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Titus-Lay EN, Jaynes HA, Tomaselli Muensterman E, Walroth TA, Ott CA, Desta Z, Williams G, Moe PR, Wilbrandt M, Tisdale JE. Methadone-associated QT interval prolongation in patients undergoing maintenance therapy in an urban opioid treatment program. Pharmacotherapy 2021; 41:238-246. [PMID: 33345336 DOI: 10.1002/phar.2498] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/27/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE Methadone is associated with QT interval prolongation and torsades de pointes. The objective of this study was to (a) determine the incidence of QT interval prolongation among patients on maintenance methadone therapy in an urban opioid treatment program (OTP), (b) compare characteristics of patients who developed methadone-associated QT prolongation with those who did not develop QT prolongation, and (c) investigate the relationship between QT interval prolongation and stereospecific serum methadone and metabolite [2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP)] concentrations. DESIGN Prospective study. SETTING Urban opioid treatment program (OTP). PATIENTS n = 93 patients on maintenance methadone therapy in an urban OTP. INTERVENTION Patients underwent a 12-lead electrocardiogram (ECG) prior to initiating methadone and again during steady-state maintenance methadone therapy. In a subset (n = 43), blood was obtained to determine serum (S)- and (R)-methadone and (S)- and (R)-EDDP concentrations, which were compared in patients who developed Bazett's-corrected QT (QTc) prolongation [≥470 ms (men) or ≥480 ms (women) and/or ≥60 ms lengthening from pretreatment value] with those who did not have QTc prolongation. MEASUREMENTS AND MAIN RESULTS Mean [± standard deviation (SD)] age was 36 ± 12 years; 73% were female, and 74% were white. QTc prolongation occurred in 14 (15.1%) patients. Patients who developed QTc prolongation were older (41 ± 13 vs. 35 ± 9 years, p = 0.03) and had a longer pre-methadone QTc compared with those who did not have QTc prolongation (429 ± 11 vs. 420 ± 20 ms, respectively, p = 0.02). Serum (S)-methadone concentrations were higher in patients with QTc prolongation compared to patients without prolongation (199 ± 81 vs. 128 ± 68 ng/ml, respectively, p = 0.01), whereas the difference in serum (R)-methadone concentrations between the groups did not reach significance (189 ± 68 vs. 125 ± 60 ng/ml, respectively, p = 0.08). Serum (R)-methadone concentrations correlated with QTc intervals [R2 = 0.15 (95% confidence interval (CI) 0.11-0.62, p = 0.0009)]. The correlation between serum (S)-methadone concentrations and QTc did not reach significance [R2 = 0.08 (95% CI -0.01 to 0.54, p = 0.06)]. Serum (S)-and (R)-EDDP concentrations were not significantly different between the groups and did not significantly correlate with QTc intervals. CONCLUSIONS Approximately 15% of patients taking maintenance methadone therapy developed QT interval prolongation. Both serum (S)- and (R)-methadone concentrations, but not (S)- or (R)-EDDP, contribute to methadone-associated QT prolongation.
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Affiliation(s)
- Erika N Titus-Lay
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA.,College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,College of Pharmacy, California Northstate University, Elk Grove, California, USA
| | - Heather A Jaynes
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA
| | - Elena Tomaselli Muensterman
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,AbbVie Inc., North Chicago, Illinois, USA
| | - Todd A Walroth
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA
| | - Carol A Ott
- Department of Pharmacy, Eskenazi Health, Indianapolis, Indiana, USA.,College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Zeruesenay Desta
- School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | | | - Paul R Moe
- Sandra Eskenazi Health Mental Health Center Opioid Treatment Program, Indianapolis, Indiana, USA
| | - Michelle Wilbrandt
- Sandra Eskenazi Health Mental Health Center Opioid Treatment Program, Indianapolis, Indiana, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, Indianapolis, Indiana, USA.,School of Medicine, Indiana University, Indianapolis, Indiana, USA
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Ansermot N, Bochatay M, Schläpfer J, Gholam M, Gonthier A, Conus P, Eap CB. Prevalence of ECG abnormalities and risk factors for QTc interval prolongation in hospitalized psychiatric patients. Ther Adv Psychopharmacol 2019; 9:2045125319891386. [PMID: 31853363 PMCID: PMC6909271 DOI: 10.1177/2045125319891386] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/21/2019] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Nicolas Ansermot
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Hospital of Cery, 1008 Prilly, Switzerland
| | - Meredith Bochatay
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - Jürg Schläpfer
- Department of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mehdi Gholam
- Centre of Psychiatric Epidemiology and Psychopathology, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - Ariane Gonthier
- General Internal Medicine Practice, Lausanne, Switzerland; University Institute of Medicine of the Family, University of Lausanne, Lausanne, Switzerland
| | - Philippe Conus
- Service of General Psychiatry, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
| | - Chin B Eap
- Unit of Pharmacogenetics and Clinical Psychopharmacology, Centre for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Prilly, Switzerland
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Salihu HM, Salemi JL, Aggarwal A, Steele BF, Pepper RC, Mogos MF, Aliyu MH. Opioid Drug Use and Acute Cardiac Events Among Pregnant Women in the United States. Am J Med 2018; 131:64-71.e1. [PMID: 28807713 DOI: 10.1016/j.amjmed.2017.07.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiovascular disease remains a leading cause of pregnancy-associated deaths in the United States. The extent to which increasing opioid use among pregnant women contributes to fatal cardiovascular events is unknown. We examined trends in opioid use among pregnant women over the previous decade and the association between changes in temporal trends in opioid drug use and the incidence of acute cardiac events among mothers. METHODS In this retrospective analysis of the Healthcare and Cost Utilization Project, we used a 2-stage stratified cluster sampling of all inpatient hospital discharges from nonfederal hospitals from January 1, 2002 through December 31, 2014. The study population comprised pregnant women aged 13-49 years and related hospitalizations, including delivery. The primary exposure of interest was opioid use during pregnancy. The primary outcome was the occurrence of acute myocardial infarction or cardiac arrest during pregnancy or childbirth. RESULTS Among the estimated 57.4 million pregnancy-related inpatient hospitalizations, 511,469 (approximately 1%) had documented use of opioids, cocaine, and/or amphetamines. There was a 300% increase in the use of opioids during pregnancy over the study period, whereas cocaine consumption significantly decreased and that of amphetamine remained stable. Over the 13-year period, the rise in opioid use paralleled a 50% increase in the incidence of acute cardiac events among mothers. CONCLUSION Over the previous decade opioid use during pregnancy increased significantly, in parallel with the rise in the incidence of acute cardiac events in pregnancy and childbirth. An effective national policy is needed to address this emerging public health challenge.
