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Galust H, Hardin JR, Friedman NA, Seltzer JA, Clark RF. QRS Prolongation After Seizure in a Patient with Venlafaxine Overdose. J Emerg Med 2024; 66:e38-e40. [PMID: 37891066 DOI: 10.1016/j.jemermed.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/13/2023] [Accepted: 07/15/2023] [Indexed: 10/29/2023]
Affiliation(s)
- Henrik Galust
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Jeremy R Hardin
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Nathan A Friedman
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Justin A Seltzer
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
| | - Richard F Clark
- UCSD Fellowship in Medical Toxicology, Department of Emergency Medicine, University of California San Diego (UCSD) Medical Center, San Diego, California
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Ollier M, Giles S, Gosselin S. The Occasional intralipid emulsion therapy. CANADIAN JOURNAL OF RURAL MEDICINE 2023; 28:195-200. [PMID: 37861604 DOI: 10.4103/cjrm.cjrm_62_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Affiliation(s)
- Mary Ollier
- Departement of Family Medicine Temerty School of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Giles
- Northern Ontario School of Medicine University, Thunder Bay, Ontario, Canada
| | - Sophie Gosselin
- Centre Intégré De Santé Et Services Sociaux De La Montérégie-Centre; Centre Antipoison Du Québec; Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Quebec, Canada
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Gutlapalli SD, Lavu VK, Mohamed RA, Huang R, Potla S, Bhalla S, Al Qabandi Y, Nandula SA, Boddepalli CS, Hamid P. The Risk of Fatal Arrhythmias in Post-Myocardial Infarction Depression in Association With Venlafaxine. Cureus 2022; 14:e29107. [PMID: 36258960 PMCID: PMC9572810 DOI: 10.7759/cureus.29107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/13/2022] [Indexed: 11/18/2022] Open
Abstract
Venlafaxine is a second line anti-depressant and the most commonly used in the treatment of selective serotonin reuptake inhibitor nonresponders in major depression; due to its effects on the noradrenergic and serotonergic systems as a serotonin and norepinephrine reuptake inhibitor, there has been considerable apprehension regarding its use in patients with cardiovascular diseases, particularly post-myocardial infarction depression, some of the feared adverse effects include QT prolongation, arrhythmias including torsades de pointes and sudden cardiac death. We tried to resolve the facts regarding the risks associated with venlafaxine use in cardiac patients. We have reviewed all the relevant information up to May 2022 regarding the risks of venlafaxine use in cardiovascular disease, particularly with a focus on post-myocardial infarction depression, and gathered around 350 articles in our research and narrowed it down to 49 articles. The database used was PubMed and the keywords used were venlafaxine, arrhythmia, major depression, post-myocardial infarction, and ventricular tachycardia. We carefully screened all relevant articles and found articles supporting and refuting the effects of venlafaxine in increasing cardiovascular morbidity and mortality. We have concluded that there is a significant variability due to confounding factors affecting individual cases. Overall there is no increased arrhythmia risk in comparison with other anti-depressants except in high-risk cases such as with pre-existing cardiovascular disease, certain genotypes, and other co-morbidities. Any patient with a high risk of arrhythmias due to any etiology should receive a screening electrocardiogram before venlafaxine prescription for baseline QT interval and periodically while on therapy to check for changes. We encourage further research, including randomized clinical trials and post-marketing surveillance regarding the use of venlafaxine in high-risk cases such as patients with multiple co-morbidities, elderly patients, or patients with certain genotypes.
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Murphy L, Rasmussen J, Murphy NG. Venlafaxine overdose treated with extracorporeal life support. CMAJ 2021; 193:E167-E170. [PMID: 33526543 PMCID: PMC7954576 DOI: 10.1503/cmaj.201318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Laurel Murphy
- Departments of Emergency Medicine and Critical Care (L. Murphy), and Surgery; Division of Plastic Surgery, Department of Critical Care (Rasmussen); Department of Emergency Medicine and IWK Regional Poison Centre (N. Murphy), Dalhousie University, Halifax, NS
| | - Jack Rasmussen
- Departments of Emergency Medicine and Critical Care (L. Murphy), and Surgery; Division of Plastic Surgery, Department of Critical Care (Rasmussen); Department of Emergency Medicine and IWK Regional Poison Centre (N. Murphy), Dalhousie University, Halifax, NS
| | - Nancy G Murphy
- Departments of Emergency Medicine and Critical Care (L. Murphy), and Surgery; Division of Plastic Surgery, Department of Critical Care (Rasmussen); Department of Emergency Medicine and IWK Regional Poison Centre (N. Murphy), Dalhousie University, Halifax, NS
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Abbas R, Riley S, Nepal S, Bachinsky M, Lee KC, Chappell PB, Damle B. Lack of an Effect of Supratherapeutic Dose of Venlafaxine on Cardiac Repolarization in Healthy Subjects. Clin Pharmacol Drug Dev 2021; 11:100-111. [PMID: 34242472 DOI: 10.1002/cpdd.989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/12/2021] [Indexed: 11/10/2022]
Abstract
This single-center, randomized, 3-way crossover thorough QT study evaluated the effect of steady-state supratherapeutic venlafaxine (Effexor) on cardiac repolarization. Fifty-four healthy adults received double-blinded extended-release venlafaxine 450 mg/d and placebo and open-label positive-control moxifloxacin 400 mg. The postdose QT intervals corrected for heart rate using the Fridericia formula (QTcF) were assessed on day 14 with an analysis of covariance using a mixed-effects model. At each time, the upper bound of the 2-sided 90%CI for time-matched least-squares (LS) mean difference between venlafaxine and placebo did not exceed the predefined cutoff of 10 milliseconds; the highest 90%CI upper bound was 5.8 milliseconds 24 hours postdose, demonstrating the lack of effect of venlafaxine on the QTc interval (primary objective). Assay sensitivity was established because the lower bound of the 2-sided 90%CI for LS mean difference in QTcF between moxifloxacin and placebo was 7.413 milliseconds on day 14 (postdose 3 hours). The exposure-response analysis demonstrated no evidence of increase in QTcF with increase in venlafaxine and desvenlafaxine concentrations. Also, supratherapeutic venlafaxine was found to be safe and well tolerated. Overall, the results demonstrated the lack of significant prolongation of the QTc interval with supratherapeutic venlafaxine 450 mg/d.
