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Nham T, Garcia MC, Tsang KLJ, Silva JM, Schneider T, Deng J, Lohit S, Mbuagbaw L, Holbrook A. Proarrhythmic major adverse cardiac events with donepezil: A systematic review with meta-analysis. J Am Geriatr Soc 2024; 72:2552-2565. [PMID: 38580328 DOI: 10.1111/jgs.18909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 02/05/2024] [Accepted: 03/16/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Cholinesterase inhibitors (ChEIs) are regularly used in Alzheimer's disease. Of the three ChEIs approved for dementia, donepezil is among the most prescribed drugs in the United States with nearly 6 million prescriptions in 2020; however, it is classified as a "known risk" QT interval-prolonging medication (QTPmed). Given this claim is derived from observational data including single case reports, we aimed to evaluate high-quality literature on the frequency and nature of proarrhythmic major adverse cardiac events (MACE) associated with donepezil. METHODS We searched Medline, Embase, International Pharmaceutical Abstracts, and Cochrane Central from 1996 onwards for randomized controlled trials (RCTs) involving patients age ≥18 years comparing donepezil to placebo. The MACE composite included mortality, sudden cardiac death, non-fatal cardiac arrest, Torsades de pointes, ventricular tachyarrhythmia, seizure or syncope. Random-effects meta-analyses were performed with a treatment-arm continuity correction for single and double zero event studies. RESULTS Sixty RCTs (n = 12,463) were included. Twenty-five of 60 trials (n = 5886) investigated participants with Alzheimer's disease and 33 trials monitored electrocardiogram data. The mean follow-up duration was 31 weeks (SD = 36). Mortality was the most commonly reported MACE (252/331, 75.8% events), the remainder were syncope or seizures, with no arrhythmia events. There was no increased risk of MACE with exposure to donepezil compared to placebo (risk ratio [RR] 1.08, 95% CI 0.88-1.33, I2 = 0%) and this was consistent in the subgroup analysis of trials including participants with cardiovascular morbidities (RR 1.14, 95% CI 0.88-1.47). Subgroup analysis suggested a trend toward more events with donepezil with follow-up ≥52 weeks (RR: 1.32, 0.98-1.79). CONCLUSIONS This systematic review with meta-analysis found donepezil may not be arrhythmogenic. Donepezil was not associated with mortality, ventricular arrhythmias, seizure or syncope, although longer durations of therapy need more study. Further research to clarify actual clinical outcomes related to QTPmed is important to inform prescribing practices.
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Affiliation(s)
- Tina Nham
- Division of Geriatrics, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Cristian Garcia
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kai La Jennifer Tsang
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Biomedical and Molecular Sciences, Queens University, Kingston, Ontario, Canada
| | - Jessyca Matos Silva
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tyler Schneider
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Jiawen Deng
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simran Lohit
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Clinical Pharmacology & Toxicology Research Group, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, St Joseph's Healthcare, Hamilton, Ontario, Canada
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Mao M, Wei Y, Wang C, Han X, Liu R, Dong Y, Song L, Cong L, Wang Y, Du Y, Qiu C. Prolonged ventricular repolarization associated with mild cognitive impairment and white matter hyperintensities: a cross-sectional study. Sci Rep 2024; 14:15162. [PMID: 38956440 PMCID: PMC11219852 DOI: 10.1038/s41598-024-65364-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024] Open
Abstract
Prolonged ventricular repolarization has been associated with cardiovascular disease. We sought to investigate the association of prolonged ventricular repolarization with mild cognitive impairment (MCI) and the potential underlying neuropathological mechanisms in older adults. This cross-sectional study included 4328 dementia-free participants (age ≥ 65 years; 56.8% female) in the baseline examination of the Multidomain INterventions to delay dementia and Disability in rural China; of these, 989 undertook structural brain magnetic resonance imaging (MRI) scans. QT, QTc, JT, JTc, and QRS intervals were derived from 12-lead electrocardiograph. MCI, amnestic MCI (aMCI), and non-amnestic MCI (naMCI) were defined following the Petersen's criteria. Volumes of gray matter (GM), white matter, cerebrospinal fluid, total white matter hyperintensities (WMH), periventricular WMH (PWMH), and deep WMH (DWMH) were automatically estimated. Data were analyzed using logistic and general linear regression models. Prolonged QT, QTc, JT, and JTc intervals were significantly associated with an increased likelihood of MCI and aMCI, but not naMCI (p < 0.05). In the MRI subsample, QT, QTc, JT, and JTc intervals were significantly associated with larger total WMH and PWMH volumes (p < 0.05), but not with DWMH volume. Statistical interactions were detected, such that prolonged QT and JT intervals were significantly associated with reduced GM volume only among participants with coronary heart disease or without APOE ε4 allele (p < 0.05). Prolonged ventricular repolarization is associated with MCI and cerebral microvascular lesions in a general population of older adults. This underlies the importance of cognitive assessments and brain MRI examination among older adults with prolonged QT interval.
