1
|
Jordaan P, Dumotier B, Traebert M, Miller PE, Ghetti A, Urban L, Abi-Gerges N. Cardiotoxic Potential of Hydroxychloroquine, Chloroquine and Azithromycin in Adult Human Primary Cardiomyocytes. Toxicol Sci 2021; 180:356-368. [PMID: 33483756 PMCID: PMC7928616 DOI: 10.1093/toxsci/kfaa194] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Substantial efforts have been recently committed to develop coronavirus disease-2019 (COVID-19) medications, and Hydroxychloroquine alone or in combination with Azithromycin has been promoted as a repurposed treatment. Although these drugs may increase cardiac toxicity risk, cardiomyocyte mechanisms underlying this risk remain poorly understood in humans. Therefore, we evaluated the proarrhythmia risk and inotropic effects of these drugs in the cardiomyocyte contractility-based model of the human heart. We found Hydroxychloroquine to have a low proarrhythmia risk, whereas Chloroquine and Azithromycin were associated with high risk. Hydroxychloroquine proarrhythmia risk changed to high with low level of K+, whereas high level of Mg2+ protected against proarrhythmic effect of high Hydroxychloroquine concentrations. Moreover, therapeutic concentration of Hydroxychloroquine caused no enhancement of elevated temperature-induced proarrhythmia. Polytherapy of Hydroxychloroquine plus Azithromycin and sequential application of these drugs were also found to influence proarrhythmia risk categorization. Hydroxychloroquine proarrhythmia risk changed to high when combined with Azithromycin at therapeutic concentration. However, Hydroxychloroquine at therapeutic concentration impacted the cardiac safety profile of Azithromycin and its proarrhythmia risk only at concentrations above therapeutic level. We also report that Hydroxychloroquine and Chloroquine, but not Azithromycin, decreased contractility while exhibiting multi-ion channel block features, and Hydroxychloroquine's contractility effect was abolished by Azithromycin. Thus, this study has the potential to inform clinical studies evaluating repurposed therapies, including those in the COVID-19 context. Additionally, it demonstrates the translational value of the human cardiomyocyte contractility-based model as a key early discovery path to inform decisions on novel therapies for COVID-19, malaria, and inflammatory diseases.
Collapse
Affiliation(s)
- Pierre Jordaan
- Chief Medical Officer and Patient Safety, Novartis AG, Basel, Switzerland
| | - Bérengère Dumotier
- Novartis Institutes for Biomedical Research, Preclinical Safety, Basel, Switzerland
| | - Martin Traebert
- Novartis Institutes for Biomedical Research, Preclinical Safety, Basel, Switzerland
| | - Paul E Miller
- AnaBios Corporation, San Diego, California 92109, USA
| | - Andre Ghetti
- AnaBios Corporation, San Diego, California 92109, USA
| | - Laszlo Urban
- Novartis Institutes for Biomedical Research, Preclinical Secondary Pharmacology, Cambridge, Massachusetts, USA
| | | |
Collapse
|
2
|
Crivelari NC, Oliveira GQD, Park CHL, Riemma GDC, Costa IBSDS, Lacerda MVGD, Oliveira GMMD, Darrieux FCDC, Sacilotto L, Hajjar LA. Severe Cardiovascular Complications of COVID-19: a Challenge for the Physician. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
3
|
Giudicessi JR, Roden DM, Wilde AAM, Ackerman MJ. Genetic susceptibility for COVID-19-associated sudden cardiac death in African Americans. Heart Rhythm 2020; 17:1487-1492. [PMID: 32380288 PMCID: PMC7198426 DOI: 10.1016/j.hrthm.2020.04.045] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- John R Giudicessi
- Clinician-Investigator Training Program, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Dan M Roden
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart)
| | - Michael J Ackerman
- Division of Heart Rhythm Services, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Department of Molecular Pharmacology & Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
4
|
Sultana J, Cutroneo PM, Crisafulli S, Puglisi G, Caramori G, Trifirò G. Azithromycin in COVID-19 Patients: Pharmacological Mechanism, Clinical Evidence and Prescribing Guidelines. Drug Saf 2020; 43:691-698. [PMID: 32696429 PMCID: PMC7371963 DOI: 10.1007/s40264-020-00976-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The global COVID-19 pandemic has led to a race to find medications that can improve the prognosis of the disease. Azithromycin, in association with hydroxychloroquine or chloroquine, has been proposed as one such medication. The aim of this review is to describe the pharmacological mechanism, clinical evidence and prescribing guidelines concerning azithromycin in COVID-19 patients. There is weak evidence on the antiviral and immunomodulating effects of azithromycin, which in addition is not based on results from COVID-19 patients specifically. Therefore, this antibacterial should be considered only as empirical treatment of community-acquired pneumonia (CAP), although not all current treatment guidelines are in agreement. After the initial expectations raised by a small trial, more recent evidence has raised serious safety concerns on the use of hydroxychloroquine or chloroquine with azithromycin to treat COVID-19 patients, as all these drugs have arrhythmogenic potential. The World Health Organization has not made recommendations suggesting the use of azithromycin with hydroxychloroquine or chloroquine as treatment for COVID-19, but some national organisations have taken a different position, recommending this as first-line treatment. Several scientific societies, including the American College of Cardiology, have cautioned about the risks of this treatment in view of the lack of evidence concerning its benefits.
Collapse
Affiliation(s)
- Janet Sultana
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Paola Maria Cutroneo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Salvatore Crisafulli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Gabriele Puglisi
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Gaetano Caramori
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Gianluca Trifirò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy.
| |
Collapse
|
5
|
Bun SS, Taghji P, Courjon J, Squara F, Scarlatti D, Theodore G, Baudouy D, Sartre B, Labbaoui M, Dellamonica J, Doyen D, Marquette CH, Levraut J, Esnault V, Bun SS, Ferrari E. QT Interval Prolongation Under Hydroxychloroquine/Azithromycin Association for Inpatients With SARS-CoV-2 Lower Respiratory Tract Infection. Clin Pharmacol Ther 2020; 108:1090-1097. [PMID: 32588427 PMCID: PMC7361407 DOI: 10.1002/cpt.1968] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/22/2020] [Indexed: 02/06/2023]
Abstract
Association between Hydroxychloroquine (HCQ) and Azithromycin (AZT) is under evaluation for patients with lower respiratory tract infection (LRTI) caused by the Severe Acute Respiratory Syndrome (SARS-CoV-2). Both drugs have a known torsadogenic potential, but sparse data are available concerning QT prolongation induced by this association. Our objective was to assess for COVID-19 LRTI variations of QT interval under HCQ/AZT in patients hospitalized, and to compare manual versus automated QT measurements. Before therapy initiation, a baseline 12 lead-ECG was electronically sent to our cardiology department for automated and manual QT analysis (Bazett and Fridericia's correction), repeated 2 days after initiation. According to our institutional protocol (Pasteur University Hospital), HCQ/AZT was initiated only if baseline QTc ≤ 480ms and potassium level> 4.0 mmol/L. From March 24th to April 20th 2020, 73 patients were included (mean age 62 ± 14 years, male 67%). Two patients out of 73 (2.7%) were not eligible for drug initiation (QTc ≥ 500 ms). Baseline average automated QTc was 415 ± 29 ms and lengthened to 438 ± 40 ms after 48 hours of combined therapy. The treatment had to be stopped because of significant QTc prolongation in two out of 71 patients (2.8%). No drug-induced life-threatening arrhythmia, nor death was observed. Automated QTc measurements revealed accurate in comparison with manual QTc measurements. In this specific population of inpatients with COVID-19 LRTI, HCQ/AZT could not be initiated or had to be interrupted in less than 6% of the cases.
