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Simpson TF, Salazar JW, Vittinghoff E, Probert J, Iwahashi A, Olgin JE, Ursell P, Hart A, Moffatt E, Tseng ZH. Association of QT-Prolonging Medications With Risk of Autopsy-Defined Causes of Sudden Death. JAMA Intern Med 2020; 180:698-706. [PMID: 32119028 PMCID: PMC7052791 DOI: 10.1001/jamainternmed.2020.0148] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 01/07/2020] [Indexed: 01/08/2023]
Abstract
Importance QT-prolonging medications (QTPMs) are a reported risk factor for sudden cardiac death (SCD) when defined by consensus criteria that presume an arrhythmic cause. The effect of QTPM on autopsy-defined sudden arrhythmic death (SAD) is unknown. Objective To evaluate the association between QTPM and autopsy-defined SAD vs nonarrhythmic cause of sudden death. Design, Setting, and Participants This prospective countywide case-control study included World Health Organization-defined (presumed) SCD cases who underwent autopsy as part of the San Francisco Postmortem Systematic Investigation of Sudden Cardiac Death Study (POST SCD) to determine arrhythmic or nonarrhythmic cause, and control deaths due to trauma (hereinafter referred to as trauma controls) in San Francisco County, California, from February 1, 2011, to March 1, 2014. Multivariate regression was used to evaluate the association of QTPM with the risk of presumed SCD, autopsy-defined SAD, and non-SAD compared with trauma controls. Medication exposure, determined by prescription lists and postmortem toxicologic findings, was used to calculate a summative QTPM exposure score (range, 0-20). Data were analyzed from September 1, 2018, to June 15, 2019. Exposure QT-prolonging medication exposure, as measured by QTPM score (1 indicated low; 2-4, moderate; and >4, high). Main Outcomes and Measures Death due to trauma, presumed SCD, and autopsy-defined non-SAD and SAD with no postmortem findings of extracardiac cause. Results A total of 629 patients (mean [SD] age, 61.4 [15.7] years; 439 men [69.8%]) were included, 525 with presumed SCDs and 104 traumatic death controls. Individuals with presumed SCDs had higher exposure and were more likely to be taking any QTPM (291 [55.4%] vs 28 [26.9%]; P < .001) than trauma controls. Use of QTPMs was associated with increased risk of presumed SCD in low (odds ratio [OR], 2.25 [95% CI, 1.03-4.96]; P = .04) and high (OR, 6.70 [95% CI, 1.47-30.67]; P = .01) exposure groups. After autopsy adjudication, use of QTPMs was associated with increased risk of non-SAD (low-risk OR, 2.88 [95% CI, 1.18-6.99; P = .02]; moderate-risk OR, 2.62 [95% CI, 1.20-5.73; P = .02]; and high-risk OR, 14.22 [95% CI, 2.91-69.30; P = .001]) but not SAD in all exposure groups. This association was attenuated by the exclusion of occult overdose non-SADs in the highest exposure group. Conclusions and Relevance These findings confirm the association between QTPMs and presumed SCD; however, after autopsy, this risk was specific for nonarrhythmic causes of sudden death. Studies using consensus SCD criteria may overestimate the association of QTPMs with the risk of SAD.
