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Castle JW, Butzbach DM, Walker GS, Lenehan CE, Reith F, Costello SP, Kirkbride KP. In vitro degradation of ziprasidone in human whole blood. Drug Test Anal 2023; 15:220-234. [PMID: 36269160 DOI: 10.1002/dta.3393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/14/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
A systematic study was performed into the degradation of ziprasidone in simulated postmortem blood. Fifteen potential degradation products not previously reported in the literature were observed. Four resulted from degradation in human blood, whereas the remaining products resulted from reaction with solvents: four from alkaline degradation, four from reaction with acetaldehyde, and three from reaction with acetone. To identify possible degradation products, a liquid chromatograph-diode array detector (LC-DAD) and liquid chromatograph quadrupole-time-of-flight mass spectrometer (LC-QTOF-MS) operating in auto-MS/MS mode were used. It was indicated from red-shifted UV-Vis spectra, accurate mass data, mass fragmentation data, and a deuteration experiment that the site of ziprasidone degradation, in the in vitro blood experiments, was the methylene carbon of the oxindole moiety. The major in vitro blood degradation products were proposed to be E/Z isomers of 3-ethylidene-ziprasidone. Further, another in vitro degradation product in microbially inoculated blood specimens was proposed to be 3-ethyl-ziprasidone. 3-Ethylidene-ziprasidone was hypothesized to form from the reaction of ziprasidone with acetaldehyde derived from the ethanol used to spike ziprasidone into the in vitro blood experiments. Data from two postmortem investigations were available for retrospective reanalysis. Attempts were made to detect degradation products of ziprasidone, but none were found.
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Affiliation(s)
- Jared W Castle
- College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
| | - Danielle M Butzbach
- College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia.,Forensic Science SA, Adelaide, South Australia, Australia
| | - G Stewart Walker
- College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
| | - Claire E Lenehan
- College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
| | - Frank Reith
- CSIRO Land & Water, Environmental Contaminant Mitigation and Technologies, Glen Osmond, South Australia, Australia.,School of Biological Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Samuel P Costello
- Department of Gastroenterology, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - K Paul Kirkbride
- College of Science and Engineering, Flinders University, Bedford Park, South Australia, Australia
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Ventricular dysrhythmias associated with poisoning and drug overdose: a 10-year review of statewide poison control center data from California. Am J Cardiovasc Drugs 2015; 15:43-50. [PMID: 25567789 DOI: 10.1007/s40256-014-0104-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Ventricular dysrhythmias are a serious consequence associated with drug overdose and chemical poisoning. The risk factors for the type of ventricular dysrhythmia and the outcomes by drug class are not well documented. OBJECTIVE The aim of this study was to determine the most common drugs and chemicals associated with ventricular dysrhythmias and their outcomes. METHODS We reviewed all human exposures reported to a statewide poison control system between 2002 and 2011 that had a documented ventricular dysrhythmia. Cases were differentiated into two groups by type of arrhythmia: (1) ventricular fibrillation and/or tachycardia (VT/VF); and (2) torsade de pointes (TdP). RESULTS Among the 300 potential cases identified, 148 cases met the inclusion criteria. Of these, 132 cases (89%) experienced an episode of VT or VF, while the remaining 16 cases (11%) had an episode of TdP. The most commonly involved therapeutic classes of drugs associated with VT/VF were antidepressants (33/132, 25%), stimulants (33/132, 25%), and diphenhydramine (16/132, 12.1%). Those associated with TdP were antidepressants (4/16, 25%), methadone (4/16, 25%), and antiarrhythmics (3/16, 18.75%). Drug exposures with the greatest risk of death in association with VT/VF were antidepressant exposure [odds ratio (OR) 1.71; 95% confidence interval (CI) 0.705-4.181] and antiarrhythmic exposure (OR 1.75; 95% CI 0.304-10.05), but neither association was statistically significant. Drug exposures with a statistically significant risk for TdP included methadone and antiarrhythmic drugs. CONCLUSIONS Antidepressants and stimulants were the most common drugs associated with ventricular dysrhythmias. Patients with suspected poisonings by medications with a high risk of ventricular dysrhythmia warrant prompt ECG monitoring.