Collapse
Affiliation(s)
- Sok-Sithikun Bun
- Cardiology Department, Pasteur University Hospital, Nice, France
| | - Philippe Taghji
- Cardiology Department, Clinique la Casamance, Aubagne, France
| | - Johan Courjon
- Infectious Diseases Department, Archet University Hospital, Nice, France
| | - Fabien Squara
- Cardiology Department, Pasteur University Hospital, Nice, France
| | - Didier Scarlatti
- Cardiology Department, Pasteur University Hospital, Nice, France
| | | | - Delphine Baudouy
- Cardiology Department, Pasteur University Hospital, Nice, France
| | - Benjamin Sartre
- Cardiology Department, Pasteur University Hospital, Nice, France
| | - Mohamed Labbaoui
- Cardiology Department, Pasteur University Hospital, Nice, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, Archet University Hospital, Nice, France
| | - Denis Doyen
- Medical Intensive Care Unit, Archet University Hospital, Nice, France
| | | | - Jacques Levraut
- Department of Emergency Medicine, Pasteur University Hospital, Nice, France
| | - Vincent Esnault
- Nephrology Department, Pasteur University Hospital, Nice, France
| | - Sok-Siya Bun
- Pharmacy Faculty, CNRS, IRD, IMBE, Aix Marseille University, Marseille, France.,Pharmacy Department, CHU Nord, APHM, Marseille, France
| | - Emile Ferrari
- Cardiology Department, Pasteur University Hospital, Nice, France
| |
Collapse
|
6
|
Alexander PE, Debono VB, Mammen MJ, Iorio A, Aryal K, Deng D, Brocard E, Alhazzani W. COVID-19 coronavirus research has overall low methodological quality thus far: case in point for chloroquine/hydroxychloroquine. J Clin Epidemiol 2020; 123:120-126. [PMID: 32330521 PMCID: PMC7194626 DOI: 10.1016/j.jclinepi.2020.04.016] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 04/10/2020] [Accepted: 04/18/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES/BACKGROUND AND OBJECTIVES Prior epidemics of high-mortality human coronaviruses, such as the acute respiratory syndrome coronavirus (SARS-CoV or SARS-1) in 2003, have driven the characterization of compounds that could be possibly active against the currently emerging novel coronavirus SARS-CoV-2 (COVID-19). Presently, no approved treatment or prophylaxis is available for COVID-19. We comment on the existing COVID-19 research methodologies in general and the published reporting. Given the media attention and claims of effectiveness, we chose chloroquine and hydroxychloroquine, in combination with azithromycin, as an area of COVID-19 research to examine. METHODS/STUDY DESIGN AND SETTING MEDLINE and EMBASE electronic databases were searched from 2019 to present (April 3rd, 2020) using a mix of keywords such as COVID-19 and chloroquine and hydroxychloroquine. We also searched the largest clinical medicine preprint repository, medRxiv.org. RESULTS We found 6 studies, 3 randomized control trials and 3 observational studies, focusing on chloroquine and hydroxychloroquine (with azithromycin). We critically appraised the evidence. CONCLUSION We found that the COVID-19 research methodology is very poor in the area of chloroquine/hydroxychloroquine research. In screening the literature, we observed the same across COVID-19 research in relation to potential treatments. The reporting is very poor and sparse, and patient-important outcomes needed to discern decision-making priorities are not reported. We do understand the barriers to perform rigorous research in health care settings overwhelmed by a novel deadly disease. However, this emergency pandemic situation does not transform flawed methods and data into credible results. The adequately powered, comparative, and robust clinical research that is needed for optimal evidence-informed decision-making remains absent in COVID-19.
Collapse
Affiliation(s)
- Paul Elias Alexander
- Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; GUIDE Research Methods Group, McMaster University, Hamilton, Ontario, Canada.
| | - Victoria Borg Debono
- Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesia, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Manoj J Mammen
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Alfonso Iorio
- Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Komal Aryal
- Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Dianna Deng
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Eva Brocard
- Graduate Student (International Intern), France
| | - Waleed Alhazzani
- Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; GUIDE Research Methods Group, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
7
|
Saleh M, Gabriels J, Chang D, Soo Kim B, Mansoor A, Mahmood E, Makker P, Ismail H, Goldner B, Willner J, Beldner S, Mitra R, John R, Chinitz J, Skipitaris N, Mountantonakis S, Epstein LM. Effect of Chloroquine, Hydroxychloroquine, and Azithromycin on the Corrected QT Interval in Patients With SARS-CoV-2 Infection. Circ Arrhythm Electrophysiol 2020; 13:e008662. [PMID: 32347743 PMCID: PMC7299095 DOI: 10.1161/circep.120.008662] [Citation(s) in RCA: 220] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The novel SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) is responsible for the global coronavirus disease 2019 pandemic. Small studies have shown a potential benefit of chloroquine/hydroxychloroquine±azithromycin for the treatment of coronavirus disease 2019. Use of these medications alone, or in combination, can lead to a prolongation of the QT interval, possibly increasing the risk of Torsade de pointes and sudden cardiac death. METHODS Hospitalized patients treated with chloroquine/hydroxychloroquine±azithromycin from March 1 to the 23 at 3 hospitals within the Northwell Health system were included in this prospective, observational study. Serial assessments of the QT interval were performed. The primary outcome was QT prolongation resulting in Torsade de pointes. Secondary outcomes included QT prolongation, the need to prematurely discontinue any of the medications due to QT prolongation, and arrhythmogenic death. RESULTS Two hundred one patients were treated for coronavirus disease 2019 with chloroquine/hydroxychloroquine. Ten patients (5.0%) received chloroquine, 191 (95.0%) received hydroxychloroquine, and 119 (59.2%) also received azithromycin. The primary outcome of torsade de pointes was not observed in the entire population. Baseline corrected QT interval intervals did not differ between patients treated with chloroquine/hydroxychloroquine (monotherapy group) versus those treated with combination group (chloroquine/hydroxychloroquine and azithromycin; 440.6±24.9 versus 439.9±24.7 ms, P=0.834). The maximum corrected QT interval during treatment was significantly longer in the combination group versus the monotherapy group (470.4±45.0 ms versus 453.3±37.0 ms, P=0.004). Seven patients (3.5%) required discontinuation of these medications due to corrected QT interval prolongation. No arrhythmogenic deaths were reported. CONCLUSIONS In the largest reported cohort of coronavirus disease 2019 patients to date treated with chloroquine/hydroxychloroquine±azithromycin, no instances of Torsade de pointes, or arrhythmogenic death were reported. Although use of these medications resulted in QT prolongation, clinicians seldomly needed to discontinue therapy. Further study of the need for QT interval monitoring is needed before final recommendations can be made.