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Affiliation(s)
| | | | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Joanne Probert
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Alan Iwahashi
- Department of Medicine, Kaiser Permanente, San Francisco, California
| | - Jeffrey E. Olgin
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco
| | - Phillip Ursell
- Department of Pathology, University of California, San Francisco
| | - Amy Hart
- Office of Chief Medical Examiner, City and County of San Francisco, San Francisco, California
| | - Ellen Moffatt
- Office of Chief Medical Examiner, City and County of San Francisco, San Francisco, California
| | - Zian H. Tseng
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco
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El Harchi A, Butler AS, Zhang Y, Dempsey CE, Hancox JC. The macrolide drug erythromycin does not protect the hERG channel from inhibition by thioridazine and terfenadine. Physiol Rep 2020; 8:e14385. [PMID: 32147975 PMCID: PMC7061092 DOI: 10.14814/phy2.14385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 12/25/2022] Open
Abstract
The macrolide antibiotic erythromycin has been associated with QT interval prolongation and inhibition of the hERG-encoded channels responsible for the rapid delayed rectifier K+ current I(Kr ). It has been suggested that low concentrations of erythromycin may have a protective effect against hERG block and associated drug-induced arrhythmia by reducing the affinity of the pore-binding site for high potency hERG inhibitors. This study aimed to explore further the notion of a potentially protective effect of erythromycin. Whole-cell patch-clamp experiments were performed in which hERG-expressing mammalian (Human Embryonic Kidney; HEK) cells were preincubated with low to moderate concentrations of erythromycin (3 or 30 µM) prior to whole-cell patch clamp recordings of hERG current (IhERG ) at 37°C. In contrast to a previous report, exposure to low concentrations of erythromycin did not reduce pharmacological sensitivity of hERG to the antipsychotic thioridazine and antihistamine terfenadine. The IC50 value for IhERG tail inhibition by terfenadine was decreased by ~32-fold in the presence of 3 µM erythromycin (p < .05 vs. no preincubation). Sensitivity to thioridazine remained unchanged (p > .05 vs. no preincubation). The effects of low concentrations of erythromycin were investigated for a series of pore blocking drugs, and the results obtained were consistent with additive and/or synergistic effects. Experiments with the externally acting blocker BeKm-1 on WT hERG and a pore mutant (F656V) were used to explore the location of the binding site for erythromycin. Our data are inconsistent with the use of erythromycin for the management of drug-induced QT prolongation.
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Affiliation(s)
- Aziza El Harchi
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Andrew S Butler
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Yihong Zhang
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Christopher E Dempsey
- School of Biochemistry, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
| | - Jules C Hancox
- School of Physiology and Pharmacology and Neuroscience, Biomedical Sciences Building, The University of Bristol, University Walk, Bristol, UK
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Hauben M, Reynolds R, Caubel P. Deconstructing the Pharmacovigilance Hype Cycle. Clin Ther 2019; 40:1981-1990.e3. [PMID: 30545608 DOI: 10.1016/j.clinthera.2018.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/11/2018] [Accepted: 10/24/2018] [Indexed: 12/31/2022]
Abstract
Data science is making increasing contributions to pharmacovigilance. Although the technical innovation of these works are indisputable, efficient progress in real-world pharmacovigilance signal detection may be hampered by corresponding technology life cycle effects, with a resulting tendency to conclude that, with large enough datasets and intricate algorithms, "the numbers speak for themselves," discounting the importance of clinical and scientific judgment. A practical consequence is overzealous declarations regarding the safety or lack of safety of drugs. We describe these concerns through a critical discussion of key results and conclusions from case studies selected to illustrate these points.