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Affiliation(s)
- Ming Mao
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China
| | - Yiran Wei
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
| | - Chaoqun Wang
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, People's Republic of China
| | - Xiaolei Han
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China
| | - Rui Liu
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China
| | - Yi Dong
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China
| | - Lin Song
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China
| | - Lin Cong
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China
| | - Yongxiang Wang
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China.
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China.
- Institute of Brain Science and Brain-Inspired Research, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, 250021, Shandong, People's Republic of China.
- Department of Neurobiology, Care Sciences and Society, Aging Research Center and Center for Alzheimer Research, Karolinska Institutet-Stockholm University, 17177, Stockholm, Sweden.
| | - Yifeng Du
- Department of Neurology, Shandong Provincial Hospital affiliated to Shandong First Medical University, No. 324 Jingwuweiqi Road, Jinan, 250021, Shandong, People's Republic of China.
- Key Laboratory of Endocrine Glucose and Lipids Metabolism and Brain Aging in Shandong First Medical University, Ministry of Education of the People's Republic of China, Jinan, 250021, Shandong, People's Republic of China.
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, People's Republic of China.
| | - Chengxuan Qiu
- Department of Neurology, Shandong Provincial Hospital, Shandong University, Jinan, 250021, Shandong, People's Republic of China
- Department of Neurobiology, Care Sciences and Society, Aging Research Center and Center for Alzheimer Research, Karolinska Institutet-Stockholm University, 17177, Stockholm, Sweden
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Zhang N, Gan L, Xiang G, Xu J, Jiang T, Li Y, Wu Y, Ni R, Liu Y. Cholinesterase inhibitors-associated torsade de pointes/QT prolongation: a real-world pharmacovigilance study. Front Pharmacol 2024; 14:1343650. [PMID: 38273821 PMCID: PMC10808573 DOI: 10.3389/fphar.2023.1343650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/28/2023] [Indexed: 01/27/2024] Open
Abstract
Objective: Cholinesterase inhibitor (ChEIs) is the first-line drug for Alzheimer's disease (AD). Understanding torsade de pointes (TdP)/QT prolongation with different ChEIs is essential for its safe and rational administration. This study aimed to evaluate the correlation between different ChEIs and TdP/QT prolongation. Methods: All ChEIs related TdP/QT prolongation cases were retrieved from the FAERS database using standard MedDRA query (SMQ) from the first quarter of 2004 to the third quarter of 2022. Disproportionality and sensitivity analysis were used to determine the signal of TdP/QT prolongation related to ChEIs. Results: 557 cases of TdP/QT prolongation related to 3 ChEIs were searched by SMQ. The patients were mostly elderly people, with markedly more female than male. The signals of TdP/QT prolongation for ChEIs were detected by disproportionality analysis, and the signal of Donepezil was the strongest. The sensitivity analysis results indicate a robust and stable correlation between these signals with ChEIs. TdP/QT prolongation usually occurs within 1 month after taking ChEIs. The drug with the highest frequency of combination with donepezil and galantamine is citalopram, and the drug with the highest frequency of combination with rivastigmine is atorvastatin. Conclusion: The signals of TdP/QT prolongation related to ChEIs were strong and stable. It is necessary to be vigilant about the TdP/QT prolongation of various ChEIs, especially in elderly women, the initial stage after taking ChEIs, and when ChEIs combining with drugs that could prolong the QT interval.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yao Liu
- Department of Pharmacy, Daping Hospital, Army Medical University, Chongqing, China
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Abd El-Karim SS, Anwar MM, Ahmed NS, Syam YM, Elseginy SA, Aly HF, Younis EA, Khalil WKB, Ahmed KA, Mohammed FF, Rizk M. Discovery of novel benzofuran-based derivatives as acetylcholinesterase inhibitors for the treatment of Alzheimer's disease: Design, synthesis, biological evaluation, molecular docking and 3D-QSAR investigation. Eur J Med Chem 2023; 260:115766. [PMID: 37678141 DOI: 10.1016/j.ejmech.2023.115766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
