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Wendl E, Telles N, Wall GC. Survey concerning internal medicine physicians and prolonged QT interval: Knowledge and treatment practices. World J Cardiol 2021; 13:42-45. [PMID: 33791077 PMCID: PMC7988595 DOI: 10.4330/wjc.v13.i3.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/03/2020] [Accepted: 01/13/2021] [Indexed: 02/06/2023] Open
Abstract
Prolongation of the QT interval is associated with adverse cardiac events specifically Torsades de pointes (TdP). There are multiple mediations that have a known, possible, or conditional risk for prolonged QT interval, but general practitioners’ knowledge of these medications is unknown. We conducted a survey to assess internal medicine (IM) providers’ knowledge of risk factors and medications associated with prolonged QT as well as provider experience and comfort when treating patients with prolonged QT. A 17-question, anonymous survey was constructed in 2019 and distributed to IM providers and residents at a tertiary care center. Questions included demographic information, 6 Likert-scale questions gauging provider experience with prolonged QT, and 10 multiple choice clinical vignettes to assess clinical knowledge. Data was analyzed descriptively. Knowledge was assessed via clinical vignettes and compared by level of training. Forty-one responses were received out of a total of 87 possible respondents (47.1% response rate). About 70% of respondents see patients with acquired prolonged QT once monthly or more. 95% rarely see congenital prolonged QT. When presented with QTc drug issues, 73% of providers seldom or sometimes consulted pharmacy, but about half used online resources. The average correct score on the clinical vignettes was 5.59/10, with the highest scores seen in attending physicians in their first five years of practice (6.96/10). Our survey suggests that IM providers commonly encounter QT prolonging drugs. Educational efforts to improve knowledge of drug and patient risk factors for TdP may be needed.
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Affiliation(s)
- Elizabeth Wendl
- Department of Medical Education, Internal Medicine Residency Program, Iowa Methodist Medical Center, Des Moines, IA 50311, United States
| | - Nelson Telles
- Department of Cardiology, Internal Medicine Residency Program, Iowa Methodist Medical Center, Des Moines, IA 50311, United States
| | - Geoff C Wall
- Department of Pharmacy Practice, Drake University College of Pharmacy and Health Sciences, Des Moines, IA 50311, United States
- Internal Medicine Residency Program, Iowa Methodist Medical Center, Des Moines, IA 50311, United States
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Thind M, Rodriguez I, Kosari S, Turner JR. How to Prescribe Drugs With an Identified Proarrhythmic Liability. J Clin Pharmacol 2019; 60:284-294. [DOI: 10.1002/jcph.1551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Munveer Thind
- Lankenau Institute for Medical Research Philadelphia Pennsylvania USA
| | - Ignacio Rodriguez
- Novartis Pharmaceutical Corporation East Hanover New Jersey USA
- Cardiac Safety Research Consortium Duke Clinical Research Institute Durham North Carolina USA
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health University of Canberra Bruce Australian Capital Territory Australia
| | - J. Rick Turner
- Cardiac Safety Research Consortium Duke Clinical Research Institute Durham North Carolina USA
- The American College of Clinical Pharmacology Rockville Maryland USA
- Department of Pharmacy Practice Campbell University College of Pharmacy & Health Sciences Buies Creek North Carolina USA
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Christensen L, Turner JR, Peterson GM, Naunton M, Thomas J, Yee KC, Kosari S. Identification of Risk of QT Prolongation by Pharmacists When Conducting Medication Reviews in Residential Aged Care Settings: A Missed Opportunity? J Clin Med 2019; 8:E1866. [PMID: 31689908 PMCID: PMC6912304 DOI: 10.3390/jcm8111866] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/22/2019] [Accepted: 10/31/2019] [Indexed: 11/16/2022] Open
Abstract
QT interval prolongation is associated with torsade de pointes and sudden cardiac death. QT prolongation can be caused by many drugs that are commonly prescribed in elderly residential aged care populations. The aim of this study was to investigate the prevalence of use of QT-prolonging drugs and to identify interventions made by pharmacists to reduce the risk of QT prolongation when conducting medication reviews in aged care. A retrospective analysis of 400 medication reviews undertaken by Australian pharmacists in aged care settings was conducted. The assessment included the risk of QT prolongation due to prescribed medications and other risk factors and the recommendations made by pharmacists to reduce the risk of QT prolongation. There was a high prevalence of the use of QT-prolonging medication, with 23% of residents (92 out of 400) taking at least one medication with a known risk of QT prolongation. Amongst the 945 prescribed drugs with any risk of QT prolongation, antipsychotics were the most common (n = 246, 26%), followed by antidepressants (19%) and proton pump inhibitors (13%). There appeared to be low awareness amongst the pharmacists regarding the risk of QT prolongation with drugs. Out of 400 reviews, 66 residents were categorised as high risk and were taking at least one medication associated with QT prolongation; yet pharmacists intervened in only six instances (9%), mostly when two QT-prolonging medications were prescribed. There is a need to increase awareness amongst pharmacists conducting medication reviews regarding the risk factors associated with QT prolongation, and further education is generally needed in this area.
