thought to be safer than older, first generation antipsychotics, mainly due to a lower risk of neurological adverse reactions, recent studies have raised significant concerns regarding their safety regarding metabolic, endocrinological and cardiovascular side effects. Aim of this paper is to update with a narrative review, the latest findings on safety of SGAs in youths. Results suggest that different SGAs may present different safety profiles. Metabolic adverse events are the most frequent and troublesome, with increasing evidences of heightened risk for type II diabetes mellitus. Results are discussed with specific emphasis on possible strategies of an active monitoring, which could enable both paediatricians and child psychiatrists to a possible prevention, early detection, and a timely management of such effects.
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Affiliation(s)
- Simone Pisano
- Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Neuropsychiatry Division, Second University of Naples, 80131, Naples, Italy
| | - Gennaro Catone
- Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Neuropsychiatry Division, Second University of Naples, 80131, Naples, Italy
| | - Stefania Veltri
- Child Neurology and Psychiatry Unit, Center for Rare Diseases, Department of Pediatrics, Catholic University, Rome, Italy
| | - Valentina Lanzara
- Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Neuropsychiatry Division, Second University of Naples, 80131, Naples, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, CNR Institute of Neuroscience, Department of Biomedical and Clinical Sciences, L. Sacco University Hospital, Università di Milano, 20157, Milan, Italy
| | | | - Maria Pia Riccio
- Department of Mental and Physical Health and Preventive Medicine, Child and Adolescent Neuropsychiatry Division, Second University of Naples, 80131, Naples, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L Sacco, L. Sacco University Hospital, Università di Milano, 20157, Milan, Italy
- Faculty of Education Science, University Suor Orsola Benincasa of Naples, Naples, Italy
| | - Massimo Molteni
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Annalisa Capuano
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Department of Experimental Medicine, Second University of Naples, 80131, Naples, Italy
| | - Antonella Gritti
- Child Neuropsychiatry, Faculty of Education, Suor Orsola Benincasa University, Naples, Italy
| | - Giangennaro Coppola
- Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, S. Giovanni di Dio and Ruggi d'Aragona Hospital, University of Salerno, Fisciano, Italy
| | - Annarita Milone
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Carmela Bravaccio
- Department of Translational Medical Sciences, University Federico II of Naples, Via Pansini 5, 80131, Naples, Italy.
| | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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13
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Jensen KG, Juul K, Fink-Jensen A, Correll CU, Pagsberg AK. Corrected QT changes during antipsychotic treatment of children and adolescents: a systematic review and meta-analysis of clinical trials. J Am Acad Child Adolesc Psychiatry 2015; 54:25-36. [PMID: 25524787 DOI: 10.1016/j.jaac.2014.10.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 08/26/2014] [Accepted: 10/13/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the effect of antipsychotics on the corrected QT (QTc) interval in youth. METHOD We searched PubMed (http://www.ncbi.nlm.nih.gov/pubmed) for randomized or open clinical trials of antipsychotics in youth <18 years with QTc data, meta-analyzing the results. Meta-regression analyses evaluated the effect of age, sex, dose, and study duration on QTc. Incidences of study-defined QTc prolongation (>440-470 milliseconds), QTc >500 milliseconds, and QTc change >60 milliseconds were also evaluated. RESULTS A total of 55 studies were meta-analyzed, evaluating 108 treatment arms covering 9 antipsychotics and including 5,423 patients with QTc data (mean age = 12.8 ± 3.6 years, female = 32.1%). Treatments included aripiprazole: studies = 14; n = 814; haloperidol: studies = 1; n = 15; molindone: studies = 3; n = 125; olanzapine: studies = 5; n = 212; paliperidone: studies = 3; n = 177; pimozide: studies = 1; n = 25; quetiapine: studies = 5; n = 336; risperidone: studies = 23; n = 2,234; ziprasidone: studies = 10, n = 523; and placebo: studies = 19, n = 962. Within group, from baseline to endpoint, aripiprazole significantly decreased the QTc interval (-1.44 milliseconds, CI = -2.63 to -0.26, p = .017), whereas risperidone (+1.68, CI = +0.67 to +2.70, p = .001) and especially ziprasidone (+8.74, CI = +5.19 to +12.30, p < .001) significantly increased QTc. Compared to pooled placebo arms, aripiprazole decreased QTc (p = .007), whereas ziprasidone increased QTc (p < .001). Compared to placebo, none of the investigated antipsychotics caused a significant increase in the incidence of the 3 studied QTc prolongation measures, but there was significant reporting bias. CONCLUSION Based on these data, the risk of pathological QTc prolongation seems low during treatment with the 9 studied antipsychotics in otherwise healthy youth. Nevertheless, because individual risk factors interact with medication-related QTc effects, both medication and patient factors need to be considered when choosing antipsychotic treatment.
