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Khederlou H, Azimi Pirsaraei V. Torsades de Pointe Associated with Trazodone Consumption. Case Rep Crit Care 2024; 2024:5759229. [PMID: 38680420 PMCID: PMC11055644 DOI: 10.1155/2024/5759229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/16/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Trazodone is a serotonin receptor antagonist and reuptake inhibitor commonly used to treat major depression disorder (MDD), anxiety, and sleep disorders. It is considered safe for the heart due to minimal anticholinergic effects. Prolonged QT intervals can cause polymorphic ventricular tachycardia, known as torsades de pointe (TdP). We present a case of a 67-year-old female with a history of MDD who developed trazodone-induced TdP. Case Presentation. The patient was referred to a tertiary hospital with a ten-hour history of nausea and vomiting. Trazodone (50 mg daily) was started for her six days ago due to her past medical history of MDD. The initial electrocardiography (ECG) revealed a prolonged corrected QT interval (QTc = 586 ms) due to a long ST segment and generalized T wave inversion. A few moments after admission to the intensive care unit, she suddenly lost consciousness. ECG monitoring showed a TdP, which terminated immediately with the asynchronous defibrillation. A temporary pacemaker was implanted due to repeated arrhythmias and bradycardia. Arrhythmia did not recur for hours and days later. After four days of stopping trazodone, all abnormal ECG findings were resolved, and she was discharged with a normal ECG. She was followed up six months later; the ECG was normal, and she had no complaints. Conclusion Trazodone may lead to QTc prolongation and TdP, potentially fatal even without risk factors for QTc prolongation. Close monitoring is essential to prevent adverse complications in trazodone users.
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Affiliation(s)
- Hamid Khederlou
- Department of Cardiology, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Vanoushe Azimi Pirsaraei
- Student Research Committee, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
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Nemati M, Hosseinzadeh Z, Nemati F, Ebrahimi B. Impact of antipsychotics and antidepressants drugs on long QT syndrome induction related to hERG channel dysfunction: A systematic review. Biochem Biophys Res Commun 2023; 681:90-96. [PMID: 37774574 DOI: 10.1016/j.bbrc.2023.09.043] [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: 07/15/2023] [Revised: 09/03/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE QT prolongation is one of the main unwanted cardiac effects caused by drugs, such as anti-psychotics and anti-depressants, inducing mainly via hERG channel dysfunction. The precise and underlying mechanism of adverse effects on hERG channel are still indecisive, but these effects limit their use in patients with cardiac risk factors. The aim of this review was studying mechanism of Long-term QT syndrome induction via hERG channel dysfunction by these Drugs. METHOD Search was performed in PubMed, and Scopus. All human, animals, and cell lines studies, English and full text publications were included. Among 1280 papers, 23 studies were eligible for more assessments. Quality of studies cheeked by two researchers independently. KEY FINDING most of studies were done on anti-psychotic drugs, especially typical class. Most used investigated method to long-term QT induction was patch clamp. SIGNIFICANCE results suggests in susceptible cases with heart risk factors, these drugs should be taken with caution and monitored.
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Affiliation(s)
- Marzieh Nemati
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Hosseinzadeh
- Endocrinology and Metabolism Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Nemati
- School of Dentistry, Shiraz University of Medical Science, Shiraz, Iran
| | - Bahareh Ebrahimi
- Geriatric Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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3
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Benjamin EJ, Nelson OL, Baumwart R, Haines J. Adverse effects of trazodone in dogs on primary hemostasis and electrocardiogram: A single-blinded placebo-controlled crossover study. J Vet Intern Med 2023; 37:2131-2136. [PMID: 37807949 PMCID: PMC10658541 DOI: 10.1111/jvim.16841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 08/21/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Trazodone is a serotonin antagonist/reuptake inhibitor medication commonly used for anxiety in dogs. Therapy with selective serotonin reuptake inhibitors in humans is associated with bleeding disorders and increased arrhythmogenesis. HYPOTHESIS/OBJECTIVES To evaluate markers of primary hemostasis and corrected QT (cQT) interval in dogs before and after oral administration of standard dosages of trazodone or placebo. ANIMALS Fifteen apparently healthy, client-owned dogs. METHODS A single-blinded, randomized placebo-controlled crossover study was performed. Dogs were administered trazodone (5 to 7.5 mg/kg PO Q12h) or placebo. [Correction added after first online publication on 14 October 2023. In the abstract (methods) section (57.5 mg/kg PO Q12h) changed as (5 to 7.5 mg/kg PO Q12h).] Buccal mucosal bleeding time (BMBT), platelet count, platelet aggregation via Plateletworks, PFA-100 closure time and cQT interval were measured. A Shapiro-Wilk test was performed followed by either a paired t test or a Wilcoxon signed-rank test. RESULTS No significant difference was detected in the BMBT, PFA-100 closure times, platelet counts, and cQT interval between trazodone or placebo. However, using Plateletworks, there was a significant decrease in platelet aggregation after administration of trazodone (95%; 81-97 vs 62%; 39-89, P = .002) and not placebo (95%; 81-97 vs 91%; 81-96, P = .21). CONCLUSIONS It is unknown if this represents a clinically relevant change or if dogs with preexisting impairment in primary hemostasis or receiving higher dosages or longer durations of trazodone could have a more substantial change in hemostatic variables.