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QTc interval prolongation and torsade de pointes associated with second-generation antipsychotics and antidepressants: a comprehensive review. CNS Drugs 2014; 28:887-920. [PMID: 25168784 DOI: 10.1007/s40263-014-0196-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We comprehensively reviewed published literature to determine whether it supported the link between corrected QT (QTc) interval prolongation and torsade de pointes (TdP) for the 11 second-generation antipsychotics and seven second-generation antidepressants commonly implicated in these complications. Using PubMed and EMBASE, we identified four thorough QT studies (one each for iloperidone, ziprasidone, citalopram, and escitalopram), 40 studies specifically designed to assess QTc interval prolongation or TdP, 58 publications based on data from efficacy and safety trials, 18 toxicology studies, and 102 case reports. Thorough QT studies, QTc prolongation-specific studies, and studies based on efficacy and safety trials did not link drug-associated QTc interval prolongation with TdP. They only showed that the drugs reviewed caused varying degrees of QTc interval prolongation, and even that information was not clear and consistent enough to stratify individual drugs for this risk. The few toxicology studies provided valuable information but their findings are pertinent only to situations of drug overdose. Case reports were most informative about the drug-QTc interval prolongation-TdP link. At least one additional well established risk factor for QTc prolongation was present in 92.2 % of case reports. Of the 28 cases of TdP, six (21.4 %) experienced it with QTc interval <500 ms; 75 % of TdP cases occurred at therapeutic doses. There is little evidence that drug-associated QTc interval prolongation by itself is sufficient to predict TdP. Future research needs to improve its precision and broaden its scope to better understand the factors that facilitate or attenuate progression of drug-associated QTc interval prolongation to TdP.
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Ries R, Sayadipour A. Management of psychosis and agitation in medical-surgical patients who have or are at risk for prolonged QT interval. J Psychiatr Pract 2014; 20:338-44. [PMID: 25226194 DOI: 10.1097/01.pra.0000454778.29433.7c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We review the literature on management of psychosis and agitation in medical-surgical patients who have or are at risk for prolonged QT interval, a risk factor for torsade de pointes (TdP), and we describe our protocols for treating these patients. We searched PubMed and PsycInfo for relevant studies and found few papers describing options for treating psychosis and agitation in these patients. Prolonged QTc interval has been more often associated with low-potency phenothiazines such as thioridazine; however, it may occur with high potency typical antipsychotics such as fluphenazine and haloperidol as well as with atypical antipsychotics such as quetiapine, risperidone, olanzapine, iloperidone, and particularly ziprasidone. Antipsychotics for which no association with prolonged QTc interval has been shown include lurasidone, clozapine, and aripiprazole. For patients who have risk factors for prolonged QTc interval but whose electrocardiograms do not show this, reasonable first choices include oral or intramuscular olanzapine or aripiprazole, followed by risperidone and quetiapine or oral or intramuscular haloperidol. For those who have prolonged QTc but that measures less than 500 ms, we limit the use of antipsychotics to aripiprazole, olanzapine, risperidone, or quetiapine. Finally, for patients who have a QTc of 500 ms or greater, we rely on aripiprazole, valproate, trazodone, and benzodiazepines.
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Affiliation(s)
- Rose Ries
- RIES and SAYADIPOUR: Drexel University College of Medicine, Philadelphia, PA
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Gardner DM, Murphy AL, Kutcher S, Beaulieu S, Carandang C, Labelle A, Lalonde P, Malla A, Milliken H, O’Donovan C, Schaffer A, Soni J, Taylor VH, Williams R. Evidence review and clinical guidance for the use of ziprasidone in Canada. Ann Gen Psychiatry 2013; 12:1. [PMID: 23347694 PMCID: PMC3564821 DOI: 10.1186/1744-859x-12-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 01/14/2013] [Indexed: 12/17/2022] Open
Abstract
While indicated for schizophrenia and acute mania, ziprasidone's evidence base and use in clinical practice extends beyond these regulatory approvals. We, an invited panel of experts led by a working group of 3, critically examined the evidence and our collective experience regarding the effectiveness, tolerability and safety of ziprasidone across its clinical uses. There was no opportunity for manufacturer input into the content of the review. As anticipated, ziprasidone was found to be effective for its indicated uses, although its utility in mania and mixed states lacked comparative data. Beyond these uses, the available data were either unimpressive or were lacking. An attractive characteristic is its neutral effect on weight thereby providing patients with a non-obesogenic long-term treatment option. Key challenges in practice include the need for dosing on a full stomach and managing its early onset adverse effect of restlessness. Addressing these issues are critical to its long-term success.