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Meid AD, Bighelli I, Mächler S, Mikus G, Carrà G, Castellazzi M, Lucii C, Martinotti G, Nosè M, Ostuzzi G, Barbui C, Haefeli WE. Combinations of QTc-prolonging drugs: towards disentangling pharmacokinetic and pharmacodynamic effects in their potentially additive nature. Ther Adv Psychopharmacol 2017; 7:251-264. [PMID: 29201344 PMCID: PMC5676495 DOI: 10.1177/2045125317721662] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/08/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Whether arrhythmia risks will increase if drugs with electrocardiographic (ECG) QT-prolonging properties are combined is generally supposed but not well studied. Based on available evidence, the Arizona Center for Education and Research on Therapeutics (AZCERT) classification defines the risk of QT prolongation for exposure to single drugs. We aimed to investigate how combining AZCERT drug categories impacts QT duration and how relative drug exposure affects the extent of pharmacodynamic drug-drug interactions. METHODS In a cohort of 2558 psychiatric inpatients and outpatients, we modeled whether AZCERT class and number of coprescribed QT-prolonging drugs correlates with observed rate-corrected QT duration (QTc) while also considering age, sex, inpatient status, and other QTc-prolonging risk factors. We concurrently considered administered drug doses and pharmacokinetic interactions modulating drug clearance to calculate individual weights of relative exposure with AZCERT drugs. Because QTc duration is concentration-dependent, we estimated individual drug exposure with these drugs and included this information as weights in weighted regression analyses. RESULTS Drugs attributing a 'known' risk for clinical consequences were associated with the largest QTc prolongations. However, the presence of at least two versus one QTc-prolonging drug yielded nonsignificant prolongations [exposure-weighted parameter estimates with 95% confidence intervals for 'known' risk drugs + 0.93 ms (-8.88;10.75)]. Estimates for the 'conditional' risk class increased upon refinement with relative drug exposure and co-administration of a 'known' risk drug as a further risk factor. CONCLUSIONS These observations indicate that indiscriminate combinations of QTc-prolonging drugs do not necessarily result in additive QTc prolongation and suggest that QT prolongation caused by drug combinations strongly depends on the nature of the combination partners and individual drug exposure. Concurrently, it stresses the value of the AZCERT classification also for the risk prediction of combination therapies with QT-prolonging drugs.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Irene Bighelli
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Sarah Mächler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Giuseppe Carrà
- Division of Psychiatry, University College of London, UK Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Mariasole Castellazzi
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Claudio Lucii
- Department of Mental Health, Company Health-ULS7-Siena, Siena, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging and Clinical Sciences, University of Chieti, Chieti, Italy
| | - Michela Nosè
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Giovanni Ostuzzi
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Corrado Barbui
- WHO Collaborating Center for Research and Training in Mental Health and Service Evaluation, University of Verona, Verona, Italy
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Smith AST, Macadangdang J, Leung W, Laflamme MA, Kim DH. Human iPSC-derived cardiomyocytes and tissue engineering strategies for disease modeling and drug screening. Biotechnol Adv 2017; 35:77-94. [PMID: 28007615 PMCID: PMC5237393 DOI: 10.1016/j.biotechadv.2016.12.002] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 12/16/2016] [Accepted: 12/17/2016] [Indexed: 01/13/2023]
Abstract
Improved methodologies for modeling cardiac disease phenotypes and accurately screening the efficacy and toxicity of potential therapeutic compounds are actively being sought to advance drug development and improve disease modeling capabilities. To that end, much recent effort has been devoted to the development of novel engineered biomimetic cardiac tissue platforms that accurately recapitulate the structure and function of the human myocardium. Within the field of cardiac engineering, induced pluripotent stem cells (iPSCs) are an exciting tool that offer the potential to advance the current state of the art, as they are derived from somatic cells, enabling the development of personalized medical strategies and patient specific disease models. Here we review different aspects of iPSC-based cardiac engineering technologies. We highlight methods for producing iPSC-derived cardiomyocytes (iPSC-CMs) and discuss their application to compound efficacy/toxicity screening and in vitro modeling of prevalent cardiac diseases. Special attention is paid to the application of micro- and nano-engineering techniques for the development of novel iPSC-CM based platforms and their potential to advance current preclinical screening modalities.
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Affiliation(s)
- Alec S T Smith
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | - Jesse Macadangdang
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | - Winnie Leung
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA
| | - Michael A Laflamme
- Toronto General Research Institute, McEwen Centre for Regenerative Medicine, University Health Network, Toronto, ON, Canada
| | - Deok-Ho Kim
- Department of Bioengineering, University of Washington, Seattle, WA 98195, USA; Center for Cardiovascular Biology, University of Washington, Seattle, WA 98109, USA; Institute for Stem Cell and Regenerative Medicine, University of Washington, Seattle, WA 98109, USA.