Collapse
Affiliation(s)
- Moussa Saleh
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
- Division of Electrophysiology, Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY (M.S., P.M., N.S., S.M.)
| | - James Gabriels
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - David Chang
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Beom Soo Kim
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Amtul Mansoor
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Eitezaz Mahmood
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Parth Makker
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
- Division of Electrophysiology, Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY (M.S., P.M., N.S., S.M.)
| | - Haisam Ismail
- Division of Electrophysiology, Department of Cardiology, Long Island Jewish Medical Center, Northwell Health, New Hyde Park (H.I., B.G.)
| | - Bruce Goldner
- Division of Electrophysiology, Department of Cardiology, Long Island Jewish Medical Center, Northwell Health, New Hyde Park (H.I., B.G.)
| | - Jonathan Willner
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Stuart Beldner
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Raman Mitra
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Roy John
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| | - Jason Chinitz
- Division of Electrophysiology, Department of Cardiology, Southside Hospital, Northwell Health, Bay Shore (J.C.)
| | - Nicholas Skipitaris
- Division of Electrophysiology, Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY (M.S., P.M., N.S., S.M.)
| | - Stavros Mountantonakis
- Division of Electrophysiology, Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, NY (M.S., P.M., N.S., S.M.)
| | - Laurence M. Epstein
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, NY (M.S., J.G., D.C., B.S.K., A.M., E.M., P.M., J.W., S.B., R.M., R.J., L.M.E.)
| |
Collapse
|
8
|
Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ. Urgent Guidance for Navigating and Circumventing the QTc-Prolonging and Torsadogenic Potential of Possible Pharmacotherapies for Coronavirus Disease 19 (COVID-19). Mayo Clin Proc 2020; 95:1213-1221. [PMID: 32359771 PMCID: PMC7141471 DOI: 10.1016/j.mayocp.2020.03.024] [Citation(s) in RCA: 286] [Impact Index Per Article: 71.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 02/08/2023]
Abstract
As the coronavirus disease 19 (COVID-19) global pandemic rages across the globe, the race to prevent and treat this deadly disease has led to the "off-label" repurposing of drugs such as hydroxychloroquine and lopinavir/ritonavir, which have the potential for unwanted QT-interval prolongation and a risk of drug-induced sudden cardiac death. With the possibility that a considerable proportion of the world's population soon could receive COVID-19 pharmacotherapies with torsadogenic potential for therapy or postexposure prophylaxis, this document serves to help health care professionals mitigate the risk of drug-induced ventricular arrhythmias while minimizing risk of COVID-19 exposure to personnel and conserving the limited supply of personal protective equipment.
Collapse
Affiliation(s)
- John R Giudicessi
- Department of Cardiovascular Medicine, Clinician-Investigator Training Program, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN
| | - Michael J Ackerman
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN; Department of Molecular Pharmacology and Experimental Therapeutics, Windland Smith Rice Sudden Death Genomics Laboratory, Mayo Clinic, Rochester, MN.
| |
Collapse
|
9
|
Polgreen LA, Riedle BN, Cavanaugh JE, Girotra S, London B, Schroeder MC, Polgreen PM. Estimated Cardiac Risk Associated With Macrolides and Fluoroquinolones Decreases Substantially When Adjusting for Patient Characteristics and Comorbidities. J Am Heart Assoc 2018; 7:e008074. [PMID: 29680825 PMCID: PMC6015293 DOI: 10.1161/jaha.117.008074] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/22/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Some studies have found that antimicrobials, especially macrolides, increase the risk of cardiovascular death. We investigated potential cardiac-related events associated with antimicrobial use in a population of patients with acute myocardial infarction. METHODS AND RESULTS For 185 010 Medicare beneficiaries, we recorded prescriptions for azithromycin, clarithromycin, levofloxacin, moxifloxacin, doxycycline, and amoxicillin-clavulanate. In the following week, we recorded death, acute myocardial infarction, atrial fibrillation or atrial flutter, a non-atrial fibrillation/atrial flutter arrhythmia, or ventricular arrhythmia. We fit unadjusted and adjusted logistic regression models using generalized estimating equations. Adjusted models included patients' comorbidities, medications, procedures, demographics, insurance status, time since index acute myocardial infarction, number of visits, and the influenza rate. In unadjusted analyses, macrolides and fluoroquinolones were associated with a risk of cardiac events. However, the risk associated with macrolide use was substantially attenuated after adjustment for a wide range of variables, and the risk associated with fluoroquinolones was no longer statistically significant. For example, for azithromycin, the odds ratio for any cardiac event or death was 1.35 (95% confidence interval, 1.27-1.44; P<0.0001), but after controlling for a wide range of covariates, the odds ratio decreased to 1.01 (95% confidence interval, 0.95-1.08; P<0.6688). CONCLUSIONS Controlling for covariates explains much of the adverse cardiac risk associated with antimicrobial use found in other studies. Most antimicrobials are not associated with risk of cardiac events, and others, specifically azithromycin and clarithromycin, may pose a small risk of certain cardiac events. However, the modest potential risks attributable to these antimicrobials must be weighed against the drugs' considerable and immediate benefits.
Collapse
Affiliation(s)
- Linnea A Polgreen
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, IA
| | | | | | - Saket Girotra
- Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Barry London
- Department of Internal Medicine, University of Iowa, Iowa City, IA
- Department of Molecular Physiology and Biophysics, University of Iowa, Iowa City, IA
| | - Mary C Schroeder
- Department of Pharmacy Practice and Science, University of Iowa, Iowa City, IA
| | - Philip M Polgreen
- Department of Internal Medicine, University of Iowa, Iowa City, IA
- Department of Epidemiology, University of Iowa, Iowa City, IA
| |
Collapse
|
10
|
Sutton SS, Hyche S, Magagnoli J, Hardin JW. Appraisal of the cardiovascular risks of azithromycin: an observational analysis. J Comp Eff Res 2017; 6:509-517. [PMID: 28960092 DOI: 10.2217/cer-2016-0080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIM To assess the association of cardiovascular mortality in patients prescribed azithromycin compared with patients prescribed alternative antibiotics in an outpatient setting. METHODS This study was a retrospective observational analysis using the South Carolina Medicaid claims and pharmacy databases over the years from 2000 to 2011 housed at the Revenue and Fiscal Affairs Office. Study antibiotics included azithromycin, amoxicillin, clindamycin, clarithromycin and quinolones (levofloxacin, ciprofloxacin and moxifloxacin), and excluded patients at a high risk of death from causes other than the study antibiotics. This study used both matching and regression adjustment with propensity scores to reduce possible bias in the estimated treatment (group) effect from confounders. RESULTS The total number of prescriptions evaluated in the study include: 283,743 azithromycin; 143,191 amoxicillin; 52,714 clindamycin; 38,133 clarithromycin and 49,734 for the quinolones. After propensity score weighting, cardiac deaths per million within the first 5 days were: 84.6 for azithromycin, 78.3 for clarithromycin, 69.4 for amoxicillin, 61.6 for quinolones and 15.0 for clindamycin. Our multivariate models reveal that the study antibiotics' (amoxicillin, clindamycin, clarithromycin, levofloxacin, ciprofloxacin and moxifloxacin) mortality rates are not statistically different from azithromycin in any time interval (days: 0-5, 6-10, 0-10 and 0-30). In comparison with previous studies, the results are consistent in Amoxicillin. In the first 5 and 10 days, it is associated with lower odds of cardiovascular death than azithromycin (5 days: odds ratio [OR]: 0.70 [95% CI: 0.25-1.99]; 10 days: OR: 0.92 [95% CI: 0.39-2.14]). However, we find no statistically significant difference between the two antibiotics. CONCLUSION Our study shows that the odds of cardiovascular mortality between azithromycin and other antibiotics are not statistically significantly different and previous published findings may not be applicable to the general population. Additionally our results suggest that while we cannot rule out the increased risk of cardiovascular death from azithromycin in patients at low risk of death, the risk may not be as large initial studies suggest. Further research is needed to define the population at greatest risk.