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Affiliation(s)
- Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Tex.
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Tex
| | - Anjali Aggarwal
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Tex
| | - Beverly F Steele
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Tex
| | - Ross C Pepper
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Tex
| | - Mulubrhan F Mogos
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois, Chicago
| | - Muktar H Aliyu
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tenn
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Isbister GK, Brown AL, Gill A, Scott AJ, Calver L, Dunlop AJ. QT interval prolongation in opioid agonist treatment: analysis of continuous 12-lead electrocardiogram recordings. Br J Clin Pharmacol 2017; 83:2274-2282. [PMID: 28488266 PMCID: PMC5595951 DOI: 10.1111/bcp.13326] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/18/2017] [Accepted: 05/01/2017] [Indexed: 12/17/2022] Open
Abstract
AIMS Methadone is a widely used opioid agonist treatment associated with QT prolongation and torsades de pointes. We investigated the QT interval in patients treated with methadone or buprenorphine using continuous 12-lead Holter recordings. METHODS We prospectively made 24-h Holter recordings in patients prescribed methadone or buprenorphine, compared to controls. After their normal dose a continuous 12-lead Holter recorder was attached for 24 h. Digital electrocardiograms were extracted hourly from the Holter recordings. The QT interval was measured automatically (H-scribe software, Mortara Pty Ltd) and checked manually. The QT interval was plotted against heart rate (HR) on the QT nomogram to determine abnormality. Demographics, dosing, medical history and laboratory investigations were recorded. RESULTS There were 58 patients (19 methadone, 20 buprenorphine and 19 control); median age 35 years (20-56 years); 33 males. Baseline characteristics were similar. Median dose of methadone was 110 mg day-1 (70-170 mg day-1 ) and buprenorphine was 16 mg day-1 (12-32 mg day-1 ). Seven participants had abnormal QT intervals. There was a significant difference in the proportion of prescribed methadone with abnormal QT intervals, 7/19 (37%; 95% confidence interval: 17-61%), compared to controls 0/19 (0%; 95% confidence interval: 0-21%; P = 0.008), but no difference between buprenorphine and controls (0/20). QT vs. HR plots showed patients prescribed methadone had higher QT-HR pairs over 24 h compared to controls. There was no difference in dose for patients prescribed methadone with abnormal QT intervals and those without. CONCLUSIONS Methadone is associated with prolonged QT intervals, but there was no association with dose. Buprenorphine did not prolong the QT interval. Twenty four-hour Holter recordings using the QT nomogram is a feasible method to assess the QT interval in patients prescribed methadone.
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Affiliation(s)
- Geoffrey K. Isbister
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesAustralia
- Department of Clinical Toxicology and PharmacologyCalvary Mater NewcastleNewcastleNew South WalesAustralia
| | - Amanda L. Brown
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesAustralia
- Drug and Alcohol Clinical ServicesHunter New England Local Health DistrictNew South WalesAustralia
- Centre for Brain and Mental HealthUniversity of Newcastle and Hunter Medical Research InstituteNew South WalesAustralia
| | - Anthony Gill
- Drug and Alcohol Clinical ServicesHunter New England Local Health DistrictNew South WalesAustralia
- Alcohol and Drug ServicesSt Vincents Hospital, DarlinghurstNew South WalesAustralia
- Drug and Alcohol Services, Central Coast Local Health DistrictNew South WalesAustralia
| | - Alexander J. Scott
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesAustralia
| | - Leonie Calver
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesAustralia
| | - Adrian J. Dunlop
- School of Medicine and Public HealthUniversity of NewcastleNew South WalesAustralia
- Drug and Alcohol Clinical ServicesHunter New England Local Health DistrictNew South WalesAustralia
- Centre for Brain and Mental HealthUniversity of Newcastle and Hunter Medical Research InstituteNew South WalesAustralia
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