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Affiliation(s)
- Richat Abbas
- Medical Product Evaluation, Upjohn, Pfizer Inc., Collegeville, Pennsylvania, USA
| | - Steve Riley
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | - Sunil Nepal
- SKN Statistical Consulting Services LLC, Schwenksville, Pennsylvania, USA
| | - Mary Bachinsky
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | - Kimberly C Lee
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | | | - Bharat Damle
- Global Research and Development, Pfizer Inc., New York, New York, USA
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Murphy L, Rasmussen J, Murphy NG. Surdose de venlafaxine traitée par assistance cardiorespiratoire extracorporelle. CMAJ 2021; 193:E531-E535. [PMID: 33846207 PMCID: PMC8087331 DOI: 10.1503/cmaj.201318-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Laurel Murphy
- Départements de médecine d'urgence et de soins intensifs (L. Murphy) et de chirurgie; Division de chirurgie plastique, Département de soins intensifs (Rasmussen); Département de médecine d'urgence et IWK Regional Poison Centre (N. Murphy), Université Dalhousie, Halifax, N-É.
| | - Jack Rasmussen
- Départements de médecine d'urgence et de soins intensifs (L. Murphy) et de chirurgie; Division de chirurgie plastique, Département de soins intensifs (Rasmussen); Département de médecine d'urgence et IWK Regional Poison Centre (N. Murphy), Université Dalhousie, Halifax, N-É
| | - Nancy G Murphy
- Départements de médecine d'urgence et de soins intensifs (L. Murphy) et de chirurgie; Division de chirurgie plastique, Département de soins intensifs (Rasmussen); Département de médecine d'urgence et IWK Regional Poison Centre (N. Murphy), Université Dalhousie, Halifax, N-É
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Jiang E, Raubenheimer JE, Isbister GK, Chan BSH, Buckley NA. Machine read frontal QRS-T angle and QTc is no substitute for manual measurement of QTc in pro-arrhythmic drug overdose. J Electrocardiol 2021; 65:151-156. [PMID: 33640634 DOI: 10.1016/j.jelectrocard.2021.02.006] [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: 10/01/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION To investigate whether there is an association between the blocking of cardiac potassium channels, which is characterised by a prolonged QTc interval and the frontal QRS-T angle after overdose by QT prolonging drugs. METHODS We obtained patient medical records associated with QT prolonging drugs from 3 different hospitals: the Calvary Mater Newcastle Hospital (CMNH), Royal Prince Alfred Hospital (RPAH) and Prince of Wales Hospital (POWH). RPAH and POWH admissions were taken between 4/01/2017 to 1/11/2019, and CMNH admissions were taken between 4/01/2013 to 24/06/2018. Demographic information and details of overdose were collected. All admission ECGs were manually measured. Linear regression was used to assess the relationship between various QTc formulas and the frontal QRS-T angle. A Bland-Altman plot was used to examine agreement between manual and machine QT intervals. RESULTS 144 patients met the inclusion criteria for analysis. None of the patients developed torsades de pointes (TdP). There was no linear association between the QRS-T angle and the various QTc formulas (For QRS-T angle: QTcRTH: p = 0.76, QTcB: p = 0.83, QTcFri: p = 0.90, QTcFra: p = 0.13, QTcH: p = 0.97; For square root transformation of the QRS-T angle: QTcRTH: p = 0.18, QTcB: p = 0.33, QTcFri: p = 0.95, QTcFra: p = 0.47, QTcH: p = 0.33). Agreement between machine and manual QT measurements was low. CONCLUSIONS The frontal QRS-T angle cannot substitute the QTc in assessing the blockage of cardiac potassium channels in drug induced long QT syndrome. We also support the consensus that despite the availability of machine measurements of the QT interval, manual measurements should also be performed.
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Affiliation(s)
- Eric Jiang
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jacques E Raubenheimer
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | | | - Betty S H Chan
- Clinical Toxicology Unit, Department of Emergency Medicine, Prince of Wales Hospital, Randwick, Australia
| | - Nicholas A Buckley
- Department of Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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Antidepressants and the Risk of Cardiovascular Events in Elderly Affected by Cardiovascular Disease: A Real-Life Investigation From Italy. J Clin Psychopharmacol 2020; 40:112-121. [PMID: 32134848 DOI: 10.1097/jcp.0000000000001189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The purpose of this study was to assess the possible relation between use of antidepressant (AD) drugs, that is, tricyclic ADs, selective serotonin reuptake inhibitors (SSRIs), and atypical ADs (AAs), and the risk of hospitalization for cardiovascular (CV) events among older patients with previous CV diseases. METHODS A nested case-control study was carried out among patients aged 65 years and older from 5 Italian health care territorial units who were discharged for CV disease during 2008 to 2010. The cohort was composed by 344,747 individuals, and of these, 97,739 (28%) experienced hospital admission for CV events (myocardial infarction, arrhythmia, stroke, heart failure) during follow-up (until 2014) and were included as cases. Up to 5 controls were randomly selected and matched to each. A conditional logistic regression was fitted to estimate the risk of CV events associated with ADs past or current use. A within-patient comparison was performed by the case-crossover design to account the effect of depression. FINDINGS Current users of SSRIs and AAs were at increased risk of CV events with odds ratios of 1.25 (95% confidence interval, 1.21-1.29) and 1.31 (1.25-1.37), respectively. An increased risk of arrhythmia and stroke was associated with current use of SSRIs and AAs, whereas an increased risk of heart failure was detected with current use of any ADs. The results were confirmed by the case-crossover approach. IMPLICATIONS Evidence that AD use is associated with an increased risk of CV events in accordance with specific mechanisms of action among older people with CV disease was added by this study.
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Delayed Sinus Tachycardia Associated With Venlafaxine Administration: A Unique Case Report and Discussion. J Clin Psychopharmacol 2020; 39:689-690. [PMID: 31688406 DOI: 10.1097/jcp.0000000000001140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cai W, Mueller C, Shetty H, Perera G, Stewart R. Predictors of mortality in people with late-life depression: A retrospective cohort study. J Affect Disord 2020; 266:695-701. [PMID: 32056946 DOI: 10.1016/j.jad.2020.01.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 11/15/2019] [Accepted: 01/05/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Late-life depression (LLD) is associated with an increased mortality risk in the general older population. It remains however unclear which signs or symptoms are predictive of mortality in those suffering from LLD. SETTING AND PARTICIPANTS Patients aged 65 years or older with depressive disorder diagnosed in Southeast London between January 2008 and December 2017. METHODS We assembled patients diagnosed with late-life depression from the Maudsley Biomedical Research Centre Case Register, which is linked to national mortality data. Using depression diagnosis as index date, we followed patients until death or censoring point. Sociodemographic data, scores of Health of the Nation Outcome Scales (HoNOS65+), which include a physical illness scale, profiles of depressive symptoms, and psychotropic medications were extracted and modeled in multivariable survival analyses to determine predictors of mortality. RESULTS Of 4,243 patients with LLD (mean age 77.0 years; 61.2% female), 2,327 (54.8%) died over a median follow-up time of 3.5 years. In multivariable Cox regression models, an increased risk of all-cause mortality was associated with older age, cognitive problems, physical illness/disability, impaired activities of daily living, apathy, lack of appetite and mirtazapine prescription; conversely, female gender, non-white ethnicity, guilt feelings, tearfulness, impaired concentration, disturbed sleep and delusions were associated with lower mortality risk. CONCLUSIONS Besides demographic factors, physical health, functioning and cognition, different depressive symptoms were significantly associated with the prognosis of LLD. Elderly patients presenting with depressive symptoms predicting higher mortality risk should be examined and followed more closely.