Collapse
Affiliation(s)
- S Scott Sutton
- Department of Clinical Pharmacy & Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, 715 Sumter Street (CLS 314b), SC 29208-0001, USA
| | - Stephanie Hyche
- Department of Clinical Pharmacy & Outcomes Sciences, South Carolina College of Pharmacy, University of South Carolina, 715 Sumter Street (CLS 314b), SC 29208-0001, USA
| | - Joseph Magagnoli
- Health & Demographics, South Carolina Revenue & Fiscal Affairs Office, 1919 Blanding Street, SC 29201, USA
| | - James W Hardin
- Department of Epidemiology & Biostatistics & Biostatistics Division, University of South Carolina, 1600 Hampton St, Suite 507, Room 539, SC 29208-3400, USA
| |
Collapse
|
11
|
Cornett E, Novitch MB, Kaye AD, Pann CA, Bangalore HS, Allred G, Bral M, Jhita PK, Kaye AM. Macrolide and fluoroquinolone mediated cardiac arrhythmias: clinical considerations and comprehensive review. Postgrad Med 2017; 129:715-724. [DOI: 10.1080/00325481.2017.1362938] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Elyse Cornett
- Departments of Anesthesiology and Pharmacology, Toxicology & Neuroscience, LSU Health Shreveport, Shreveport, LA, USA
| | | | - Alan D. Kaye
- Department of Anesthesiology, LSU-Health Science Center-New Orleans, New Orleans, LA, USA
| | - Chris A. Pann
- Department of Molecular & Cellular Biology, College of Science & Mathematics, California Polytechnic State University, San Luis Obispo, CA, USA
| | | | - Gregory Allred
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Matthew Bral
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | | | - Adam M. Kaye
- Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA, USA
| |
Collapse
|
12
|
Yang Z, Prinsen JK, Bersell KR, Shen W, Yermalitskaya L, Sidorova T, Luis PB, Hall L, Zhang W, Du L, Milne G, Tucker P, George AL, Campbell CM, Pickett RA, Shaffer CM, Chopra N, Yang T, Knollmann BC, Roden DM, Murray KT. Azithromycin Causes a Novel Proarrhythmic Syndrome. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.115.003560. [PMID: 28408648 DOI: 10.1161/circep.115.003560] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 01/26/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND The widely used macrolide antibiotic azithromycin increases risk of cardiovascular and sudden cardiac death, although the underlying mechanisms are unclear. Case reports, including the one we document here, demonstrate that azithromycin can cause rapid, polymorphic ventricular tachycardia in the absence of QT prolongation, indicating a novel proarrhythmic syndrome. We investigated the electrophysiological effects of azithromycin in vivo and in vitro using mice, cardiomyocytes, and human ion channels heterologously expressed in human embryonic kidney (HEK 293) and Chinese hamster ovary (CHO) cells. METHODS AND RESULTS In conscious telemetered mice, acute intraperitoneal and oral administration of azithromycin caused effects consistent with multi-ion channel block, with significant sinus slowing and increased PR, QRS, QT, and QTc intervals, as seen with azithromycin overdose. Similarly, in HL-1 cardiomyocytes, the drug slowed sinus automaticity, reduced phase 0 upstroke slope, and prolonged action potential duration. Acute exposure to azithromycin reduced peak SCN5A currents in HEK cells (IC50=110±3 μmol/L) and Na+ current in mouse ventricular myocytes. However, with chronic (24 hour) exposure, azithromycin caused a ≈2-fold increase in both peak and late SCN5A currents, with findings confirmed for INa in cardiomyocytes. Mild block occurred for K+ currents representing IKr (CHO cells expressing hERG; IC50=219±21 μmol/L) and IKs (CHO cells expressing KCNQ1+KCNE1; IC50=184±12 μmol/L), whereas azithromycin suppressed L-type Ca++ currents (rabbit ventricular myocytes, IC50=66.5±4 μmol/L) and IK1 (HEK cells expressing Kir2.1, IC50=44±3 μmol/L). CONCLUSIONS Chronic exposure to azithromycin increases cardiac Na+ current to promote intracellular Na+ loading, providing a potential mechanistic basis for the novel form of proarrhythmia seen with this macrolide antibiotic.
Collapse
Affiliation(s)
- Zhenjiang Yang
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Joseph K Prinsen
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Kevin R Bersell
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Wangzhen Shen
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Liudmila Yermalitskaya
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Tatiana Sidorova
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Paula B Luis
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Lynn Hall
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Wei Zhang
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Liping Du
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Ginger Milne
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Patrick Tucker
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alfred L George
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Courtney M Campbell
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Robert A Pickett
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Christian M Shaffer
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Nagesh Chopra
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Tao Yang
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Bjorn C Knollmann
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Dan M Roden
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN
| | - Katherine T Murray
- From the Department of Medicine and Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN.
| |
Collapse
|
13
|
Trifirò G, de Ridder M, Sultana J, Oteri A, Rijnbeek P, Pecchioli S, Mazzaglia G, Bezemer I, Garbe E, Schink T, Poluzzi E, Frøslev T, Molokhia M, Diemberger I, Sturkenboom MCJM. Use of azithromycin and risk of ventricular arrhythmia. CMAJ 2017; 189:E560-E568. [PMID: 28420680 DOI: 10.1503/cmaj.160355] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND There are conflicting findings from observational studies of the arrhythrogenic potential of azithromycin. Our aim was to quantify the association between azithromycin use and the risk of ventricular arrhythmia. METHODS We conducted a nested case-control study within a cohort of new antibiotic users identified from a network of 7 population-based health care databases in Denmark, Germany, Italy, the Netherlands and the United Kingdom for the period 1997-2010. Up to 100 controls per case were selected and matched by age, sex and database. Recency of antibiotic use and type of drug (azithromycin was the exposure of interest) at the index date (occurrence of ventricular arrhythmia) were identified. We estimated the odds of ventricular arrhythmia associated with current azithromycin use relative to current amoxicillin use or nonuse of antibiotics (≥ 365 d without antibiotic exposure) using conditional logistic regression, adjusting for confounders. RESULTS We identified 14 040 688 new antibiotic users who met the inclusion criteria. Ventricular arrhythmia developed in 12 874, of whom 30 were current azithromycin users. The mean age of the cases and controls was 63 years, and two-thirds were male. In the pooled data analyses across databases, azithromycin use was associated with an increased risk of ventricular arrhythmia relative to nonuse of antibiotics (adjusted odds ratio [OR] 1.97, 95% confidence interval [CI] 1.35-2.86). This increased risk disappeared when current amoxicillin use was the comparator (adjusted OR 0.90, 95% CI 0.48-1.71). Database-specific estimates and meta-analysis confirmed results from the pooled data analysis. INTERPRETATION Current azithromycin use was associated with an increased risk of ventricular arrhythmia when compared with nonuse of antibiotics, but not when compared with current amoxicillin use. The decreased risk with an active comparator suggests significant confounding by indication.