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Affiliation(s)
- Karsten Gjessing Jensen
- Child and Adolescent Mental Health Centre, Mental Health Services Capital Region and Faculty of Health Science, University of Copenhagen, Denmark.
| | - Klaus Juul
- Rigshospitalet University Hospital, Copenhagen
| | - Anders Fink-Jensen
- Laboratory of Neuropsychiatry, University of Copenhagen and Psychiatric Centre Copenhagen, University Hospital Copenhagen
| | - Christoph U Correll
- Hofstra North Shore Long Island Jewish School of Medicine and the Recognition and Prevention Program, Zucker Hillside Hospital, Glen Oaks, NY
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Centre, Mental Health Services Capital Region and Faculty of Health Science, University of Copenhagen, Denmark
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14
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Lamberti M, Italiano D, Guerriero L, D'Amico G, Siracusano R, Ingrassia M, Germanò E, Calabrò MP, Spina E, Gagliano A. Evaluation of acute cardiovascular effects of immediate-release methylphenidate in children and adolescents with attention-deficit hyperactivity disorder. Neuropsychiatr Dis Treat 2015; 11:1169-74. [PMID: 26056451 PMCID: PMC4431494 DOI: 10.2147/ndt.s79866] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Attention-deficit hyperactivity disorder is a frequent condition in children and often extends into adulthood. Use of immediate-release methylphenidate (MPH) has raised concerns about potential cardiovascular adverse effects within a few hours after administration. This study was carried out to investigate acute effects of MPH on electrocardiogram (ECG) in a pediatric population. A total of 54 consecutive patients with attention-deficit hyperactivity disorder (51 males and 3 females; mean age =12.14±2.6 years, range 6-19 years), receiving a new prescription of MPH, underwent a standard ECG 2 hours before and after the administration of MPH 10 mg per os. Basal and posttreatment ECG parameters, including mean QT (QT interval when corrected for heart rate [QTc]), QTc dispersion (QTd) interval duration, T-peak to T-end (TpTe) intervals, and TpTe/QT ratio were compared. Significant modifications of both QTc and QTd values were not found after drug administration. QTd fluctuated slightly from 25.7±9.3 milliseconds to 25.1±8.4 milliseconds; QTc varied from 407.6±12.4 milliseconds to 409.8±12.7 milliseconds. A significant variation in blood pressure (systolic blood pressure 105.4±10.3 vs 109.6±11.5; P<0.05; diastolic blood pressure 59.2±7.1 vs 63.1±7.9; P<0.05) was observed, but all the data were within normal range. Heart rate moved from 80.5±15.5 bpm to 87.7±18.8 bpm. No change in TpTe values was found, but a statistically significant increase in TpTe/QTc intervals was found with respect to basal values (0.207±0.02 milliseconds vs 0.214±0.02 milliseconds; P<0.01). The findings of this study show no significant changes in ECG parameters. TpTe values can be an additional parameter to evaluate borderline cases.