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Affiliation(s)
- Wa Cai
- Institute of Acupuncture and Anesthesia, Shanghai Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201314, China.
| | - Christoph Mueller
- South London and Maudsley NHS Foundation Trust, London, United Kingdom; Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Hitesh Shetty
- South London and Maudsley NHS Foundation Trust, London, United Kingdom.
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Robert Stewart
- South London and Maudsley NHS Foundation Trust, London, United Kingdom; Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
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The Effect of Venlafaxine on Electrocardiogram Intervals During Treatment for Depression in Older Adults. J Clin Psychopharmacol 2020; 40:553-559. [PMID: 33044352 PMCID: PMC7606781 DOI: 10.1097/jcp.0000000000001287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE/BACKGROUND Venlafaxine is a commonly used antidepressant with both serotonergic and noradrenergic activity. There are concerns that it may prolong the corrected QT interval (QTc), and older adults may be at higher risk for this adverse effect, especially at higher dosages of the medication. METHODS/PROCEDURES In this secondary analysis of a prospective clinical trial, we measured changes in QTc and other electrocardiogram (ECG) parameters in 169 adults 60 years or older with a major depressive disorder treated acutely with venlafaxine extended release up to 300 mg daily. We examined the relationship of venlafaxine dosage and ECG parameters, as well as the relationship between serum levels of venlafaxine and ECG parameters. FINDINGS/RESULTS Venlafaxine exposure was not associated with an increase in QTc. Heart rate increased with venlafaxine treatment, whereas the PR interval shortened, and QRS width did not change significantly. The QTc change from baseline was not associated with venlafaxine dosages or serum concentrations. Age, sex, cardiovascular comorbidities, and depression remission status did not predict changes in QTc with venlafaxine. IMPLICATIONS/CONCLUSIONS Venlafaxine treatment did not prolong QTc or other ECG parameters, even in high dosages in older depressed adults. These findings indicate that venlafaxine does not significantly affect cardiac conduction in most older patients.
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Cairns R, Karanges EA, Wong A, Brown JA, Robinson J, Pearson SA, Dawson AH, Buckley NA. Trends in self-poisoning and psychotropic drug use in people aged 5-19 years: a population-based retrospective cohort study in Australia. BMJ Open 2019; 9:e026001. [PMID: 30787095 PMCID: PMC6398641 DOI: 10.1136/bmjopen-2018-026001] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To characterise trends in self-poisoning and psychotropic medicine use in young Australians. DESIGN Population-based retrospective cohort study. SETTING Calls taken by the New South Wales and Victorian Poisons Information Centres (2006-2016, accounting for 70% of Australian poisoning calls); medicine dispensings in the 10% sample of Australian Pharmaceutical Benefits Scheme data (July 2012 to June 2016). PARTICIPANTS People aged 5-19 years. MAIN OUTCOME MEASURES Yearly trends in intentional poisoning exposure calls, substances taken in intentional poisonings, a prevalence of psychotropic use (dispensing of antidepressants, antipsychotics, benzodiazepines and medicines for attention deficit hyperactivity disorder (ADHD)). RESULTS There were 33 501 intentional poisonings in people aged 5-19 years, with an increase of 8.39% per year (95% CI 6.08% to 10.74%, p<0.0001), with a 98% increase overall, 2006-2016. This effect was driven by increased poisonings in those born after 1997, suggesting a birth cohort effect. Females outnumbered males 3:1. Substances most commonly taken in self-poisonings were paracetamol, ibuprofen, fluoxetine, ethanol, quetiapine, paracetamol/opioid combinations, sertraline and escitalopram. Psychotropic dispensing also increased, with selective serotonin reuptake inhibitors (SSRIs) increasing 40% and 35% July 2012 to June 2016 in those aged 5-14 and 15-19, respectively. Fluoxetine was the most dispensed SSRI. Antipsychotics increased by 13% and 10%, while ADHD medication dispensing increased by 16% and 10%, in those aged 5-14 and 15-19, respectively. Conversely, dispensing of benzodiazepines to these age groups decreased by 4% and 5%, respectively. CONCLUSIONS Our results signal a generation that is increasingly engaging in self-harm and is increasingly prescribed psychotropic medications. These findings indicate growing mental distress in this cohort. Since people who self-harm are at increased risk of suicide later in life, these results may foretell future increases in suicide rates in Australia.
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Affiliation(s)
- Rose Cairns
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Emily A Karanges
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jeff Robinson
- Victorian Poisons Information Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Pharmacology, University of Sydney, Sydney, New South Wales, Australia
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Tay E, Sotiriou A, Graham GG, Wilhelm K, Snowden L, Day RO. Restarting antidepressant and antipsychotic medication after intentional overdoses: need for evidence-based guidance. Ther Adv Psychopharmacol 2019; 9:2045125319836889. [PMID: 30956788 PMCID: PMC6444415 DOI: 10.1177/2045125319836889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 02/13/2019] [Indexed: 11/16/2022] Open
Abstract
Intentional drug overdoses with antidepressant and antipsychotic medications are an increasingly common problem. Currently, there is little guidance with regard to reintroduction of these medications after intentional overdoses. We have used published toxicological and pharmacokinetic data to obtain factors which control the recovery from overdoses. From such data, we have proposed guidance regarding their reintroduction, provided there are no adverse effects or contraindications. Tentatively, we suggest that when adverse effects from the overdose are lost, treatment could recommence after a further mean half-life of elimination. Most antidepressant and antipsychotic drugs are metabolized by cytochrome P450 enzymes and, where cytochrome P450 inhibitors are co-ingested, serial plasma concentrations should optimally be obtained in order to assess a suitable time for reintroduction of the psychoactive drugs. We hope the proposals presented will stimulate research and discussion that lead to better guidance for clinicians concerning reintroduction of psychoactive medication after intentional overdose.