Collapse
Affiliation(s)
- Gianluca Trifirò
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Maria de Ridder
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Janet Sultana
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Alessandro Oteri
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Peter Rijnbeek
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Serena Pecchioli
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Giampiero Mazzaglia
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Irene Bezemer
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Edeltraut Garbe
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Tania Schink
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Elisabetta Poluzzi
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Trine Frøslev
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Mariam Molokhia
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| | - Miriam C J M Sturkenboom
- Department of Medical Informatics (Trifirò, de Ridder, Sultana, Oteri, Rijnbeek, Sturkenboom), Erasmus University Medical Center, Rotterdam, Netherlands; Department of Biomedical and Dental Sciences and Morpho-functional Imaging (Trifirò), and Department of Clinical and Experimental Medicine (Sultana), University of Messina, Messina, Italy; Health Search, Italian College of General Practitioners (Pecchioli, Mazzaglia), Florence, Italy; PHARMO Institute for Drug Outcomes Research (Bezemer), Utrecht, Netherlands; Leibniz Institute for Prevention Research and Epidemiology - BIPS GmbH (Garbe, Schink), Bremen, Germany; Department of Medical and Surgical Sciences (Poluzzi), University of Bologna, Bologna, Italy; Department of Clinical Epidemiology (Frøslev), Aarhus University Hospital, Aarhus, Denmark; Department of Primary Care and Public Health Sciences (Molokhia), King's College, London, United Kingdom; Department of Experimental, Diagnostic and Specialty Medicine (Diemberger), University of Bologna, Bologna, Italy
| |
Collapse
|
14
|
Valdés SO, Kim JJ, Niu MC, de la Uz CM, Miyake CY, Moffett BS. Cardiac Arrest in Pediatric Patients Receiving Azithromycin. J Pediatr 2017; 182:311-314.e1. [PMID: 27912925 DOI: 10.1016/j.jpeds.2016.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 09/13/2016] [Accepted: 11/02/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare outcomes of pediatric patients treated with azithromycin compared with penicillin or cephalosporin. We hypothesized that azithromycin use would not be associated with increased cardiac mortality in the pediatric population. STUDY DESIGN Retrospective cohort study from the Pediatric Health Information System database between 2008 and 2012. Patients <19 years of age with a principal diagnosis of community-acquired pneumonia who received an antibiotic were included. Primary outcomes were cardiopulmonary resuscitation (CPR) and mortality. Secondary outcomes were ventricular arrhythmias incidences and readmission for ventricular arrhythmia. Statistical analysis was performed with the χ2 test. Multivariable analysis was performed to control for potential confounders among patient, event, and treatment characteristics. RESULTS A total of 82 982 patients (54.3% males) met study criteria. Median age was 2.6 years (IQR 1.2-5.9 years) and median length of stay was 2 days (IQR 2-4 days). Azithromycin was used in 5039 (6.1%); penicillin or cephalosporin was used in 77 943 (93.9%). Overall prevalence of antibiotic-associated CPR was 0.14%. Patients receiving a macrolide antibiotic had a lower prevalence of CPR compared with patients receiving a penicillin or cephalosporin (0.04% vs 0.14%, P = .04), and there was no difference in mortality. Multivariable analysis did not find an association between macrolide use and CPR. CONCLUSIONS In contrast to recent adult studies, among children hospitalized for community-acquired pneumonia, azithromycin use was not associated with a greater prevalence of cardiac arrest compared with penicillin or cephalosporin use.
Collapse
Affiliation(s)
- Santiago O Valdés
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Jeffrey J Kim
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Mary C Niu
- Oklahoma Children's Heart Center, Oklahoma University Health Sciences Center, Oklahoma City, OK
| | - Caridad M de la Uz
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Christina Y Miyake
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| |
Collapse
|
15
|
An evaluation strategy for potential QTc prolongation with chronic azithromycin therapy in cystic fibrosis. J Cyst Fibros 2016; 15:192-5. [DOI: 10.1016/j.jcf.2015.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 10/24/2015] [Accepted: 11/23/2015] [Indexed: 01/08/2023]
|
16
|
Trac MH, McArthur E, Jandoc R, Dixon SN, Nash DM, Hackam DG, Garg AX. Macrolide antibiotics and the risk of ventricular arrhythmia in older adults. CMAJ 2016; 188:E120-E129. [PMID: 26903359 DOI: 10.1503/cmaj.150901] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Many respiratory tract infections are treated with macrolide antibiotics. Regulatory agencies warn that these antibiotics increase the risk of ventricular arrhythmia. We examined the 30-day risk of ventricular arrhythmia and all-cause mortality associated with macrolide antibiotics relative to nonmacrolide antibiotics. METHODS We conducted a population-based retrospective cohort study involving older adults (age > 65 yr) with a new prescription for an oral macrolide antibiotic (azithromycin, clarithromycin or erythromycin) in Ontario from 2002 to 2013. Our primary outcome was a hospital encounter with ventricular arrhythmia within 30 days after a new prescription. Our secondary outcome was 30-day all-cause mortality. We matched patients 1:1 using propensity scores to patients prescribed nonmacrolide antibiotics (amoxicillin, cefuroxime or levofloxacin). We used conditional logistic regression to measure the association between macrolide exposure and outcomes, and repeated the analysis in 4 subgroups defined by the presence or absence of chronic kidney disease, congestive heart failure, coronary artery disease and concurrent use of a drug known to prolong the QT interval. RESULTS Compared with nonmacrolide antibiotics, macrolide antibiotics were not associated with a higher risk of ventricular arrhythmia (0.03% v. 0.03%; relative risk [RR] 1.06, 95% confidence interval [CI] 0.83-1.36) and were associated with a lower risk of all-cause mortality (0.62% v. 0.76%; RR 0.82, 95% CI 0.78-0.86). These associations were similar in all subgroups. INTERPRETATION Among older adults, macrolide antibiotics were not associated with a higher 30-day risk of ventricular arrhythmia than nonmacrolide antibiotics. These findings suggest that current warnings from the US Food and Drug Administration may be overstated.
Collapse
Affiliation(s)
- Mai H Trac
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Eric McArthur
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Racquel Jandoc
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Stephanie N Dixon
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Danielle M Nash
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Daniel G Hackam
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont
| | - Amit X Garg
- Department of Epidemiology and Biostatistics (Trac, Garg), Western University; Lawson Health Research Institute (Trac), London Health Sciences Centre; Institute for Clinical Evaluative Sciences (ICES) Western (McArthur, Jandoc, Dixon, Nash, Garg); Divisions of Clinical Pharmacology (Hackam) and Nephrology (Garg), Department of Medicine, Western University, London, Ont.
| |
Collapse
|
17
|
Lu ZK, Yuan J, Li M, Sutton SS, Rao GA, Jacob S, Bennett CL. Cardiac risks associated with antibiotics: azithromycin and levofloxacin. Expert Opin Drug Saf 2015; 14:295-303. [PMID: 25494485 PMCID: PMC4404501 DOI: 10.1517/14740338.2015.989210] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Azithromycin and levofloxacin have been shown to be efficacious in treating infections. The adverse drug events associated with azithromycin and levofloxacin were considered rare. However, the US FDA released warnings regarding the possible risk of QT prolongation with azithromycin and levofloxacin. AREAS COVERED Case reports/case series, observational studies and clinical trials assessing cardiovascular risks associated with azithromycin and levofloxacin were critically reviewed, including 15 case reports/series, 5 observational studies and 5 clinical trials that investigated the cardiac risks associated azithromycin and levofloxacin. EXPERT OPINION Results are discordant. Two retrospective studies utilizing large databases demonstrated an increased risk of cardiovascular death with azithromycin, when azithromycin was compared with amoxicillin. Two other retrospective studies found no difference in cardiovascular death associated with azithromycin and other antibiotics. For levofloxacin, the increased risk of cardiovascular death was only found in one retrospective study. Therefore, the risks and benefits of antibacterial therapies should be considered when making prescription decisions. This study should not preclude clinicians from avoiding azithromycin and levofloxacin. If a patient has an indication to receive an antibiotic and if azithromycin or levofloxacin is needed, it may be used, but the potential risks must be understood.