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Affiliation(s)
- David M Gardner
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Andrea L Murphy
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Stan Kutcher
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Serge Beaulieu
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Carlo Carandang
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Alain Labelle
- Department of Psychiatry, University of Ottawa, Ottawa, ON, Canada
| | - Pierre Lalonde
- Centre de recherche Fernand-Seguin de l’Hôpital Louis-H. Lafontaine, Montreal, QC, Canada
| | - Ashok Malla
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Heather Milliken
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Claire O’Donovan
- Department of Psychiatry, Dalhousie University, Halifax, NS, Canada
| | - Ayal Schaffer
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Jorge Soni
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Valerie H Taylor
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Richard Williams
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
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Levine M, Ruha AM. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management. CNS Drugs 2012; 26:601-11. [PMID: 22668123 DOI: 10.2165/11631640-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Historically, treatment for schizophrenia focused on sedation. The advent of the typical antipsychotics resulted in treatment aimed specifically at the underlying disease, but these agents were associated with numerous adverse effects, and were not particularly effective at treatment of the negative symptoms of schizophrenia. As a result, numerous atypical agents have been developed over the past 2 decades, including several agents within the past 5 years. Overdose of antipsychotics remains quite common in Western society. In 2010, poison control centres in the US received nearly 43,000 calls related to atypical antipsychotics alone. Due to underreporting, the true incidence of overdose with atypical antipsychotics is likely much greater. Following overdose of an atypical antipsychotic, the clinical effects observed, such as CNS depression, tachycardia and orthostasis are largely predictable based on the unique receptor binding profile of the agent. This article, which focuses on the atypical antipsychotics commonly used in the treatment of schizophrenia, discusses the features commonly encountered in overdose. Specifically, agents that result in QT prolongation and the corresponding potential for torsades de pointes, as well as unique features encountered with the various medications are discussed. The diagnosis of this overdose is largely based on history. Routine use of drug screens is unlikely to be beneficial. The primary goal of management is aggressive supportive care. Patients with significant CNS depression with associated loss of airway reflexes and respiratory failure need advanced airway management. Hypotension should be treated first with intravenous fluids, with the use of direct acting vasopressors reserved for persistent hypotension. Benzodiazepines should be used for seizures, with barbiturates used for refractory seizures. Intravenous magnesium can be administered for patients with a corrected QT interval exceeding 500 milliseconds.
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Affiliation(s)
- Michael Levine
- Section of Medical Toxicology, Department of Emergency Medicine, University of Southern California, Los Angeles, CA 90033, USA.
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Minns AB, Clark RF. Toxicology and overdose of atypical antipsychotics. J Emerg Med 2012; 43:906-13. [PMID: 22555052 DOI: 10.1016/j.jemermed.2012.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Revised: 02/27/2012] [Accepted: 03/09/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Second-generation antipsychotic medications, or "atypical antipsychotics," are now first-line therapy in the treatment of schizophrenia and other psychotic disorders, and are additionally being used in a wide array of other psychiatric and non-psychiatric conditions in both adults and children. Overdose is frequently reported to poison control centers. OBJECTIVES We review the toxicology and general management of poisonings involving the atypical antipsychotic medications. DISCUSSION The most serious toxicity involves the cardiovascular system and the central nervous system. All typical and atypical antipsychotics cause sedation, which is pronounced in overdose. The most common cardiovascular effects that occur after atypical antipsychotic overdose are tachycardia, mild hypotension, and prolongation of the QTc interval. Other clinical syndromes in overdose include neuroleptic malignant syndrome (NMS) and antimuscarinic delirium. Seizures may be observed. No antidotes exist for these poisonings, but they most often do well with supportive care. CONCLUSION Antipsychotic overdose produces a gamut of manifestations that affect multiple organ systems. Treatment is primarily supportive. Specific therapies for NMS, hypotension, and seizures are discussed.