A series of novel benzofuran-based compounds 7a-s were designed, synthesized, and investigated in vitro as acetylcholinesterase inhibitors (AChEIs). Compounds 7c and 7e displayed promising inhibitory activity with IC50 values of 0.058 and 0.086 μM in comparison to donepezil with an IC50 value of 0.049 μM. The new molecules' antioxidant evaluation revealed that 7c, 7e, 7j, 7n, and 7q produced the strongest DPPH scavenging activity when compared to vitamin C. As it was the most promising AChEI, compound 7c was selected for further biological evaluation. Acute and chronic toxicity studies exhibited that 7c showed no signs of toxicity or adverse events, no significant differences in the blood profile, and an insignificant difference in hepatic enzymes, glucose, urea, creatinine, and albumin levels in the experimental rat group. Furthermore, 7c did not produce histopathological damage to normal liver, kidney, heart, and brain tissues, ameliorated tissue malonaldehyde (MDA) and glutathione (GSH) levels and reduced the expression levels of the APP and Tau genes in AD rats. Molecular docking results of compounds 7c and 7e showed good binding modes in the active site of the acetylcholinesterase enzyme, which are similar to the native ligand donepezil. 3D-QSAR analysis revealed the importance of the alkyl group in positions 2 and 3 of the phenyl moiety for the activity. Overall, these findings suggested that compound 7c could be deemed a promising candidate for the management of Alzheimer's disease.
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Affiliation(s)
- Somaia S Abd El-Karim
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt.
| | - Manal M Anwar
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt.
| | - Nesreen S Ahmed
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt
| | - Yasmin M Syam
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt
| | - Samia A Elseginy
- Green Chemistry Department, Chemical Industries Research Division, National Research Centre, P. O. Box 12622, El-Bohouth St, Dokki, Cairo, Egypt
| | - Hanan F Aly
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt
| | - Eman A Younis
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt
| | - Wagdy K B Khalil
- Department of Cell Biology, National Research Centre, P.O. Box 12262 El-Bohouth St, Dokki, Cairo, Egypt
| | - Kawkab A Ahmed
- Pathology Departments, Faculty of Veterinary Medicine, Cairo University, Giza, 12211, Egypt
| | - Faten F Mohammed
- Pathology Departments, Faculty of Veterinary Medicine, Cairo University, Giza, 12211, Egypt
| | - Maha Rizk
- Department of Therapeutic Chemistry, National Research Centre, P.O. Box 12262 El-Bohouth St, Cairo, Egypt
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Grosu L, Grosu AI, Crisan D, Zlibut A, Perju-Dumbrava L. Parkinson's disease and cardiovascular involvement: Edifying insights (Review). Biomed Rep 2023; 18:25. [PMID: 36846617 PMCID: PMC9944619 DOI: 10.3892/br.2023.1607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
Parkinson's disease (PD) is one of the most common neurodegenerative illnesses, and is a major healthcare burden with prodigious consequences on life-quality, morbidity, and survival. Cardiovascular diseases are the leading cause of mortality worldwide and growing evidence frequently reports their co-existence with PD. Cardiac dysautonomia due to autonomic nervous system malfunction is the most prevalent type of cardiovascular manifestation in these patients, comprising orthostatic and postprandial hypotension, along with supine and postural hypertension. Moreover, many studies have endorsed the risk of patients with PD to develop ischemic heart disease, heart failure and even arrhythmias, but the underlying mechanisms are not entirely clear. As importantly, the medication used in treating PD, such as levodopa, dopamine agonists or anticholinergic agents, is also responsible for cardiovascular adverse reactions, but further studies are required to elucidate the underlying mechanisms. The purpose of this review was to provide a comprehensive overview of current available data regarding the overlapping cardiovascular disease in patients with PD.