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Affiliation(s)
- Louise Christensen
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - J Rick Turner
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, 239 J.P. Riddle Building, PO Box 1090, Buies Creek, NC 27506, USA.
| | - Gregory M Peterson
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
- Faculty of Health, University of Tasmania, Hobart 7005, Tasmania, Australia.
| | - Mark Naunton
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - Jackson Thomas
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - Kwang Choon Yee
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
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Buss VH, Lee K, Naunton M, Peterson GM, Kosari S. Identification of Patients At-Risk of QT Interval Prolongation during Medication Reviews: A Missed Opportunity? J Clin Med 2018; 7:jcm7120533. [PMID: 30544669 PMCID: PMC6306817 DOI: 10.3390/jcm7120533] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 11/30/2018] [Accepted: 12/07/2018] [Indexed: 01/08/2023] Open
Abstract
The prolongation of the QT interval is a relatively rare but serious adverse drug reaction. It can lead to torsade de pointes, which is potentially life-threatening. The study’s objectives were: determine the use of QT interval-prolonging drugs in an elderly community-dwelling population at risk of medication misadventure and identify recommendations regarding the risk of QT interval prolongation made by pharmacists when performing medication reviews. In a retrospective evaluation, 500 medication review reports from Australian pharmacists were analysed. In patients taking at least one QT interval-prolonging drug, the individual risk of drug-induced QT interval prolongation was assessed. Recommendations of pharmacists to avoid the occurrence of this drug-related problem were examined. There was a high prevalence of use of potentially QT interval-prolonging drugs (71% patients), with 11% of patients taking at least one drug with a known risk. Pharmacists provided specific recommendations in only eight out of 35 patients (23%) with a high-risk score and taking drugs with known risk of QT interval prolongation. Pharmacists’ recommendations, when present, were focused on drugs with known risk of QT interval prolongation, rather than patients’ additional risk factors. There is a need to improve knowledge and awareness of this topic among pharmacists performing medication reviews.
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Affiliation(s)
- Vera H Buss
- Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - Kayla Lee
- Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - Mark Naunton
- Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
| | - Gregory M Peterson
- Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
- School of Medicine, University of Tasmania, Sandy Bay, TAS 7005, Australia.
| | - Sam Kosari
- Faculty of Health, University of Canberra, Bruce, ACT 2617, Australia.
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Turner JR. Proposed Proarrhythmic Cardiac Safety Education in Medical, Pharmacy, and Nursing Schools: An Interprofessional Model. Ther Innov Regul Sci 2018; 52:529-530. [PMID: 30204494 DOI: 10.1177/2168479018797715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Turner JR, Rodriguez I, Mantovani E, Gintant G, Kowey PR, Klotzbaugh RJ, Prasad K, Sager PT, Stockbridge N, Strnadova C. Drug-induced Proarrhythmia and Torsade de Pointes: A Primer for Students and Practitioners of Medicine and Pharmacy. J Clin Pharmacol 2018; 58:997-1012. [PMID: 29672845 DOI: 10.1002/jcph.1129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
Multiple marketing withdrawals due to proarrhythmic concerns occurred in the United States, Canada, and the United Kingdom in the late 1980s to early 2000s. This primer reviews the clinical implications of a drug's identified proarrhythmic liability, the issues associated with these safety-related withdrawals, and the actions taken by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) and by regulatory agencies in terms of changing drug development practices and introducing new nonclinical and clinical tests to asses proarrhythmic liability. ICH Guidelines S7B and E14 were released in 2005. Since then, they have been adopted by many regional regulatory authorities and have guided nonclinical and clinical proarrhythmic cardiac safety assessments during drug development. While this regulatory paradigm has been successful in preventing drugs with unanticipated potential for inducing the rare but potentially fatal polymorphic ventricular arrhythmia torsade de pointes from entering the market, it has led to the termination of drug development programs for other potentially useful medicines because of isolated results from studies with limited predictive value. Research efforts are now exploring alternative approaches to better predict potential proarrhythmic liabilities. For example, in the domain of human electrocardiographic assessments, concentration-response modeling conducted during phase 1 clinical development has recently become an accepted alternate primary methodology to the ICH E14 "thorough QT/QTc" study for defining a drug's corrected QT interval prolongation liability under certain conditions. When a drug's therapeutic benefit is considered important at a public health level but there is also an identified proarrhythmic liability that may result from administration of the single drug in certain individuals and/or drug-drug interactions, marketing approval will be accompanied by appropriate directions in the drug's prescribing information. Health-care professionals in the fields of medicine and pharmacy need to consider the prescribing information in conjunction with individual patients' clinical characteristics and concomitant medications when prescribing and dispensing such drugs.
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Affiliation(s)
- J Rick Turner
- Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
| | - Ignacio Rodriguez
- Cardiac Safety Research Consortium, Roche TCRC, Inc., New York, NY, USA
| | - Emily Mantovani
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ, USA
| | | | - Peter R Kowey
- Lankenau Heart Institute and Jefferson Medical College, Philadelphia, PA, USA
| | - Ralph J Klotzbaugh
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Krishna Prasad
- Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Philip T Sager
- Sager Consulting and Stanford University, San Francisco, CA, USA
| | - Norman Stockbridge
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD, USA
| | - Colette Strnadova
- Therapeutic Products Directorate, Health Canada, Ottawa, Ontario, Canada
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Turner JR. Integrated cardiovascular safety: multifaceted considerations in drug development and therapeutic use. Expert Opin Drug Saf 2017; 16:481-492. [DOI: 10.1080/14740338.2017.1300252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J. Rick Turner
- Cardiac Safety Services, QuintilesIMS, Durham, NC, USA
- Department of Pharmacy Practice, Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC, USA
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