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Affiliation(s)
- Emma Tay
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia
| | - Andreas Sotiriou
- University College London Medical School, University College London, London, UK
| | - Garry G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia Department of Pharmacology, University of New South Wales, Sydney, Australia
| | - Kay Wilhelm
- Department of Liaison Psychiatry, St Vincent's Hospital, Sydney, Australia Department of Psychiatry, University of New South Wales, Sydney, Australia
| | - Leone Snowden
- NSW Medicines Information Centre, Darlinghurst, NSW, Australia
| | - Richard O Day
- Department of Pharmacology, University of New South Wales, Sydney, Australia
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Hu MX, Lamers F, Penninx BWJH, de Geus EJC. Association Between Depression, Anxiety, and Antidepressant Use With T-Wave Amplitude and QT-Interval. Front Neurosci 2018; 12:375. [PMID: 29922124 PMCID: PMC5996116 DOI: 10.3389/fnins.2018.00375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 05/15/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives: Cardiac repolarization may be affected by psychiatric disorders and/or antidepressant use, but evidence for this is inconclusive. This study examined the relationship between depressive and anxiety disorder and use of antidepressants with T-wave amplitude (TWA) and QT-interval. Methods: Data was obtained from the Netherlands Study of Depression and Anxiety (n = 1,383). Depression/anxiety was diagnosed with the DSM-IV based Composite International Diagnostic Interview. The use of tricyclic antidepressants (TCAs), selective serotonin and noradrenalin reuptake inhibitors (SNRIs), and selective serotonin reuptake inhibitors (SSRIs) was established. T-wave amplitude and QT-interval corrected for heart rate (QTc) were obtained from an ECG measured in a type II axis configuration. Results: Compared to controls, persons with depression or anxiety disorders did not show a significantly different TWA (p = 0.58; Cohen's d = 0.046) or QTc (p = 0.48; Cohen's d = −0.057). In spite of known sympathomimetic effects, TCA use (p = 0.26; Cohen's d = −0.162) and SNRI use (p = 0.70; Cohen's d = −0.055) were not significantly associated with a lower TWA. TCA use (p = 0.12; Cohen's d = 0.225) and SNRI use (p = 0.11; Cohen's d = 0.227) were also not significantly associated with a prolonged QTc. Conclusion: We did not find evidence that either depressive/anxiety disorder or antidepressant use is associated with abnormalities in TWA or QTc. Earlier found sympathomimetic effects of TCAs and SNRIs are not evident in these measures of cardiac repolarization.
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Affiliation(s)
- Mandy X Hu
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
| | - Femke Lamers
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
| | - Brenda W J H Penninx
- Department of Psychiatry, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
| | - Eco J C de Geus
- Department of Biological Psychology, VU University, Amsterdam, Netherlands
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Biffi A, Rea F, Scotti L, Mugelli A, Lucenteforte E, Bettiol A, Chinellato A, Onder G, Vitale C, Agabiti N, Trifirò G, Roberto G, Corrao G. Antidepressants and the risk of arrhythmia in elderly affected by a previous cardiovascular disease: a real-life investigation from Italy. Eur J Clin Pharmacol 2017; 74:119-129. [PMID: 29046942 DOI: 10.1007/s00228-017-2352-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 10/09/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE The study aimed to fill existing knowledge gaps on the safety of antidepressant drugs (ADs) by estimating the risk of hospitalization for arrhythmia associated with use of selective serotonin reuptake inhibitors (SSRIs) and newer atypical ADs (NAAs) among elderly with previous cardiovascular (CV) events. METHODS The cohort was composed by 199,569 individuals aged ≥ 65 years from five Italian healthcare territorial units who were discharged for cardiovascular outcomes in the years 2008-2010. The 17,277 patients who experienced hospital admission for arrhythmia during follow-up were included as cases. Odds of current ADs use among cases (i.e., 14 days before hospital admission) was compared with (i) odds of current use of 1:5 matched controls (between-patients case-control) and with (ii) odds of previous use during 1:5 matched control periods (within-patient case-crossover). The risk of arrhythmia associated with ADs current use was modelled fitting a conditional logistic regression. A set of sensitivity analyses was performed to account for sources of systematic uncertainty. RESULTS Current users of SSRIs and NAAs were at increased risk of arrhythmia with case-control odds ratios (OR) of 1.37 (95% confidence interval, CI 1.18 to 1.58) and 1.41 (1.16 to 1.71) and case-crossover OR of 1.48 (1.20 to 1.81) and 1.72 (1.31 to 2.27). An increased risk of arrhythmia was associated with current use of trazodone (NAA) consistently in case-control and case-crossover designs. CONCLUSIONS Evidence that current use of SSRIs and NAAs is associated to an increased risk of arrhythmia among elderly with CV disease was consistently supplied by two observational approaches.
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Affiliation(s)
- A Biffi
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.
| | - F Rea
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - L Scotti
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - A Mugelli
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - E Lucenteforte
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy
| | - A Bettiol
- Department of Neurosciences, Psychology, Drug Research and Children's Health, University of Florence, Florence, Italy.,Treviso Local Health Unit, Treviso, Italy
| | | | - G Onder
- Department of Geriatrics, Neurosciences and Orthopaedics, A. Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Vitale
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy
| | - N Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - G Trifirò
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - G Roberto
- Epidemiology Unit, Regional Agency for Healthcare Services of Tuscany, Florence, Italy
| | - G Corrao
- Laboratory of Healthcare Research & Pharmacoepidemiology, Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
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Gosselin S, Hoegberg LC, Hayes BD, Ghannoum M, Hoffman RS, Odigwe C, Tariq M, Ojiako KC, Iroegbu NA. Reader Comments. Proc (Bayl Univ Med Cent) 2016. [DOI: 10.1080/08998280.2016.11929508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Sophie Gosselin
- McGill University Health Centre, Montreal Centre Antipoison du Québec Poison and Drug Information Service, Alberta
| | | | - Bryan D. Hayes
- Department of Emergency Medicine, Harvard Medical School and Massachusetts General Hospital
| | | | - Robert S. Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine
| | - Chibuzo Odigwe
- Department of Medicine, Palmetto Health Richland, Columbia, SC
| | - Madiha Tariq
- Department of Medicine, Presence St. Joseph Hospital, Chicago, IL
| | - Kizito C. Ojiako
- Rosalind Franklin University of Medicine and Science, Chicago, IL
| | - Nkem A. Iroegbu
- Department of Clinical Medicine, University of Illinois at Chicago
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17
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Lipid therapy and plasmapheresis in tricyclic poisoning. Proc AMIA Symp 2016; 29:444-445. [PMID: 28018049 PMCID: PMC5178867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
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18
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Cooper JM, Brown JA, Cairns R, Isbister GK. Desvenlafaxine overdose and the occurrence of serotonin toxicity, seizures and cardiovascular effects. Clin Toxicol (Phila) 2016; 55:18-24. [DOI: 10.1080/15563650.2016.1223847] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- J. M. Cooper
