Risk Management of Hospitalized Psychiatric Patients Taking Multiple QTc-Prolonging Drugs

Determinants of severe QTc prolongation in a real-world gerontopsychiatric setting

Introduction

QT_c prolongation carries the risk of ventricular tachyarrhythmia (Torsades de Pointes) and sudden cardiac death. Psychotropic drugs can affect ventricular repolarization and thus prolong the QT_c interval. The present study sought to investigate the risk factors (pharmacological and non-pharmacological) of severe QT_c prolongation in gerontopsychiatric patients.

Methods

Electrocardiograms of patients on a gerontopsychiatric ward were screened for QT_c prolongation. Medication lists were examined utilizing the AzCERT classification. Potential drug interactions were identified with the electronic drug interaction program mediQ.

Results

The overall prevalence of QT_c prolongation was 13.6%, with 1.9% displaying severe QT_c prolongation (≥ 500 ms). No statistically significant differences between patients with moderate and severe QT_c prolongation were identified; however, patients with severe QT_c prolongation tended to take more drugs (p = 0.063). 92.7% of patients with QT_c prolongation took at least one AzCERT-listed drug, most frequently risperidone and pantoprazole. Risperidone and pantoprazole, along with pipamperone, were also most frequently involved in potential drug interactions. All patients displayed additional risk factors for QT_c prolongation, particularly cardiac diseases.

Conclusion

In addition to the use of potentially QT_c-prolonging drugs, other risk factors, especially cardiac diseases, appear to be relevant for the development of QT_c prolongation in gerontopsychiatric patients. Pantoprazole was frequently involved in potential drug interactions and should generally not be used for more than 8 weeks in geriatric populations. As clinical consequences of QT_c prolongation were rare, potentially QT_c-prolonging drugs should not be used overcautiously; their therapeutic benefit should be considered as well. It is paramount to perform diligent benefit-risk analyses prior to the initiation of potentially QT_c-prolonging drugs and to closely monitor their clinical (side) effects.

Leading 20 drug-drug interactions, polypharmacy, and analysis of the nature of risk factors due to QT interval prolonging drug use and potentially inappropriate psychotropic use in elderly psychiatry outpatients

BACKGROUND

Psychotropic medications extend corrected QT (QTc) period in the electrocardiogram (ECG). Psychiatric patients exposed to ⩾1 psychotropic medication(s) represent a group with marked probability of drug-activated QTc-prolongation. Prolonged QTc interval in elderly patients (age > 60 years) is connected to greater risk of all-cause and coronary heart disease deaths. This study aimed at investigating pattern of utilization of QTc-interval protracting medications, QT-extending drug interactions, and prevalence of QTc-interval extending hazard factors in elderly patients.

METHODS

This was a cross-sectional, prospective study at the Psychiatry OPD at All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India from 1 October 2017 to 30 August 2019 employing the pertinent prescriptions.

RESULTS

A total of 832 elderly patients (age 60 years or more) visiting the Psychiatry OPD during the aforementioned study duration were investigated. About 420 (50.5%) patients were males while 412 (49.5%) were females. Of the 832 patients, 588 (70.7%) were using interacting agents with capacity to produce TdP. Almost 1152 interacting torsadogenic medication pairs were unraveled. As per AzCERT/CredibleMeds Classification, 1016 (48.8%), 724 (34.8%), and 248 (12%) agents with potential to interact were identified with 'known', 'possible', and 'conditional risk of TdP', respectively. The common interacting medications belonged to antidepressant (288), proton pump inhibitor (364), antipsychotic (340), antinausea (184), antimicrobial (156), and H₂ receptor antagonist (60) therapeutic categories. The all-inclusive frequency of potentially inappropriate psychotropic (PIP) agents administered was 62% (1343/2166) with Beers Criteria 2019, and 46% (997/2166) with STOPP Criteria 2015.

CONCLUSION

Many geriatric patients were administered drugs and drug combinations with heightened proclivity toward QT-interval prolongation. Furthermore, reliable evidence-based online drug knowledge resources, such as AzCERT/CredibleMeds Drug Lists, Medscape Drug Interactions Checker, Epocrates Online Interaction Check, and Drugs.com Drug Interactions Checker, can facilitate clinical professionals in selecting drugs for psychiatric patients. A wise choice of medications is imperative to preclude serious adverse sequelae. Therefore, we need to exigently embrace precautionary safety means, be vigilant, and forestall QT-extension and TdP in clinical environments.