Collapse
Affiliation(s)
- Zhiqiang Kevin Lu
- University of South Carolina, South Carolina College of Pharmacy, Clinical Pharmacy and Outcomes Sciences Department , 715 Sumter Street, CLS Building, Room 311G, Columbia, SC 29208 , USA +1 803 777 2653 ; +1 803 777 2820 ;
| | | | | | | | | | | | | |
Collapse
|
18
|
Albert RK, Schuller JL. Macrolide antibiotics and the risk of cardiac arrhythmias. Am J Respir Crit Care Med 2014; 189:1173-80. [PMID: 24707986 DOI: 10.1164/rccm.201402-0385ci] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Randomized, controlled trials have demonstrated that chronic therapy with macrolide antibiotics reduces the morbidity of patients with cystic fibrosis, non-cystic fibrosis bronchiectasis, chronic obstructive pulmonary disease, and nontuberculous mycobacterial infections. Lower levels of evidence indicate that chronic macrolides are also effective in treating patients with panbronchiolitis, bronchiolitis obliterans, and rejection after lung transplant. Macrolides are known to cause torsade des pointes and other ventricular arrhythmias, and a recent observational study prompted the FDA to strengthen the Warnings and Precautions section of azithromycin drug labels. This summary describes the electrophysiological effects of macrolides, reviews literature indicating that the large majority of subjects experiencing cardiac arrhythmias from macrolides have coexisting risk factors and that the incidence of arrhythmias in absence of coexisting risk factors is very low, examines recently published studies describing the relative risk of arrhythmias from macrolides, and concludes that this risk has been overestimated and suggests an approach to patient evaluation that should reduce the relative risk and the incidence of arrhythmias to the point that chronic macrolides can be used safely in the majority of subjects for whom they are recommended.
Collapse
|
19
|
Giudicessi JR, Ackerman MJ. Azithromycin and risk of sudden cardiac death: guilty as charged or falsely accused? Cleve Clin J Med 2014; 80:539-44. [PMID: 24001961 DOI: 10.3949/ccjm.80a.13077] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- John R Giudicessi
- Mayo Medical School, Mayo Graduate School, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
20
|
Trinkley KE, Page RL, Lien H, Yamanouye K, Tisdale JE. QT interval prolongation and the risk of torsades de pointes: essentials for clinicians. Curr Med Res Opin 2013; 29:1719-26. [PMID: 24020938 DOI: 10.1185/03007995.2013.840568] [Citation(s) in RCA: 161] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE QT interval prolongation signifies an increased risk of the life-threatening arrhythmia torsades de pointes (TdP). The purpose of this paper is to review the diverse methods for assessing and monitoring the risk of TdP, discuss risk factors for TdP, and recommend interventions that may mitigate the risk of TdP. METHODS A non-systematic search of PubMed (through March 2013) was conducted to determine the optimal approach to assessing and monitoring QT interval, prevention of TdP, and to identify risks factors for TdP. Papers known to the authors were included, as were scientific statements. Articles were chosen based on the judgment of the authors. RESULTS Risk factors for drug-induced TdP include hypokalemia, female sex, drug-drug interactions, advancing age, genetic predisposition, hypomagnesemia, heart failure, bradycardia, and corrected QT (QTc) interval prolongation. Many risk factors, including hypokalemia, use of QT-interval-prolonging drugs, and drug interactions are potentially modifiable and should be corrected in persons at risk for QT interval prolongation. Given the variable onset of TdP following initiation of QT-interval-prolonging drugs, careful and regular monitoring of electrocardiography (EKG) and electrolytes are necessary. Patients at risk for QT interval prolongation should be educated to go directly to the emergency room if they experience palpitations, lightheadedness, dizziness or syncope. When the QTc interval is 470-500 ms for males, or 480-500 ms for females, or the QTc interval increases 60 ms or more from pretreatment values, dose reduction or discontinuation of the offending drug should be considered where possible, and electrolytes corrected as needed. Furthermore, if the QTc interval is ≥500 ms, the offending drug should be discontinued, and continuous EKG telemetry monitoring should be performed, or the 12-lead EKG should be repeated every 2-4 hours, until the QT interval has normalized. CONCLUSIONS Close monitoring for QTc prolongation is necessary to prevent TdP. The recommendations in this paper are limited by the available evidence and additional studies are needed to better define the approach to monitoring.
Collapse
Affiliation(s)
- Katy E Trinkley
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences , Aurora, CO , USA
| | | | | | | | | |
Collapse
|
21
|
Hancox JC, Hasnain M, Vieweg WVR, Crouse ELB, Baranchuk A. Azithromycin, cardiovascular risks, QTc interval prolongation, torsade de pointes, and regulatory issues: A narrative review based on the study of case reports. Ther Adv Infect Dis 2013; 1:155-65. [PMID: 25165550 PMCID: PMC4040726 DOI: 10.1177/2049936113501816] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Over the past year, three articles have appeared in the New England Journal of Medicine describing conflicting findings about azithromycin and cardiac safety, particular azithromycin-induced QTc interval prolongation and torsade de pointes. The FDA wants healthcare providers to consider azithromycin-induced fatal cardiac arrhythmias for patients already at risk for cardiac death and other potentially arrhythmogenic cardiovascular conditions. In a systematic review of case reports we sought to determine factors that link to azithromycin-induced/associated QTc interval prolongation and torsade de pointes. We found 12 cases: seven female and five male. Of the nine adults with reported azithromycin doses, concurrent QTc interval measurement, and without congenital long QT syndrome, we found no significant relationship between dose and QTc interval duration. Additional risk factors were female sex, older age, heart disease, QTc interval prolonging drugs and metabolic inhibitors, hypokalemia, and bradycardia. All 12 subjects had at least two additional risk factors. Elderly women with heart disease appear to be at particularly risk for drug-related QTc interval prolongation and torsade de pointes.