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Investigating the Additive Interaction of QT-Prolonging Drugs in Older People Using Claims Data. Drug Saf 2016; 40:133-144. [DOI: 10.1007/s40264-016-0477-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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McKittrick BA, Caldwell JP, Bara T, Boykow G, Chintala M, Clader J, Czarniecki M, Courneya B, Duffy R, Fleming L, Giessert R, Greenlee WJ, Heap C, Hong L, Huang Y, Iserloh U, Josien H, Khan T, Korfmacher W, Liang X, Mazzola R, Mitra S, Moore K, Orth P, Rajagopalan M, Roy S, Sakwa S, Strickland C, Vaccaro H, Voigt J, Wang H, Wong J, Zhang R, Zych A. Iminopyrimidinones: A novel pharmacophore for the development of orally active renin inhibitors. Bioorg Med Chem Lett 2015; 25:1592-6. [DOI: 10.1016/j.bmcl.2015.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 01/30/2015] [Accepted: 02/02/2015] [Indexed: 10/24/2022]
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Hreiche R, Plante I, Drolet B, Morissette P, Turgeon J. Lengthening of cardiac repolarization in isolated guinea pigs hearts by sequential or concomitant administration of two IKr blockers. J Pharm Sci 2010; 100:2469-81. [PMID: 21491454 DOI: 10.1002/jps.22437] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 11/15/2010] [Accepted: 11/18/2010] [Indexed: 01/08/2023]
Abstract
Block of I(Kr) is of major concern in drug safety. The objective of this study was to assess prolongation of cardiac repolarization during the combined use of two I(Kr) blockers when administered concomitantly or sequentially. (1) When isolated hearts from male guinea pigs were perfused concomitantly with two I(Kr) blockers, prolongation of monophasic action potential duration measured at 90% (MAPD(90)) was less than the summation of effects observed for each drug perfused alone. (2) In sequential administration, when ketoconazole or erythromycin was perfused first, they antagonized MAPD(90)-prolonging effects of domperidone. This effect was absent when domperidone or dofetilide was perfused first. Patch-clamp experiments confirmed that the order of sequential perfusion impacts the decrease in HERG tail amplitude. In conclusion, this study does not support the concept that potentiation of drug effects is observed during the combined administration of two I(Kr) blockers. Furthermore, order of administration of two I(Kr) blockers together may be an important factor in drug-induced long QT syndrome.
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Affiliation(s)
- Raymond Hreiche
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
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Qu Y, Fang M, Gao B, Chui RW, Vargas HM. BeKm-1, a Peptide Inhibitor of Human ether-a-go-go-Related Gene Potassium Currents, Prolongs QTc Intervals in Isolated Rabbit Heart. J Pharmacol Exp Ther 2010; 337:2-8. [DOI: 10.1124/jpet.110.176883] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
Several noncardiovascular drugs have the potential to induce Torsades de Pointes cardiac arrhythmias via blockade of the rapid component of the cardiac delayed rectifier K(+) current (I(Kr)), which is encoded by human ether-à-go-go-related gene (hERG). The aim of the present study was to characterize possible interactions between terfenadine, binding to a site located inside the central cavity, and the following substances with various binding sites: dofetilide, fluvoxamine, chlorobutanol, and a hERG-specific toxin isolated from scorpion venom (CnErg1). The whole-cell configuration of the patch-clamp technique was employed on hERG channels stably expressed in human embryonic kidney 293 cells. Terfenadine does not interact with dofetilide or fluvoxamine at hERG channels. Slight subadditive inhibitory effects on hERG peak tail currents were observed when terfenadine and CnErg1 were administered in combination. Terfenadine and chlorobutanol synergistically inhibit hERG peak tail currents and enhance each other's inhibitory effect in a concentration-dependent way. In conclusion, terfenadine interacts with CnErg1 and chlorobutanol, but not with dofetilide or fluvoxamine, at hERG channels. It is shown that interactions between chlorobutanol and a hERG channel blocker binding inside the central cavity (terfenadine) produce synergistic effects on hERG currents.
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Affiliation(s)
- Anne Friemel
- Federal Institute for Drugs and Medical Devices, D-53175 Bonn, Germany
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