QT interval prolongation and the risk of malignant ventricular dysrhythmia and/or cardiac arrest: Systematic search and narrative review of risk related to the magnitude of QT interval length

Prolongation of the QTc interval is associated with an increased risk of malignant ventricular dysrhythmias, such as ventricular tachycardia (VT), and sudden cardiac death. The quantifiable risk rates of adverse dysrhythmic outcome in relation to specific QTc interval length are not known. We conducted a literature review on the topic of QT interval prolongation in adult patients and the associated risk of malignant dysrhythmic event. We specifically formulated our literature search and subsequent literature review to address the following question: Can the clinician identify specific QTc intervals at which a specific quantifiable risk of malignant dysrhythmic event (malignant ventricular dysrhythmia and/or cardiac arrest) occurs in an undifferentiated adult patient population? In the literature search, we identified 701 studies; upon review using specific, pre-determined inclusion criteria, we identified 16 articles for inclusion in the review. From this literature, we were unable to answer the question in a quantifiable manner and only noted that the risk of malignant dysrhythmic event increases with progressively longer QTc interval. The current literature on this topic is inadequate to answer this important question due to heterogenous study methodology, patient populations, endpoints, and periods of observation. Additional prospective research is required on this topic, aimed at addressing the important issue of specific, quantifiable risk and its relation to degree of prolongation of the QTc interval.

QT interval prolongation and the rate of malignant ventricular dysrhythmia and cardiac arrest in adult poisoned patients

INTRODUCTION

Prolongation of QTc interval, a common electrocardiographic (ECG) abnormality encountered in the toxicology patient, is reportedly associated with an increased risk of malignant ventricular dysrhythmias (MVD), such as ventricular tachycardia (VT, with and without a pulse), ventricular fibrillation (VF), and/or cardiac arrest. Quantifiable cardiac arrest risk in relation to specific QTc interval length is not known in this population.

METHODS

We conducted a retrospective, observational study to assess the rate of cardiac arrest and its association with degree of QTc prolongation in a cohort of patients requiring toxicology consultation.

RESULTS

550 patients were included in our analysis (average age 36 years and 49% male). Average QTc was 453 milliseconds (ms). Overall incidence of cardiac arrest in the study cohort was 1.1% with 6 reported cases; when considering patients with QTc > 500 ms, incidence was 1.7%. Two patients with cardiac arrest experienced ventricular dysrhythmia with decompensation prior to cardiac arrest; four patients developed sudden cardiac arrest.

CONCLUSIONS

The risk of malignant ventricular dysrhythmia, including cardiac arrest, is low in this poisoned patient population with an overall rate of 1.1%. Two-thirds of cardiac arrest cases occurred in patients with normal QTc intervals. When considering patients with prolonged QTc intervals, the rate of cardiac arrest remains very low at 0.8%. Considering QTc greater than 500 ms, the rate of cardiac arrest is 1.7%. Further prospective studies are required to quantify the risk of malignant ventricular dysrhythmias, including cardiac arrest, and its relation to the degree of QTc interval in poisoned patients.

Applying the Infectious Diseases Literature to People who Inject Drugs

People who inject drugs (PWID) presenting with injection drug use-associated infections are an understudied population excluded from most prospective infectious disease (ID) clinical trials. Careful application of the existing ID literature to PWID must consider their unique medical, psychological, and social challenges. Identification and treatment of the underlying substance use disorder are key underpinnings to any successful ID intervention.

Pharmacodynamic Drug-Drug interactions of QT-prolonging drugs in hospitalized psychiatric patients