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Hobbs K, Luethy D, Davis J, Mallicote M, Torcivia C, Kulp J, Stefanovski D, Futterman C, Cooper F, van Eps A. The effects of orally administered trazodone on ambulation and recumbency in healthy horses. J Vet Intern Med 2023; 37:1899-1906. [PMID: 37489582 PMCID: PMC10472990 DOI: 10.1111/jvim.16821] [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: 09/16/2022] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Trazodone, a serotonin receptor antagonist and reuptake inhibitor, might be a useful adjunctive treatment in the initial management of horses with acute laminitis if it minimizes ambulation or encourages recumbency. OBJECTIVES (1) Evaluate the effects of PO trazodone on ambulatory activity and recumbency in healthy horses; and (2) assess the pharmacokinetics of multiple PO doses of trazodone. ANIMALS/METHODS In a randomized cross-over design, 8 healthy horses received placebo or trazodone at 2 doses (2.5 and 7.5 mg/kg) PO q12h for 48 hours with a 14-day washout period between treatments. Forelimb step frequency was measured using a hoof-mounted accelerometer and continuous video monitoring was used to detect recumbency. Groups were compared using repeated measures analysis of variance with Tukey's post hoc test. Trazodone and m-chlorophenylpiperazine (m-CPP) plasma concentrations were determined by ultra-high performance liquid chromatography-tandem mass spectrometry and pharmacokinetics were analyzed using noncompartmental methods. RESULTS Step frequency was lower in horses receiving 7.5 mg/kg trazodone than in the control group (mean step reduction: 44% ± 11%). Steps-area under the curve were significantly lower in the 7.5 mg/kg group (mean ± SD: 3375 ± 525 steps × hour) as compared to the 2.5 mg/kg group (mean ± SD: 5901 ± 2232; P = .02) and compared to control (mean ± SD: 6590 ± 1241; P = .001). No difference was found in the number of recumbent episodes (P = .92) or total duration of recumbency (P = .9). Trazodone and m-CPP achieved steady-state concentrations, with an accumulation ratio of 1.45 ± 0.2. CONCLUSIONS AND CLINICAL IMPORTANCE Although it did not affect recumbency, trazodone at 7.5 mg/kg q12h decreased step frequency by approximately 44%.