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
| | - J. A. Brown
- New South Wales Poison Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
| | - R. Cairns
- New South Wales Poison Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
| | - G. K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, Australia
- New South Wales Poison Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Newcastle, Newcastle, Australia
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Castanares-Zapatero D, Gillard N, Capron A, Haufroid V, Hantson P. Reversible cardiac dysfunction after venlafaxine overdose and possible influence of genotype and metabolism. Forensic Sci Int 2016; 266:e48-e51. [DOI: 10.1016/j.forsciint.2016.05.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/18/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
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20
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Mermet C, Capaldo L, Bouchet S, Saint-Léger M, De Guillebon S, Labadie M. Intoxication à la venlafaxine responsable d’un syndrome sérotoninergique sévère chez une patiente déficitaire en cytochrome P450 2D6. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2016.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Berling I, Isbister GK. The Half RR Rule: A Poor Rule of Thumb and Not a Risk Assessment Tool for QT Interval Prolongation. Acad Emerg Med 2015; 22:1139-44. [PMID: 26375169 DOI: 10.1111/acem.12752] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 05/06/2015] [Accepted: 05/09/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Measuring the QT interval on an electrocardiogram (ECG) is integral to risk assessment of Torsade de Pointes (TdP). This study aimed to investigate the accuracy of the 1/2 RR rule as a risk assessment tool for drug-induced TdP, comparing it to the QT nomogram, Bazett's corrected QT (QTcB), and Fridericia's corrected QT (QTcF). METHODS The authors calculated sensitivity and specificity of the 1/2 RR rule using a published data set of 129 cases of drug-induced TdP and 316 controls (noncardiotoxic overdoses), compared to the QT nomogram, QTcB > 500 msec and QTcF > 500 msec. To further determine the value of the 1/2 RR rule, its observed positive, and negative agreement were calculated when compared to the QT nomogram for determining an abnormal QT in eight samples of different drugs in overdose. RESULTS The sensitivity and specificity of the 1/2 RR rule were 88% (95% confidence interval [CI] = 80% to 93%) and 53% (95% CI = 47% to 58%), respectively, compared to the QT nomogram (sensitivity = 97%, 95% CI = 92% to 99%; specificity = 99%, 95% CI = 97% to 100%). It was also less sensitive than QTcB > 500 msec and had a lower specificity than QTcB > 500 msec and QTcF > 500 msec. In drug overdose patients, the 1/2 RR rule had poor observed agreement averaging 41%, which was mainly due to poor positive agreement, except for amisulpride where there was good agreement. CONCLUSIONS The 1/2 RR rule was not as sensitive as the QT nomogram or QTcB > 500 msec for drug-induced TdP. It had poor positive agreement in almost all overdose patients, resulting in over half of patients receiving unnecessary cardiac monitoring and repeat ECGs.
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Affiliation(s)
- Ingrid Berling
- Department of Clinical Toxicology and Pharmacology; Calvary Mater Newcastle; Newcastle NSW Australia
- Clinical Toxicology Research Group; University of Newcastle; Newcastle NSW Australia
| | - Geoffrey K. Isbister
- Department of Clinical Toxicology and Pharmacology; Calvary Mater Newcastle; Newcastle NSW Australia
- Clinical Toxicology Research Group; University of Newcastle; Newcastle NSW Australia
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Rabkin SW. Impact of Age and Sex on QT Prolongation in Patients Receiving Psychotropics. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:206-14. [PMID: 26174524 PMCID: PMC4484689 DOI: 10.1177/070674371506000502] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 02/01/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To assess older age and female sex, 2 of the major risk factors for potentially fatal cardiac arrhythmias or sudden cardiac death in patients prescribed psychotropics, within the context of electrocardiographic evidence of time between start of Q wave and end of T wave (QT) interval prolongation, which is an indicator of an increased risk for potentially fatal cardiac arrhythmias. METHOD The literature on the relation between age, sex, and QT interval with respect to psychotropic drugs was reviewed. RESULTS The QT interval must be corrected (QTc) for heart rate. Because slower heart rates prolong and faster heart rates shorten the QT interval, people with faster heart rates may have a prolonged QT interval that is not apparent until the correction is performed. QTc values for apparently healthy post-pubertal people are less than 450 ms for males and less than 470 ms for females. The longer QT intervals in women may account for their increased risk of potentially fatal cardiac arrhythmias on psychotropics. QTc increases with increasing age. Assessment of QTc in older people is especially important to identify people with a longer QTc who are more likely to attain a serious QT level with drugs that prolong QTc. The age-related increase in QTc is more evident in men than women, suggesting that male sex does not afford protection against potentially fatal arrhythmias at older age. CONCLUSION The association of increasing age and female sex with greater QT intervals indicates the need to have an increased awareness of the QTc prior to use of these psychotropics and to evaluate the QTc after initiation of therapy.
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Affiliation(s)
- Simon W Rabkin
- Professor of Medicine (Cardiology), Department of Medicine (Cardiology), University of British Columbia, Vancouver, British Columbia
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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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Jasiak NM, Bostwick JR. Risk of QT/QTc Prolongation Among Newer Non-SSRI Antidepressants. Ann Pharmacother 2014; 48:1620-8. [DOI: 10.1177/1060028014550645] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To review QT prolongation potential with newer nonselective serotonin reuptake inhibitor (non-SSRI) antidepressants. Data Sources: A PubMed literature search was performed from 1982 through June 16, 2014. Search terms included bupropion, desvenlafaxine, duloxetine, levomilnacipran, mirtazapine, venlafaxine, and vilazodone in combination with each of the following terms: cardiac toxicity, QTc prolongation, QT prolongation, torsades de pointes, and TdP. Study Selection and Data Extraction: English-language human studies, case reports, package inserts, manufacturer electronic communications, and ArizonaCert database were utilized. Data Synthesis: Rare QT prolongation has been reported with venlafaxine at therapeutic doses and in overdose. Bupropion has also been linked to QT prolongation in overdose situations. In elderly patients with a variety of high-risk comorbidities, mirtazapine did demonstrate higher odds of sudden cardiac death and ventricular arrhythmias when compared with paroxetine. Largely because of a lack of available data, existing studies fail to demonstrate QT prolongation with desvenlafaxine, duloxetine, levomilnacipran, and vilazodone. Conclusion: Based on the current literature, risk of QT/QTc prolongation with the majority of newer non-SSRI antidepressants at therapeutic doses is low. The highest risk for QT prolongation appears to exist in overdose situations with venlafaxine and bupropion. Given the few to nonexistent controlled studies and confounding variables present in case reports, it is difficult to draw conclusions on QT prolongation risk with many of the newer non-SSRI antidepressants.