At least 170 approved drugs are linked to QT prolongation, which can lead to serious adverse drug reactions (ADRs), such as Torsade de Pointes (TdP). The aim of this study was to analyze the prevalence and type of pharmacodynamic drug-drug interactions (DDIs) between QT-prolonging drugs in psychiatry. The present retrospective analysis used data from a large pharmacovigilance study, conducted in 10 psychiatric hospitals in Germany. Patients medication lists were screened for QT-prolonging drugs, classified according to the Arizona Center for Education and Research on Therapeutics (AZCERT). In total, 27,396 patient cases (46% female) with a mean (± standard deviation) age of 47 ± 18 years were included in the study. Altogether, 83% of the cases received at least one and up to eight QT-prolonging drugs at the same time. Combination of drugs with a known or possible risk for TdP (according to the AZCERT) was detected in 13,670 cases (50%). Most frequently prescribed psychotropic high-risk drugs (n = 48,995) were the antipsychotics pipamperone (n = 6202), quetiapine (n = 5718), prothipendyl (n = 4298), and risperidone (n = 4265). The replacement of high-risk drugs such as tricyclic antidepressants, levomepromazine, melperone, and promethazine with more tolerable drugs could avoid 11% of QT-prolonging drugs and increase the tolerability of psychopharmacological treatment. More than 80% of psychiatric patients receive at least one QT-prolonging drug during their hospital stay, and almost 50% of these drugs are combined in clinical practice. For the prevention of cardiac ADRs, the physician should evaluate the risk for QT prolongation for each drug and patient-specific risk factors before prescribing these drugs or drug combinations.

Top 20 drug - drug interactions, polypharmacy and analysis of the nature of risk factors due to QT interval prolonging drug use in elderly psychiatry outpatients

INTRODUCTION AND OBJECTIVES

Psychotropic medications extend the corrected QT (QTc) period in the ECG. Psychiatric patients exposed to ≥ 1 psychotropic medication (s) represent a group with a marked probability of drug-activated QTc-prolongation. Prolonged QTc interval in elderly patients (age > 60 years) is connected to a greater risk of all-cause and coronary heart disease deaths. We investigated the pattern of utilization of QTc-interval prolonging medications, QT-extending interactions between drugs, and prevalence of QTc-interval prolonging risk factors in elderly patients.

METHODS

This was a cross-sectional, prospective study at the Psychiatry OPD at All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India from October 1, 2017 to December 31, 2018 employing the pertinent prescriptions.

RESULTS

A total of 208 elderly patients (age 60 years or more) visiting the Psychiatry OPD during the aforementioned study period were investigated. 105 (50.5%) patients were males whereas 103 (49.5%) were females in our study. 147 out of 208 patients (70.7%) were using interacting agents with the capacity to produce TdP. 288 interacting torsadogenic medication pairs were unraveled. As per AzCERT/CredibleMeds Classification, 254 (48.8%), 181 (34.8%), and 62 (12%) interacting medications were identified with known, possible, and conditional risk of TdP, respectively. The common interacting medications belonged to antidepressant (144), proton pump inhibitor (91), antipsychotic (85), anti-nausea (46), antimicrobial (39), and H₂ receptor antagonist (15) therapeutic categories.

CONCLUSIONS

Many geriatric patients were administered drugs and drug combinations with heightened proclivity towards QT-interval prolongation. Therefore, we need to exigently embrace precautionary safety interventions, to be vigilant, and forestall QT-prolongation and TdP in clinical settings. Online evidence-based drug information resources can aid clinicians in choosing drugs for psychiatric patients.

Coprescription of QT interval-prolonging antipsychotics with potentially interacting medications in Thailand

Background

The US FDA has designated pimozide, thioridazine, and ziprasidone as contraindicated for patients at risk of QT interval prolongation, and assigned haloperidol, olanzapine, paliperidone, quetiapine, and risperidone as associated with a significant risk of QT prolongation. This study aimed to examine trends and hospital variations in concomitant prescribing among these eight selected antipsychotics, and coprescription with interacting drugs known to increase QT prolongation risk.

Methods

Data on outpatient antipsychotic prescriptions during 2012-2015 were obtained from 16 general hospitals and 10 university hospitals nationwide. A time-series analysis was used for estimating trends in coprescription that led to drug interactions.

Results

Coprescribing among the eight antipsychotics ranged from 7.5% for quetiapine to 33.1% for thioridazine. The rate of coprescription with contraindicated interacting drugs was 9.7% for thioridazine and 21.9% for pimozide, and increased by 1.1 and 1.4 percentage points (% pt.) yearly for thioridazine in general and university hospitals, respectively. Coprescribing with interacting drugs with precautions was 2.8% for quetiapine, 7.4% for ziprasidone, and 27.9% for risperidone; these percentages increased yearly by 1.7% pt. for ziprasidone and 2.6% pt. for risperidone in general hospitals, as well as by 1.0% pt. for risperidone in university hospitals. The median proportion of patients exposed to a QT-prolonging interaction was 12.3% across hospitals (interquartile range, 9.9-19.5%). Wide interhospital variation was found in percentages of drug interactions among patients receiving thioridazine, ziprasidone, paliperidone, or olanzapine in general hospitals, and among patients receiving paliperidone or pimozide in university hospitals.