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Affiliation(s)
- Laura Grosu
- Department of Neurology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania,Department of Neurology, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Alin Ionut Grosu
- Department of Internal Medicine, 5th Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania,Department of Cardiology, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania,Correspondence to: Dr Alin Ionut Grosu, Department of Internal Medicine, 5th Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, 11 Tabacarilor street, 400139 Cluj-Napoca, Romania
| | - Dana Crisan
- Department of Internal Medicine, 5th Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania,Department of Internal Medicine, Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Alexandru Zlibut
- Department of Internal Medicine, 5th Medical Clinic, Iuliu Hatieganu University of Medicine and Pharmacy, 400139 Cluj-Napoca, Romania,Department of Cardiology, Emergency Clinical Hospital of Bucharest, 014461 Bucharest, Romania
| | - Lacramioara Perju-Dumbrava
- Department of Neurology, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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Sahin Z, Biltekin SN, Yurttaş L, Berk B, Küçükkılınç TT, Demirayak Ş. Novel benzofurane carbonyl analogs of donepezil as acetylcholinesterase inhibitors. J Mol Struct 2022. [DOI: 10.1016/j.molstruc.2022.133193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Young S, Chung E, Chen MA. Cardiovascular Complications of Acetylcholinesterase Inhibitors in Patients with Alzheimer's Disease: A Narrative Review. Ann Geriatr Med Res 2021; 25:170-177. [PMID: 34610666 PMCID: PMC8497945 DOI: 10.4235/agmr.21.0079] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/11/2021] [Accepted: 09/16/2021] [Indexed: 12/06/2022] Open
Abstract
While acetylcholinesterase inhibitors are used to treat a wide range of patients with Alzheimer's disease, acetylcholinesterase inhibitor use has also been associated with a variety of cardiovascular complications, including bradycardia and syncope. Herein, we review the pathophysiology and clinical evidence for cardiovascular complications caused by acetylcholinesterase inhibitors in patients being treated for dementia and discuss options for their management.
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Affiliation(s)
- Sara Young
- Boston University School of Medicine, Boston, MA, USA
| | - Enoch Chung
- Boston University School of Medicine, Boston, MA, USA
| | - Michael A. Chen
- Division of Cardiology, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
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Donepezil induces ventricular arrhythmias by delayed repolarisation. Naunyn Schmiedebergs Arch Pharmacol 2020; 394:559-560. [PMID: 33230575 DOI: 10.1007/s00210-020-02028-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022]
Abstract
Acetylcholinesterase inhibitors such as donepezil delay the progression of Alzheimer's dementia by increasing acetylcholine concentrations in the central nervous system. However, it is becoming apparent that cholinesterase inhibition by donepezil is not confined to the brain. This is supported by previous case reports of peripheral cholinergic side effects and adverse cardiac arrhythmias such as Torsades de Pointes which are reversible upon cessation of donepezil. The augmented acetylcholine concentrations and IKr inhibition in cardiomyocytes caused by donepezil are believed to mediate this effect.
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