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Affiliation(s)
- Natalia M. Jasiak
- University of Michigan Health System, Ann Arbor, MI, USA
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Jolene R. Bostwick
- University of Michigan Health System, Ann Arbor, MI, USA
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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25
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Mago R, Tripathi N, Andrade C. Cardiovascular adverse effects of newer antidepressants. Expert Rev Neurother 2014; 14:539-51. [DOI: 10.1586/14737175.2014.908709] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Isbister GK, Page CB. Drug induced QT prolongation: the measurement and assessment of the QT interval in clinical practice. Br J Clin Pharmacol 2014; 76:48-57. [PMID: 23167578 DOI: 10.1111/bcp.12040] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 11/06/2012] [Indexed: 01/22/2023] Open
Abstract
There has been an increasing focus on drug induced QT prolongation including research on drug development and QT prolongation, following the removal of drugs due to torsades de pointes (TdP). Although this has improved our understanding of drug-induced QT prolongation there has been much less research aimed at helping clinicians assess risk in individual patients with drug induced QT prolongation. This review will focus on assessment of drug-induced QT prolongation in clinical practice using a simple risk assessment approach. Accurate measurement of the QT interval is best done manually, and not using the measurement of standard ECG machines. Correction for heart rate (HR) using correction formulae such as Bazett's is often inaccurate. These formulae underestimate and overestimate the duration of cardiac repolarization at low and high heart rates, respectively. Numerous cut-offs have been suggested as an indicator of an abnormal QT, but are problematic in clinical practice. An alternative approach is the QT nomogram which is a plot of QT vs. HR. The nomogram has an 'at risk' line and QT-HR pairs above this line have been shown in a systematic study to be associated with TdP and the line is more sensitive and specific than Bazett's QTc of 440 ms or 500 ms. Plotting the QT-HR pair for patients on drugs suspected or known to cause QT prolongation allows assessment of the QT interval based on normal population QT variability. This risk assessment then allows the safer commencement of drugs therapeutically or management of drug induced effects in overdose.
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Affiliation(s)
- Geoffrey K Isbister
- Discipline of Clinical Pharmacology, University of Newcastle, Newcastle, NSW 2298, Australia.
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27
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Diaper A, Rich AS, Wilson SJ, Craig K, Dourish CT, Dawson GR, Nutt DJ, Bailey JE. Changes in cardiovascular function after venlafaxine but not pregabalin in healthy volunteers: a double-blind, placebo-controlled study of orthostatic challenge, blood pressure and heart rate. Hum Psychopharmacol 2013; 28:562-75. [PMID: 23955418 DOI: 10.1002/hup.2346] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 06/26/2013] [Indexed: 11/06/2022]
Abstract
It is generally thought that venlafaxine raises blood pressure at higher doses; however, some studies have found no effect or a decrease in blood pressure. The aim of this study was to evaluate the cardiovascular (CV) effects of 3 weeks of dosing with venlafaxine, pregabalin and placebo on young healthy adults. Fifty-four participants, of mean age 23.1 years (sd 4.68), 29 male, were randomised into three parallel groups. Each group received one of the three drugs, dosed incrementally over a 3-week period to reach daily doses of 150 mg/day venlafaxine and 200 mg/day pregabalin. Blood pressure sphygmomanometer measurements, heart rate measurements, and orthostatic challenges recorded continuously beat-to-beat were performed weekly over this period and 5 days after treatment cessation. Results showed resting systolic blood pressure (SBP) and resting and standing diastolic blood pressure (DBP) and heart rate (HR) were significantly raised by venlafaxine compared with the pregabalin and placebo groups. SBP drop on standing was larger, the resulting overshoot was smaller, and recovery was slower on venlafaxine. HR recovery was significantly impaired by venlafaxine. CV changes were observed after only 1 week of dosing at 112.5 mg/day. These effects of venlafaxine are likely to be due to its action of noradrenergic reuptake inhibition.
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Affiliation(s)
- Alison Diaper
- Psychopharmacology Unit; University of Bristol; Bristol UK
| | - Ann S. Rich
- Psychopharmacology Unit; University of Bristol; Bristol UK
| | - Sue J. Wilson
- Psychopharmacology Unit; University of Bristol; Bristol UK
- Neuropsychopharmacology Unit, Division of Experimental Medicine; Imperial College London; UK
| | | | | | | | - David J. Nutt
- Neuropsychopharmacology Unit, Division of Experimental Medicine; Imperial College London; UK
| | - Jayne E. Bailey
- Severnside Alliance for Translational Research; School of Medical Sciences, University of Bristol; Bristol UK
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Abstract
AbstractIn treatment of manic-depressive conditions long-term lithium therapy may be combined with an effective and relatively safe antidepressant venlafaxine. Combined overdose may increase the risk of early toxicity of both drugs and of delayed lithium intoxication, responding to symptomatic and renal replacement therapy. We present a patient with combined lithium and venlafaxine self-poisoning with nothing but delayed signs of lithium intoxication with the emphasis on early and late treatment. 41-year old woman attempted suicide by large amount of lithium and venlafaxine. On admission she was asymptomatic, but with increased serum lithium over 5mmol/L. After gastric lavage, active charcoal and laxative administration she was receiving IV fluids. After a delay of 63 hours she deteriorated acutely by disorientation, confusion, fasciculation and tremor and was readmitted to Intensive care unit. In spite serum lithium decreased to 2mmol/L clinical signs were attributed to delayed lithium intoxication. After symptomatic and renal replacement therapy the patient’s condition improved after few days. We conclude that decontamination procedures are effective in particular for venlafaxine poisoning. If increased serum lithium levels are noted renal replacement therapy may be started even in asymptomatic patients as delayed lithium intoxication is most likely after few days.
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Pugh CM, Sweeney JT, Bloch CP, Lee JA, Johnson JA, Hovda LR. Selective serotonin reuptake inhibitor (SSRI) toxicosis in cats: 33 cases (2004-2010). J Vet Emerg Crit Care (San Antonio) 2013; 23:565-70. [PMID: 24016243 DOI: 10.1111/vec.12091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 07/30/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate a population of cats with selective-serotonin reuptake inhibitor (SSRI) toxicosis and characterize the population affected, list products ingested, the clinical signs observed, treatments performed, length of hospitalization, patient outcome, and overall prognosis. DESIGN Retrospective study from 2004 to 2010. SETTING Referral veterinary center. ANIMALS Thirty-three witnessed cat SSRI ingestions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The medical records of cats with a witnessed SSRI ingestion identified by review of an animal poison control center electronic database were evaluated. The most common SSRIs ingested were venlafaxine (Effexor; 12/33; 36%), fluoxetine (Prozac; 12/33; 36%), citalopram (Celexa; 6/33; 18%), and escitalopram (Lexapro; 3/33; 9%). Overall, 24% of cats (8/33) became symptomatic, while 76% (25/33) remained asymptomatic. Of the symptomatic cats, sedation was the most common clinical sign (6/8; 75%), followed by gastrointestinal signs (4/8; 50%), central nervous system stimulation (1/8; 13%), cardiovascular signs (1/8; 13%), and hyperthermia (1/8; 13%). Veterinary care was sought in 20 cats (20/33; 61%). Sixteen cats (16/20; 80%) were hospitalized, while 4 cats (4/20; 20%) were treated as outpatients. Treatment for hospitalized patients included administration of IV fluid therapy (14/16; 88%), activated charcoal (12/16; 75%), anti-arrhythmic agents (7/16; 44%), methocarbamol (6/16; 38%), cyproheptadine (6/16; 38%), anti-emetics (5/16; 31%), and sedation (5/16; 31%). Diagnostics included blood work (7/16; 44%), blood pressure measurement (3/16; 19%), and electrocardiogram monitoring (2/16; 13%). Mean hospitalization time for all cases of SSRI ingestion was 14.6 ± 7.8 hours (n = 16). All symptomatic cats in this study (8/8; 100%) had resolution of clinical signs and survived to discharge. CONCLUSIONS The prognosis for SSRI ingestion in this population of cats was excellent. Decontamination and supportive care for at least 12-24 hours can be considered in cats with SSRI ingestion, particularly venlafaxine to monitor resolution of clinical signs.