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Affiliation(s)
- Marco Lamberti
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy ; Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Italiano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Laura Guerriero
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy
| | - Gessica D'Amico
- Division of Pediatric Cardiology, Department of Pediatrics, University of Messina, Messina, Italy
| | - Rosamaria Siracusano
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy ; Institution of Clinical Physiology, CNR, Pisa, Italy
| | - Massimo Ingrassia
- Division of Psychology, Department of Humanities and Social Sciences, University of Messina, Messina, Italy
| | - Eva Germanò
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy
| | - Maria Pia Calabrò
- Division of Pediatric Cardiology, Department of Pediatrics, University of Messina, Messina, Italy
| | - Edoardo Spina
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonella Gagliano
- Division of Child Neurology and Psychiatry, Department of Pediatrics, University of Messina, Messina, Italy
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15
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Kirino E. Profile of aripiprazole in the treatment of bipolar disorder in children and adolescents. Adolesc Health Med Ther 2014; 5:211-21. [PMID: 25473324 PMCID: PMC4250023 DOI: 10.2147/ahmt.s50015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Bipolar disorder is a pernicious illness. Compared with the later-onset form, early onset bipolar disorder is associated with worse psychosocial outcomes, and is characterized by rapid cycling and increased risks of substance abuse and suicide attempts. Controlling mood episodes and preventing relapse in this group of pediatric patients requires careful treatment. Here, we review the effectiveness of aripiprazole for bipolar disorder in children and adolescents, with discussion of this drug's unique pharmacological profile and various clinical study outcomes. Aripiprazole acts as a serotonin 5-HT2A receptor antagonist, as well as a partial agonist of the serotonin 5-HT1A and dopamine D2 receptors. It can be safely used in children and adolescents, as it is highly tolerated and shows lower rates of the side effects typically observed with other antipsychotic drugs, including sedation, weight gain, hyperprolactinemia, and extrapyramidal syndrome. The presently reviewed randomized controlled trials (RCTs) and non-RCTs generally reported aripiprazole to be effective and well-tolerated in children and adolescents with bipolar disorder. However, due to the limited number of RCTs, the present conclusions must be evaluated cautiously. Furthermore, aripiprazole cannot yet be considered a preferred treatment for children and adolescents with bipolar disorder, as there is not yet evidence that aripiprazole shows greater efficacy compared to other second-generation antipsychotics. Additional data are needed from future head-to-head comparison studies.
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Affiliation(s)
- Eiji Kirino
- Department of Psychiatry, Juntendo University School of Medicine, Japan
- Department of Psychiatry, Juntendo University Shizuoka Hospital, Japan
- Juntendo Institute of Mental Health, Shizuoka, Japan
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16
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QTc interval prolongation and torsade de pointes associated with second-generation antipsychotics and antidepressants: a comprehensive review. CNS Drugs 2014; 28:887-920. [PMID: 25168784 DOI: 10.1007/s40263-014-0196-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We comprehensively reviewed published literature to determine whether it supported the link between corrected QT (QTc) interval prolongation and torsade de pointes (TdP) for the 11 second-generation antipsychotics and seven second-generation antidepressants commonly implicated in these complications. Using PubMed and EMBASE, we identified four thorough QT studies (one each for iloperidone, ziprasidone, citalopram, and escitalopram), 40 studies specifically designed to assess QTc interval prolongation or TdP, 58 publications based on data from efficacy and safety trials, 18 toxicology studies, and 102 case reports. Thorough QT studies, QTc prolongation-specific studies, and studies based on efficacy and safety trials did not link drug-associated QTc interval prolongation with TdP. They only showed that the drugs reviewed caused varying degrees of QTc interval prolongation, and even that information was not clear and consistent enough to stratify individual drugs for this risk. The few toxicology studies provided valuable information but their findings are pertinent only to situations of drug overdose. Case reports were most informative about the drug-QTc interval prolongation-TdP link. At least one additional well established risk factor for QTc prolongation was present in 92.2 % of case reports. Of the 28 cases of TdP, six (21.4 %) experienced it with QTc interval <500 ms; 75 % of TdP cases occurred at therapeutic doses. There is little evidence that drug-associated QTc interval prolongation by itself is sufficient to predict TdP. Future research needs to improve its precision and broaden its scope to better understand the factors that facilitate or attenuate progression of drug-associated QTc interval prolongation to TdP.
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