Collapse
Affiliation(s)
- Jules C Hancox
- School of Physiology and Pharmacology and Cardiovascular Research Laboratories, Medical Sciences Building, University of Bristol, University Walk, Bristol, UK
| | - Mehrul Hasnain
- Department of Psychiatry, Memorial University, St John's, Newfoundland, Canada
| | - W Victor R Vieweg
- School of Physiology and Pharmacology and Cardiovascular Research Laboratories, Medical Sciences Building, University of Bristol, Bristol, UK
| | | | - Adrian Baranchuk
- Department of Cardiology, Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| |
Collapse
|
22
|
Stratov I, Denholm J, Kent SJ. Azithromycin: more lethal than chloramphenicol? Sex Health 2013; 10:179-82. [DOI: 10.1071/sh12128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 11/18/2012] [Indexed: 11/23/2022]
Abstract
Azithromycin is commonly used in sexual health and respiratory medicine, often when the diagnosis is presumptive. A recent article by Ray et al. reported that 1 out of 20 000 courses of low-dose azithromycin was associated with (sudden) cardiovascular death (including 1 out of 4000 courses in high-risk cardiovascular patients), ascribing these deaths to azithromycin itself. Here, we critique the actual study and examine conflicting data from randomised control trials, animal studies and observational data.
Collapse
|
23
|
Abstract
BACKGROUND Although several macrolide antibiotics are proarrhythmic and associated with an increased risk of sudden cardiac death, azithromycin is thought to have minimal cardiotoxicity. However, published reports of arrhythmias suggest that azithromycin may increase the risk of cardiovascular death. METHODS We studied a Tennessee Medicaid cohort designed to detect an increased risk of death related to short-term cardiac effects of medication, excluding patients with serious noncardiovascular illness and person-time during and shortly after hospitalization. The cohort included patients who took azithromycin (347,795 prescriptions), propensity-score-matched persons who took no antibiotics (1,391,180 control periods), and patients who took amoxicillin (1,348,672 prescriptions), ciprofloxacin (264,626 prescriptions), or levofloxacin (193,906 prescriptions). RESULTS During 5 days of therapy, patients taking azithromycin, as compared with those who took no antibiotics, had an increased risk of cardiovascular death (hazard ratio, 2.88; 95% confidence interval [CI], 1.79 to 4.63; P<0.001) and death from any cause (hazard ratio, 1.85; 95% CI, 1.25 to 2.75; P=0.002). Patients who took amoxicillin had no increase in the risk of death during this period. Relative to amoxicillin, azithromycin was associated with an increased risk of cardiovascular death (hazard ratio, 2.49; 95% CI, 1.38 to 4.50; P=0.002) and death from any cause (hazard ratio, 2.02; 95% CI, 1.24 to 3.30; P=0.005), with an estimated 47 additional cardiovascular deaths per 1 million courses; patients in the highest decile of risk for cardiovascular disease had an estimated 245 additional cardiovascular deaths per 1 million courses. The risk of cardiovascular death was significantly greater with azithromycin than with ciprofloxacin but did not differ significantly from that with levofloxacin. CONCLUSIONS During 5 days of azithromycin therapy, there was a small absolute increase in cardiovascular deaths, which was most pronounced among patients with a high baseline risk of cardiovascular disease. (Funded by the National Heart, Lung, and Blood Institute and the Agency for Healthcare Quality and Research Centers for Education and Research on Therapeutics.).
Collapse
Affiliation(s)
- Wayne A Ray
- Division of Pharmacoepidemiology, Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | | | | | | | | |
Collapse
|
24
|
Huang BH, Wu CH, Hsia CP, Yin Chen C. Azithromycin-induced torsade de pointes. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 30:1579-82. [PMID: 18070319 DOI: 10.1111/j.1540-8159.2007.00912.x] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although erythromycin frequently induces long QT interval and torsade de pointes, the newer drug, azithromycin, has rarely been reported to be associated with torsade de pointes. We report here the occurrence of a significant typical QT prolongation within a few hours after taking azithromycin which lead to torsade de pointes.
Collapse
Affiliation(s)
- Bien-Hsien Huang
- Kuang Tien General Hospital, Cardiology Division, Internal Medicine Department, Taichung, Taiwan
| | | | | | | |
Collapse
|
25
|
Lim JH, Kim ES, Chung MH, Kang JS. Torsades de Pointes by Azithromycin in Scrub Typhus and Review on Cardiac Manifestations of Scrub Typhus. Infect Chemother 2008. [DOI: 10.3947/ic.2008.40.1.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Joo-Han Lim
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Eun Sil Kim
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Moon-Hyun Chung
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jae-Seung Kang
- Department of Microbiology, Inha University College of Medicine, Incheon, Korea
| |
Collapse
|
26
|
Kezerashvili A, Khattak H, Barsky A, Nazari R, Fisher JD. Azithromycin as a cause of QT-interval prolongation and torsade de pointes in the absence of other known precipitating factors. J Interv Card Electrophysiol 2007; 18:243-6. [PMID: 17546486 DOI: 10.1007/s10840-007-9124-y] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Accepted: 04/03/2007] [Indexed: 01/08/2023]
Abstract
During treatment with azithromycin, a 55 year-old woman developed a newly prolonged QT interval and torsade de pointes in the absence of known risk factors. Female gender and acute renal failure may be considerations in patients treated with azithromycin.
Collapse
Affiliation(s)
- Anna Kezerashvili
- Department of Medicine, Cardiology Division, Arrhythmia Service, Montefiore Medical Center/Cardiology-N2, Albert Einstein College of Medicine, Bronx, NY 10467, USA
| | | | | | | | | |
Collapse
|
27
|
Owens RC, Nolin TD. Antimicrobial-associated QT interval prolongation: pointes of interest. Clin Infect Dis 2006; 43:1603-11. [PMID: 17109296 DOI: 10.1086/508873] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Accepted: 07/17/2006] [Indexed: 01/16/2023] Open
Abstract
Until recently, cardiac toxicity manifesting in the form of arrhythmias related to QT interval prolongation was uncommonly appreciated within the antimicrobial class of drugs, but it was well described among antiarrhythmic agents. Antimicrobials that are associated with QT prolongation include the macrolides/ketolides, certain fluoroquinolones and antimalarials, pentamidine, and the azole antifungals. Although, in most cases, mild delays in ventricular repolarization caused by these drugs are clinically unnoticeable, they may serve to amplify the risk for torsades de pointes (TdP) when prescribed in the setting of other risk factors. Conditions or variables that influence proarrhythmic risk include sex, age, electrolyte derangements, structural heart disease, pharmacokinetic/pharmacodynamic interactions, and genetic predisposition. It is important that clinicians be knowledgeable about drugs with QT liability, as well as the risk factors that increase the probability of TdP. Additionally, because TdP remains a difficult-to-measure adverse event, we must rely upon multiple data sources to determine the risk versus the benefit for newly approved drugs.
Collapse
Affiliation(s)
- Robert C Owens
- Department of Clinical Pharmacy Services, Maine Medical Center, Portland, ME 04102, USA.
| | | |
Collapse
|
28
|
Justo D, Zeltser D. Torsades de pointes induced by antibiotics. Eur J Intern Med 2006; 17:254-9. [PMID: 16762774 DOI: 10.1016/j.ejim.2005.12.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2005] [Revised: 11/16/2005] [Accepted: 12/15/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Several frequently used antibiotics are associated with an arrhythmia called "torsades de pointes" (TdP). This potentially fatal arrhythmia is considered unpredictable. METHODS In order to investigate the prevalence of risk factors for TdP prior to initiation of antibiotic therapy, we conducted a literature search for all published reports on TdP induced by antibiotics and we asked pharmaceutical companies for additional unpublished reports. RESULTS We studied 61 reports on 78 patients with TdP induced by antibiotics. Female gender was the most common risk factor for TdP: 66.7% (n=52) of all patients were women. Advanced heart disease and concomitant use of a QT interval-prolonging agent or an inhibitor of liver drug metabolism were also frequently present (59% and 48.7%, respectively). Most patients had at least one and 58 patients (74.3%) had two risk factors or more for TdP prior to initiation of antibiotic therapy. CONCLUSION Contrary to common belief, TdP induced by antibiotics may be predictable by simple history-taking and by obtaining a baseline electrocardiogram. We wish to draw attention to risk factors for TdP prior to the initiation of antibiotic therapy.