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Affiliation(s)
- Cassandra M Pugh
- Department of Emergency and Critical Care, Ocean State Veterinary Specialists, 1480 South County Trail, East Greenwich, RI 02818
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Morissette P, Nishida M, Trepakova E, Imredy J, Lagrutta A, Chaves A, Hoagland K, Hoe CML, Zrada MM, Travis JJ, Zingaro GJ, Gerenser P, Friedrichs G, Salata JJ. The anesthetized guinea pig: An effective early cardiovascular derisking and lead optimization model. J Pharmacol Toxicol Methods 2013; 68:137-49. [DOI: 10.1016/j.vascn.2013.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/19/2013] [Accepted: 04/27/2013] [Indexed: 10/26/2022]
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Taylor D, Lenox-Smith A, Bradley A. A review of the suitability of duloxetine and venlafaxine for use in patients with depression in primary care with a focus on cardiovascular safety, suicide and mortality due to antidepressant overdose. Ther Adv Psychopharmacol 2013; 3:151-61. [PMID: 24167687 PMCID: PMC3805457 DOI: 10.1177/2045125312472890] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Depression and anxiety disorders are among the most common disorders treated by general practitioners (GPs) in the UK. Since both disorders are associated with a significantly increased risk of suicide, including with antidepressant overdose, the safety of antidepressants in overdose is of paramount importance. Numerous updates relating to antidepressant safety have been issued by regulators in the UK which may have eroded GP confidence in antidepressants. Venlafaxine, a serotonin nor adrenaline reuptake inhibitor (SNRI) had primary care prescribing restrictions placed on it in 2004 due to concerns about cardiotoxicity and mortality in overdose. Although a review of the evidence led to a reversal of the majority of restrictions in 2006, evidence suggests GPs may still be cautious in their prescribing of venlafaxine and possibly other SNRI antidepressants for patients with depression and anxiety disorders. This paper reviews the evidence pertaining to the safety of SNRI antidepressants from a perspective of cardiovascular safety and overdose. The currently available evidence suggests a marginally higher toxicity of venlafaxine in overdose compared with another SNRI duloxetine and the selective serotonin reuptake inhibitors (SSRIs), although this may be related to differential patterns of prescribing in high-risk patients. Based on this review SNRIs have a positive risk benefit profile in the treatment of depression and generalized anxiety disorder in primary care, especially as second-line agents to SSRIs.
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Affiliation(s)
- David Taylor
- Pharmacy Department, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK
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Darracq MA, Clark A, Qian L, Cantrell FL. A retrospective review of isolated duloxetine-exposure cases. Clin Toxicol (Phila) 2013; 51:106-10. [DOI: 10.3109/15563650.2013.766749] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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33
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Batista M, Dugernier T, Simon M, Haufroid V, Capron A, Fonseca S, Bonbled F, Hantson P. The spectrum of acute heart failure after venlafaxine overdose. Clin Toxicol (Phila) 2013; 51:92-5. [DOI: 10.3109/15563650.2012.763133] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
The topic of central nervous system intoxicants encompasses a multitude of agents. This article focuses on three classes of therapeutic drugs, with specific examples in which overdoses require admission to the intensive care unit. Included are some of the newer antidepressants, the atypical neuroleptic agents, and selected anticonvulsant drugs. The importance of understanding pertinent physiology and applicable supportive care is emphasized.
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Affiliation(s)
- Matthew W Hedge
- Department of Emergency Medicine, Detroit Receiving Hospital, Children's Hospital of Michigan Regional Poison Control Center, Wayne State University, Hutzel Building, 4707 Street Antoine, Suite 302, Detroit, MI 48201, USA.
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Raffa RB, Burmeister JJ, Yuvasheva E, Pergolizzi JV. QTc interval prolongation byd-propoxyphene: what about other analgesics? Expert Opin Pharmacother 2012; 13:1397-409. [DOI: 10.1517/14656566.2012.682150] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vinetti M, Haufroid V, Capron A, Classen JF, Marchandise S, Hantson P. Severe acute cardiomyopathy associated with venlafaxine overdose and possible role of CYP2D6 and CYP2C19 polymorphisms. Clin Toxicol (Phila) 2011; 49:865-9. [DOI: 10.3109/15563650.2011.626421] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Marco Vinetti
- Cliniques St-Luc, Université catholique de Louvain, Intensive Care,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | - Vincent Haufroid
- Université catholique de Louvain, Louvain Centre for Toxicology and Applied Pharmacology,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | - Arnaud Capron
- Université catholique de Louvain, Louvain Centre for Toxicology and Applied Pharmacology,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | - Jean-François Classen
- Université catholique de Louvain, Louvain Centre for Toxicology and Applied Pharmacology,
Avenue Hippocrate 10, Brussels, 1200 Belgium
| | | | - Philippe Hantson
- Cliniques St-Luc, Université catholique de Louvain, Intensive Care,
Avenue Hippocrate 10, Brussels, 1200 Belgium
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Windfuhr K, Turnbull P, While D, Swinson N, Mehta H, Hadfield K, Hiroeh U, Watkinson H, Dixon C, Flynn S, Thomas S, Lewis G, Ferrier IN, Amos T, Skapinakis P, Shaw J, Kapur N, Appleby L. The incidence and associated risk factors for sudden unexplained death in psychiatric in-patients in England and Wales. J Psychopharmacol 2011; 25:1533-42. [PMID: 20952453 DOI: 10.1177/0269881110379288] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Clinical characteristics and risk factors associated with sudden unexplained death (SUD) in the psychiatric population are unclear. Psychiatric in-patients (England, Wales) who met criteria for SUD were identified (1 March 1999-31 December 2005). Cases were matched with controls (in-patients alive on the day a SUD occurred). Data were collected via questionnaires. Some 283 cases of SUD were identified (41 annually), with a rate of 2.33/10,000 mental health admissions (in England). Electrocardiograms were not routine, cardiopulmonary resuscitation equipment was sometimes unavailable, attempts to resuscitate patients were carried out on one-half of all patients and post mortems/inquiries were not routine. Restraint and seclusion were uncommon. Risk factors included: benzodiazepines (odds ratio (OR): 1.83); ≥ 2 antipsychotics (OR: 2.35); promazine (OR: 4.02); diazepam (OR: 1.71); clozapine (OR: 2.10); cardiovascular disease (OR: 2.00); respiratory disease (OR: 1.98); diagnosis of dementia (OR: 2.08). Venlafaxine and a diagnosis of affective disorder were associated with reduced ORs (OR: 0.42; OR: 0.65). SUD is relatively rare, although it is more common in older patients and males. Prevention measures may include safer prescribing of antipsychotics and improved physical health care. The contribution of restraint or seclusion to SUD in individual cases is unclear. A uniform definition of SUD may help to identify contributing factors.