Conclusions

Coprescription of antipsychotics with interacting drugs that could increase the risk of QT prolongation was common in Thailand, and thioridazine, ziprasidone, and risperidone showed increasing trends. We urge the incorporation of a unified list of QT-prolonging antipsychotics and interacting drugs into a computerized drug interaction warning system, and existing national rational drug use campaigns should cover this important issue.

QTc Prolongation Associated With Psychiatric Medications: A Retrospective Cross-Sectional Study of Adult Inpatients

OBJECTIVE

The aim of our study was to assess the impact of psychiatric medications and concomitant risk factors on the prevalence of QTc prolongation and torsades de pointes (TdP) in hospitalized subjects. We examined the association between individual risk scores and QTc prolongation and proposed an evidence-based protocol for electrocardiogram monitoring on psychotropic medications.

METHOD

Electrocardiograms (ECGs) of subjects hospitalized over a 1-year period were analyzed for QTc prolongation, associated risk factors, and use of medications. Analysis was performed using logistic regression to identify independent predictors of QTc prolongation, and the Pearson χ test was used for risk score assessment.

RESULTS

A total of 1249 ECGs of 517 subjects were included in this study. Eighty-seven subjects had QTcB intervals greater than 470 milliseconds for females and greater than 450 milliseconds for males. Twelve (2.3%) subjects had QTcB of 500 milliseconds or greater, or greater than 60 milliseconds of change from baseline. Of these subjects, only 1 case of QTc interval change was related to routine use of psychiatric medications. There were no incidents of TdP. Age, diabetes, hypokalemia, overdose, diphenhydramine, and haloperidol were significant independent predictors of QTc prolongation. Risk scores were significantly correlated with QTc prolongation (P = 0.001).

CONCLUSION

Our retrospective review study found that the occurrence of TdP and QTc prolongation was low in this subject population. QT abnormalities were associated with known risk factors, and risk scores correlated well with QTc prolongation. Providers can use the protocol proposed in this study, which incorporates risk scores and the CredibleMeds classification system to determine the need for ECG monitoring and to guide treatment.

Prevalence of ECG abnormalities and risk factors for QTc interval prolongation in hospitalized psychiatric patients

BACKGROUND

Psychiatric patients are at risk of cardiovascular diseases, and many psychotropic drugs can prolong QTc interval. Requirements for electrocardiogram (ECG) monitoring have been set up in our psychiatric university hospital. The objective of this study was to determine the proportion of adult patients who had an ECG during their hospitalization, the prevalence of ECG abnormalities, the evolution of the QTc after admission, and the risk factors for QTc prolongation.

METHODS

Retrospective analysis of ECGs and clinical data of all patients with a complete hospitalization in 2015. Assessment of the influence of covariates on QTc using linear mixed-effects models.

RESULTS

At least one ECG (n = 600) was performed during 37.6% of the stays (n = 1198) and in 45.5% of the patients (n = 871). Among the patients with an ECG, 17.9% had significant ECG abnormalities, including 7.6% with a prolonged QTc. QTc measured at admission and during hospitalization did not change significantly (n = 46, 419.4 ± 29.7 ms, 417.2 ± 27.6 ms, p = 0.71). In the multivariate model (292 patients, 357 ECGs), the covariates significantly associated with the QTc were gender (+15.9 ms if female, p < 0.0001), age (+0.4 ms/year, p = 0.0001), triglyceride levels (+5.7 ms/mmol/l, p = 0.005), and drugs with known risk of torsades de pointes (+6.2 ms if ⩾1 drug, p = 0.028).

CONCLUSIONS

The prevalence of hospitalized psychiatric patients with an abnormal ECG indicates that ECGs should be performed systematically in this population. Prescription of psychotropic drugs should be done cautiously, particularly in patients with QTc prolongation risk factors.