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Affiliation(s)
- Kallie Hobbs
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Daniela Luethy
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Jennifer Davis
- Department of Biomedical Sciences and PathobiologyVirginia‐Maryland College of Veterinary MedicineBlacksburgVirginiaUSA
| | - Martha Mallicote
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Catherine Torcivia
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
| | - Jeaneen Kulp
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
| | - Darko Stefanovski
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
| | - Catherine Futterman
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Freya Cooper
- Department of Large Animal Clinical SciencesUniversity of Florida College of Veterinary MedicineGainesvilleFloridaUSA
| | - Andrew van Eps
- Department of Clinical Studies‐New Bolton Center, School of Veterinary MedicineUniversity of PennsylvaniaKennett SquarePennsylvaniaUSA
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Myocardial Cell Preservation from Potential Cardiotoxic Drugs: The Role of Nanotechnologies. Pharmaceutics 2022; 15:pharmaceutics15010087. [PMID: 36678717 PMCID: PMC9865222 DOI: 10.3390/pharmaceutics15010087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/16/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022] Open
Abstract
Cardiotoxic therapies, whether chemotherapeutic or antibiotic, represent a burden for patients who may need to interrupt life-saving treatment because of serious complications. Cardiotoxicity is a broad term, spanning from forms of heart failure induction, particularly left ventricular systolic dysfunction, to induction of arrhythmias. Nanotechnologies emerged decades ago. They offer the possibility to modify the profiles of potentially toxic drugs and to abolish off-target side effects thanks to more favorable pharmacokinetics and dynamics. This relatively modern science encompasses nanocarriers (e.g., liposomes, niosomes, and dendrimers) and other delivery systems applicable to real-life clinical settings. We here review selected applications of nanotechnology to the fields of pharmacology and cardio-oncology. Heart tissue-sparing co-administration of nanocarriers bound to chemotherapeutics (such as anthracyclines and platinum agents) are discussed based on recent studies. Nanotechnology applications supporting the administration of potentially cardiotoxic oncological target therapies, antibiotics (especially macrolides and fluoroquinolones), or neuroactive agents are also summarized. The future of nanotechnologies includes studies to improve therapeutic safety and to encompass a broader range of pharmacological agents. The field merits investments and research, as testified by its exponential growth.
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Föhr KJ, Rapp M, Fauler M, Zimmer T, Jungwirth B, Messerer DAC. Block of Voltage-Gated Sodium Channels by Aripiprazole in a State-Dependent Manner. Int J Mol Sci 2022; 23:ijms232112890. [PMID: 36361681 PMCID: PMC9656591 DOI: 10.3390/ijms232112890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/05/2022] [Accepted: 10/20/2022] [Indexed: 11/24/2022] Open
Abstract
Aripiprazole is an atypical antipsychotic drug, which is prescribed for many psychiatric diseases such as schizophrenia and mania in bipolar disorder. It primarily acts as an agonist of dopaminergic and other G-protein coupled receptors. So far, an interaction with ligand- or voltage-gated ion channels has been classified as weak. Meanwhile, we identified aripiprazole in a preliminary test as a potent blocker of voltage-gated sodium channels. Here, we present a detailed analysis about the interaction of aripiprazole with the dominant voltage-gated sodium channel of heart muscle (hNav1.5). Electrophysiological experiments were performed by means of the patch clamp technique at human heart muscle sodium channels (hNav1.5), heterologously expressed in human TsA cells. Aripiprazole inhibits the hNav1.5 channel in a state- but not use-dependent manner. The affinity for the resting state is weak with an extrapolated Kr of about 55 µM. By contrast, the interaction with the inactivated state is strong. The affinities for the fast and slow inactivated state are in the low micromolar range (0.5–1 µM). Kinetic studies indicate that block development for the inactivated state must be described with a fast (ms) and a slow (s) time constant. Even though the time constants differ by a factor of about 50, the resulting affinity constants were nearly identical (in the range of 0.5 µM). Besides this, aripirazole also interacts with the open state of the channel. Using an inactivation deficit mutant, an affinity of about 1 µM was estimated. In summary, aripiprazole inhibits voltage-gated sodium channels at low micromolar concentrations. This property might add to its possible anticancer and neuroprotective properties.