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Affiliation(s)
- Alicia B Minns
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, San Diego, California 92103, USA
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Dubovsky SL, Dubovsky AN. Maintenance Treatment of Bipolar Disorder with Ziprasidone in Adjunctive Use with Lithium or Valproate. ACTA ACUST UNITED AC 2012. [DOI: 10.4137/cmt.s7369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ziprasidone is a second generation (“atypical”) antipsychotic drug that has been used alone and as an adjunct to standard mood stabilizers to reduce recurrence rates in bipolar disorder. Approval of ziprasidone as an adjunct to lithium or valproate in 2009 was based on an industry sponsored study of 584 outpatients with a current or recent manic episode; 240 of these subjects were randomized to adjunctive ziprasidone or placebo and 138 completed a six month trial. Patients enrolled in maintenance studies did not have refractory mood disorders, comorbid conditions or risk of dangerousness. Maintenance ziprasidone augmentation is an option for patients who do not respond to a single mood stabilizer rapidly, and possibly for those with residual psychotic symptoms, but there are insufficient data to prefer this approach to combinations of mood stabilizers or augmentation with other agents. Ziprasidone is generally well tolerated, with less sedation and weight gain than many other antipsychotic drugs; it should be taken with food. Primary interactions of concern are with other serotonergic medications, MAO inhibitors, and other medications that prolong the QT interval.
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Affiliation(s)
- Steven L. Dubovsky
- Departments of Psychiatry, University at Buffalo, Massachusetts General Hospital, University of Colorado, and Department of Medicine, University of Colorado
| | - Amelia N. Dubovsky
- Departments of Psychiatry, University at Buffalo, Massachusetts General Hospital, University of Colorado, and Department of Medicine, University of Colorado
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Berling I, Isbister GK, Calver L, Clunas S. Digital Holter measurement of QT prolongation in ziprasidone overdose. Clin Toxicol (Phila) 2011; 49:694-6. [PMID: 21819290 DOI: 10.3109/15563650.2011.597035] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE QT prolongation is an important complication in drug overdose, particularly with some antidepressants and antipsychotics. There are problems with the accurate measurement of the QT interval and determining for what QT interval patients should be monitored, because of the risk of torsades des pointes (TdP). We report a case of ziprasidone overdose with QT prolongation, demonstrating different methods of measuring the QT interval. CASE REPORT A 47-year-old female presented after taking 1.2 g of ziprasidone and 250 mg of diazepam. She was taking propranolol and venlafaxine therapeutically. She developed bradycardia and QT prolongation (540 msec). She was transferred to a telemetry bed and observed for 48 h until her QT interval returned to normal (460 msec). QT intervals were extracted from (1) 12-lead digital Holter recordings (gold standard); (2) automated measurements on standard electrocardiograms (ECGs); and (3) manual measurements on standard ECGs, and compared on a QT versus time plot. An abnormal QT was determined based on the QT nomogram. Manual QT measurements showed a clear temporal association between ziprasidone overdose and a long QT, consistent with accurate QT measurements using continuous 12-lead Holter recordings with automatic QT measurements. However, standard automated measurements did not indicate an abnormal QT. CONCLUSIONS Manual measurement of the QT interval appeared to be similar to the more accurate measurement of the QT by automated digital Holter recordings and better than standard automated measurements. Manual QT measurements would be more appropriate in clinical assessment of patients.
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Affiliation(s)
- Ingrid Berling
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia.
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Dubovsky SL, Dubovsky AN. Ziprasidone for maintenance treatment of bipolar I disorder in adults. Expert Opin Pharmacother 2011; 12:817-24. [DOI: 10.1517/14656566.2011.563237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
INTRODUCTION Ziprasidone is a second-generation antipsychotic approved for the treatment of schizophrenia and bipolar disorder. The purpose of this review is to assess the overall safety profile of ziprasidone, including its risk for prolonging the electrocardiogram (ECG) QT interval. AREAS COVERED This paper is a review of product labeling and English language reports located through PubMed and information available on regulatory agency websites, with a focus on the safety and tolerability of ziprasidone. EXPERT OPINION Although ziprasidone can prolong the ECG QT interval, this has not resulted in increases in sudden death or cardiac sudden death as noted in a large, simple trial and supported by almost a decade of real-world use in the US. Ziprasidone's principal advantage over some other second-generation antipsychotics has been its overall favorable weight and metabolic profile. Similar to most second-generation antipsychotics, ziprasidone has a lower propensity for extrapyramidal side effects and hyperprolactinemia compared to first-generation antipsychotics.
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Affiliation(s)
- Leslie Citrome
- New York University School of Medicine, 11 Medical Park Drive, Suite 106, Pomona, NY 10970, USA.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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