Collapse
Affiliation(s)
- Dan Justo
- Department of Internal Medicine "D", Tel-Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel
| | | |
Collapse
|
29
|
Liu T, Brown BS, Wu Y, Antzelevitch C, Kowey PR, Yan GX. Blinded validation of the isolated arterially perfused rabbit ventricular wedge in preclinical assessment of drug-induced proarrhythmias. Heart Rhythm 2006; 3:948-56. [PMID: 16876745 PMCID: PMC1955432 DOI: 10.1016/j.hrthm.2006.04.021] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 04/16/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND The development of preclinical models with high predictive value for the identification of drugs with a proclivity to induce Torsade de Pointes (TdP) in the clinic has long been a pressing goal of academia, industry and regulatory agencies alike. The present study provides a blinded appraisal of drugs, in an isolated arterially-perfused rabbit ventricular wedge preparation, with and without the potential to produce TdP. METHODS AND RESULTS Thirteen compounds were tested for their potential for TdP using the rabbit left ventricular wedges. All investigators were blinded to the names, concentrations and molecular weights of the drugs. The compounds were prepared by the study sponsor and sent to the investigator as 4 sets of 13 stock solutions with the order within each set being assigned by a random number generator. Each compound was scored semi-quantitatively for its relative potential for TdP based on its effect on ventricular repolarization measured as QT interval, dispersion of repolarization measured as T(p-e)/QT ratio and early afterdepolarizations. Disclosure of the names and concentrations after completion of the study revealed that all compounds known to be free of TdP risk received a score of less or equal to 0.25, whereas those with known TdP risk received a score ranging from 1.00 to 7.25 at concentrations less than 100X their free therapeutic plasma C(max). CONCLUSIONS Our study provides a blinded evaluation of the isolated arterially-perfused rabbit wedge preparation demonstrating both a high sensitivity and specificity in the assessment of 13 agents with varying propensity for causing TdP.
Collapse
Affiliation(s)
| | | | - Ying Wu
- Main Line Health Heart Center, Wynnewood, PA
| | | | - Peter R Kowey
- Main Line Health Heart Center, Wynnewood, PA
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, 19107
| | - Gan-Xin Yan
- Main Line Health Heart Center, Wynnewood, PA
- Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, 19107
| |
Collapse
|
30
|
Kim MH, Berkowitz C, Trohman RG. Polymorphic ventricular tachycardia with a normal QT interval following azithromycin. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2006; 28:1221-2. [PMID: 16359290 DOI: 10.1111/j.1540-8159.2005.50146.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Michael H Kim
- The Heart Center, Regions Hospital, St. Paul, Minnesota 55101-2595, USA.
| | | | | |
Collapse
|
31
|
Champeroux P, Viaud K, El Amrani AI, Fowler JSL, Martel E, Le Guennec JY, Richard S. Prediction of the risk of Torsade de Pointes using the model of isolated canine Purkinje fibres. Br J Pharmacol 2005; 144:376-85. [PMID: 15655517 PMCID: PMC1576014 DOI: 10.1038/sj.bjp.0706070] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Torsade de Pointes (TdP) is a well-described major risk associated with various kinds of drugs. However, prediction of this risk is still uncertain both in preclinical and clinical trials. We tested 45 reference compounds on the model of isolated canine Purkinje fibres. Of them, 22 are clearly associated and/or labelled with a risk of TdP, and 13 others are drugs with published clinical evidence of QT prolongation, with only one or two exceptional cases of TdP. The 10 remaining drugs are without reports of TdP and QT prolongation. The relevance of different indicators such as APD(90) increase, reverse use dependency, action potential triangulation or effect on V(max) was evaluated by comparison with available clinical data. Finally, a complex algorithm called TDPscreen and based on two subalgorithms corresponding to particular electrophysiological patterns was defined. This latter algorithm enabled a clear separation of drugs into three groups: (A) drugs with numerous or several reports (>2 cases) of TdP, (B) drugs causing QT prolongation and/or TdP only, the latter at a very low frequency (< or =2 cases), (C) drugs without reports of TdP or QT prolongation. The use of such an algorithm combined with a database accrued from reference compounds with available clinical data is suggested as a basis for testing new candidate drugs in the early stages of development for proarrhythmic risk prediction.
Collapse
Affiliation(s)
- Pascal Champeroux
- Centre de Recherches Biologiques, Chemin de Montifault, 18800 Baugy, France.
| | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
Cardiac toxicity has been relatively uncommon within the antimicrobial class of drugs, but well described for antiarrhythmic agents and certain antihistamines. Macrolides, pentamidine and certain antimalarials were traditionally known to cause QT-interval prolongation, and now azole antifungals, fluoroquinolones and ketolides can be added to the list. Over time, advances in preclinical testing methods for QT-interval prolongation and a better understanding of its sequelae, most notably torsades de pointes (TdP), have occurred. This, combined with the fact that five drugs have been removed from the market over the last several years, in part because of QT-interval prolongation-related toxicity, has elevated the urgency surrounding early detection and characterisation methods for evaluating non-antiarrhythmic drug classes. With technological advances and accumulating literature regarding QT prolongation, it is currently difficult or overwhelming for the practising clinician to interpret these data for purposes of formulary review or for individual patient treatment decisions. Certain patients are susceptible to the effects of QT-prolonging drugs. For example, co-variates such as gender, age, electrolyte derangements, structural heart disease, end organ impairment and, perhaps most important, genetic predisposition, underlie most if not all cases of TdP. Between and within classes of drugs there are important differences that contribute to delayed repolarisation (e.g. intrinsic potency to inhibit certain cardiac ion currents or channels, and pharmacokinetics). To this end, a risk stratification scheme may be useful to rank and compare the potential for cardiotoxicity of each drug. It appears that in most published cases of antimicrobial-associated TdP, multiple risk factors are present. Macrolides in general are associated with a greater potential than other antimicrobials for causing TdP from both a pharmacodynamic and pharmacokinetic perspective. The azole antifungal agents also can be viewed as drugs that must be weighed carefully before use since they also have both pharmacodynamic and pharmacokinetic characteristics that may trigger TdP. The fluoroquinolones appear less likely to be associated with TdP from a pharmacokinetic perspective since they do not rely on cytochrome P450 (CYP) metabolism nor do they inhibit CYP enzyme isoforms, with the exception of grepafloxacin and ciprofloxacin. Nonetheless, patient selection must be carefully made for all of these drugs. For clinicians, certain responsibilities are assumed when prescribing antimicrobial therapy: (i) appropriate use to minimise resistance; and (ii) appropriate patient and drug selection to minimise adverse event potential. Incorporating information learned regarding QT interval-related adverse effects into the drug selection process may serve to minimise collateral iatrogenic toxicity.
Collapse
Affiliation(s)
- Robert C Owens
- Department of Clinical Pharmacy, Maine Medical Center, Portland, 04102, USA.
| |
Collapse
|