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Sadlonova M, Beach SR, Funk MC, Rosen JH, Ramirez Gamero AF, Karlson RA, Huffman JC, Celano CM. Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms. J Intensive Care Med 2023:8850666231222470. [PMID: 38130132 DOI: 10.1177/08850666231222470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. METHODS Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. RESULTS Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. CONCLUSIONS Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. AIMS This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.
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Affiliation(s)
- Monika Sadlonova
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
- Department of Cardiovascular and Thoracic Surgery, University of Göttingen Medical Center, Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Margo C Funk
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Jordan H Rosen
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Andres F Ramirez Gamero
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Rebecca A Karlson
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Izat N, Bolleddula J, Abbasi A, Cheruzel L, Jones RS, Moss D, Ortega-Muro F, Parmentier Y, Peterkin VC, Tian DD, Venkatakrishnan K, Zientek MA, Barber J, Houston JB, Galetin A, Scotcher D. Challenges and Opportunities for In Vitro-In Vivo Extrapolation of Aldehyde Oxidase-Mediated Clearance: Toward a Roadmap for Quantitative Translation. Drug Metab Dispos 2023; 51:1591-1606. [PMID: 37751998 DOI: 10.1124/dmd.123.001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 09/28/2023] Open
Abstract
Underestimation of aldehyde oxidase (AO)-mediated clearance by current in vitro assays leads to uncertainty in human dose projections, thereby reducing the likelihood of success in drug development. In the present study we first evaluated the current drug development practices for AO substrates. Next, the overall predictive performance of in vitro-in vivo extrapolation of unbound hepatic intrinsic clearance (CLint,u) and unbound hepatic intrinsic clearance by AO (CLint,u,AO) was assessed using a comprehensive literature database of in vitro (human cytosol/S9/hepatocytes) and in vivo (intravenous/oral) data collated for 22 AO substrates (total of 100 datapoints from multiple studies). Correction for unbound fraction in the incubation was done by experimental data or in silico predictions. The fraction metabolized by AO (fmAO) determined via in vitro/in vivo approaches was found to be highly variable. The geometric mean fold errors (gmfe) for scaled CLint,u (mL/min/kg) were 10.4 for human hepatocytes, 5.6 for human liver cytosols, and 5.0 for human liver S9, respectively. Application of these gmfe's as empirical scaling factors improved predictions (45%-57% within twofold of observed) compared with no correction (11%-27% within twofold), with the scaling factors qualified by leave-one-out cross-validation. A road map for quantitative translation was then proposed following a critical evaluation on the in vitro and clinical methodology to estimate in vivo fmAO In conclusion, the study provides the most robust system-specific empirical scaling factors to date as a pragmatic approach for the prediction of in vivo CLint,u,AO in the early stages of drug development. SIGNIFICANCE STATEMENT: Confidence remains low when predicting in vivo clearance of AO substrates using in vitro systems, leading to de-prioritization of AO substrates from the drug development pipeline to mitigate risk of unexpected and costly in vivo impact. The current study establishes a set of empirical scaling factors as a pragmatic tool to improve predictability of in vivo AO clearance. Developing clinical pharmacology strategies for AO substrates by utilizing mass balance/clinical drug-drug interaction data will help build confidence in fmAO.
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Affiliation(s)
- Nihan Izat
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Jayaprakasam Bolleddula
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Armina Abbasi
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Lionel Cheruzel
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Robert S Jones
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Darren Moss
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Fatima Ortega-Muro
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Yannick Parmentier
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Vincent C Peterkin
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Dan-Dan Tian
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Karthik Venkatakrishnan
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Michael A Zientek
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Jill Barber
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - J Brian Houston
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Aleksandra Galetin
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
| | - Daniel Scotcher
- Centre for Applied Pharmacokinetic Research, The University of Manchester, Manchester, UK (N.I., Ji.B., J.B.H., A.G., D.S.); EMD Serono Research & Development Institute, Inc., Billerica, Massachusetts (Ja.B., K.V.); Amgen Inc., South San Francisco, California (A.A.); Genentech, Inc., South San Francisco, California (L.C., R.S.J.); Janssen Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium (D.M.); GSK R&D, Tres Cantos, Madrid, Spain (F.O.M.); Technologie Servier, Orléans, France (Y.P.); AbbVie Inc., North Chicago, Illinois (V.C.P.); Eli Lilly and Company, Indianapolis, Indiana (D.-D.T.); and Takeda Pharmaceuticals Limited, San Diego, California (M.A.Z.)
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