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Affiliation(s)
- Kirsten Windfuhr
- National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, University of Manchester, Manchester, UK.
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Kumar VVP, Isbister GK, Duffull SB. The effect of decontamination procedures on the pharmacodynamics of venlafaxine in overdose. Br J Clin Pharmacol 2011; 72:125-32. [PMID: 21306417 PMCID: PMC3141194 DOI: 10.1111/j.1365-2125.2011.03934.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2010] [Accepted: 01/20/2011] [Indexed: 11/29/2022] Open
Abstract
AIMS To investigate the relationship between decontamination procedures and seizure events caused by venlafaxine overdose and to estimate the time at which 90% of patients would have had their first seizure in the presence and absence of decontamination. METHODS Data were collected from 319 patients who took an overdose of venlafaxine on 436 occasions. Seizures occurred on 24 of 436 occasions (5%). Patients received one of single dose activated charcoal (SDAC), whole bowel irrigation (WBI), a combination of either (SDAC/WBI) or no decontamination. Logistic regression and time to event analysis were used to investigate the influence of dose and decontamination on the probability of seizures and time to 90% (t(90) ) of seizure, respectively. RESULTS A linear logistic regression model described the data. Simulation from the model showed that the probability of seizure was 0.05 (0.03-0.08), 0.19 (0.09-0.35) and 0.75 (0.30-0.96) at 1000, 5000 and 10 000 mg, respectively (median and 95% credible interval). At the mean dose of 2100 mg the odds ratios (OR) in the presence of SDAC, WBI and SDAC/WBI were 0.48 (0.25-0.89), 0.71 (0.35-1.22) and 0.25 (0.08-0.62), respectively. A modified Gompertz model described the time to seizure events. Simulations from the Gompertz model showed that the t(90) values for first seizure was 26 h and was not affected by dose or decontamination procedure. CONCLUSION SDAC/WBI provided greater benefits than the sum of the independent effects of SDAC and WBI. Patients should be observed for at least 24 h for seizures based on the dose and risk of seizure occurring.
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Heath B, Cui Y, Worton S, Lawton B, Ward G, Ballini E, Doe C, Ellis C, Patel B, McMahon N. Translation of flecainide- and mexiletine-induced cardiac sodium channel inhibition and ventricular conduction slowing from nonclinical models to clinical. J Pharmacol Toxicol Methods 2011; 63:258-68. [DOI: 10.1016/j.vascn.2010.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Revised: 12/20/2010] [Accepted: 12/21/2010] [Indexed: 10/18/2022]
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Abstract
OBJECTIVE The aim of this study was to describe the clinical and electrocardiographic features of risperidone overdose, including the frequency of dystonic reactions. METHODS A consecutive series of admissions for risperidone overdose (>6 mg) were identified from a prospective database of poisoning admissions to a regional toxicology service. Data extracted included patient demographics, details of ingestion, clinical features including neurological findings and evidence of dystonias, electrocardiographic parameters (heart rate [HR], QRS, and QT intervals), complications, and medical outcomes including intensive care unit admission. In addition to descriptive statistics, visual inspection of plots of QT-HR pairs compared with the QT nomogram was performed. RESULTS There were 107 patients with 157 presentations, including 38 patients with 45 risperidone-alone overdoses. Of the 38 patients who ingested risperidone alone, the median age was 25 years (interquartile range [IQR],16-31 years), and 19 (50%) were female. The median dose ingested was 33 mg (IQR, 15-75 mg; range, 8-248 mg). Median length of stay was 16 hours (IQR, 8-18 hours), and none was ventilated or admitted to the intensive care unit. There were 5 cases (11%) with dystonic reactions, 26 (58%) with tachycardia (HR >or=100 beats/min), and no cases with hypotension (blood pressure <90 mm Hg). Only 1 patient (2%) recorded a decreased Glasgow Coma Scale score of 14, and there were no seizures or deaths. On review of electrocardiograms in 41 of the 45 cases where risperidone was ingested alone, there were no acute dysrhythmias. In 4 electrocardiograms (10%), there was an abnormal QT-HR pair, but all bar one were associated with an HR of greater than 110 beats/min. The median maximum QRS width was 80 milliseconds (IQR, 80-80 milliseconds; range, 40-120 milliseconds). CONCLUSIONS Risperidone taken alone in overdose causes minimal effects. Tachycardia and dystonic reactions were the main features of toxicity. Significant cardiac and other neurological features seem to be uncommon.
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Smithburger PL, Seybert AL, Armahizer MJ, Kane-Gill SL. QT prolongation in the intensive care unit: commonly used medications and the impact of drug–drug interactions. Expert Opin Drug Saf 2010; 9:699-712. [DOI: 10.1517/14740331003739188] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Isbister GK, Calver L, Van Gorp F, Stokes B, Page CB. Inter-rater reliability of manual QT measurement and prediction of abnormal QT,HR pairs. Clin Toxicol (Phila) 2009; 47:884-8. [DOI: 10.3109/15563650903333820] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Clinical and ECG Effects of Escitalopram Overdose. Ann Emerg Med 2009; 54:404-8. [DOI: 10.1016/j.annemergmed.2009.04.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 03/31/2009] [Accepted: 04/17/2009] [Indexed: 11/21/2022]
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The Effect of Decontamination Procedures on the Pharmacokinetics of Venlafaxine in Overdose. Clin Pharmacol Ther 2009; 86:403-10. [DOI: 10.1038/clpt.2009.114] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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