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Affiliation(s)
- Karl Josef Föhr
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, 89081 Ulm, Germany
- Correspondence:
| | - Michael Rapp
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, 89081 Ulm, Germany
| | - Michael Fauler
- Institute of General Physiology, University of Ulm, 89081 Ulm, Germany
| | - Thomas Zimmer
- Institute of Physiology, University Hospital of Jena, 07747 Jena, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, 89081 Ulm, Germany
| | - David Alexander Christian Messerer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, 89081 Ulm, Germany
- Department of Transfusion Medicine and Hemostaseology, Friedrich-Alexander University Erlangen-Nuremberg, University Hospital Erlangen, 91052 Erlangen, Germany
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Kny M, Fielitz J. Hidden Agenda - The Involvement of Endoplasmic Reticulum Stress and Unfolded Protein Response in Inflammation-Induced Muscle Wasting. Front Immunol 2022; 13:878755. [PMID: 35615361 PMCID: PMC9124858 DOI: 10.3389/fimmu.2022.878755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Critically ill patients at the intensive care unit (ICU) often develop a generalized weakness, called ICU-acquired weakness (ICUAW). A major contributor to ICUAW is muscle atrophy, a loss of skeletal muscle mass and function. Skeletal muscle assures almost all of the vital functions of our body. It adapts rapidly in response to physiological as well as pathological stress, such as inactivity, immobilization, and inflammation. In response to a reduced workload or inflammation muscle atrophy develops. Recent work suggests that adaptive or maladaptive processes in the endoplasmic reticulum (ER), also known as sarcoplasmic reticulum, contributes to this process. In muscle cells, the ER is a highly specialized cellular organelle that assures calcium homeostasis and therefore muscle contraction. The ER also assures correct folding of proteins that are secreted or localized to the cell membrane. Protein folding is a highly error prone process and accumulation of misfolded or unfolded proteins can cause ER stress, which is counteracted by the activation of a signaling network known as the unfolded protein response (UPR). Three ER membrane residing molecules, protein kinase R-like endoplasmic reticulum kinase (PERK), inositol requiring protein 1a (IRE1a), and activating transcription factor 6 (ATF6) initiate the UPR. The UPR aims to restore ER homeostasis by reducing overall protein synthesis and increasing gene expression of various ER chaperone proteins. If ER stress persists or cannot be resolved cell death pathways are activated. Although, ER stress-induced UPR pathways are known to be important for regulation of skeletal muscle mass and function as well as for inflammation and immune response its function in ICUAW is still elusive. Given recent advances in the development of ER stress modifying molecules for neurodegenerative diseases and cancer, it is important to know whether or not therapeutic interventions in ER stress pathways have favorable effects and these compounds can be used to prevent or treat ICUAW. In this review, we focus on the role of ER stress-induced UPR in skeletal muscle during critical illness and in response to predisposing risk factors such as immobilization, starvation and inflammation as well as ICUAW treatment to foster research for this devastating clinical problem.
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Affiliation(s)
- Melanie Kny
- Experimental and Clinical Research Center (ECRC), Charité-Universitätsmedizin Berlin, Max Delbrück Center (MDC) for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Jens Fielitz
- Department of Molecular Cardiology, DZHK (German Center for Cardiovascular Research), Partner Site, Greifswald, Germany
- Department of Internal Medicine B, Cardiology, University Medicine Greifswald, Greifswald, Germany
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Husak N, Leonard JB, Seung H, Klein-Schwartz W. Single-substance trazodone exposures reported to US poison centers from 2000 to 2019. Clin Toxicol (Phila) 2022; 60:1032-1038. [PMID: 35475757 DOI: 10.1080/15563650.2022.2068423] [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: 11/03/2022]
Abstract
BACKGROUND Individual case reports describe trazodone overdose resulting in QTc prolongation and cardiac arrhythmias. The clinical effects and outcomes associated with trazodone exposures on a large-scale basis are less well known. OBJECTIVE The primary objective was to characterize the severity of single substance trazodone exposures and identify any relationships that may exist between dose of trazodone and severity of exposure. The secondary objective was to describe these exposures from a demographic and clinical symptom standpoint. METHODS A retrospective review of single-substance trazodone exposures reported to the National Poison Data System (NPDS) from 1 January 2000 to 31 December 2019 was performed. The primary objective was to characterize the severity of trazodone exposures and relationships between ingested dose and level of care required or medical outcome. RESULTS A total of 118,773 cases were included in the analysis of demographics and level of care required. A majority (59.5%) of cases did not require medical admission. Of the 81,698 cases with known medical outcomes, the most common clinical effects included mild-moderate CNS depression (49.7%), QTc prolongation (12.2% of cases in 2019), vomiting (9.0%), hypotension (7.0%), and tachycardia (7.0%). The median ingested dose associated with treatment, and release from the emergency department was 600 mg compared to 1500 mg in those admitted to the intensive care unit (ICU). Regarding medical outcome, median ingested dose ranged from 600 mg in those experiencing no effect to 1500 mg in those experiencing major effects. Cardiac-related clinical effects and the need for cardiac-specific interventions were overall infrequent. A dose-response relationship was identified for level of care and medical outcome. CONCLUSIONS Many trazodone exposures can be characterized as low severity due to the infrequent need for healthcare facility admission and large proportion of cases that experienced no effects or only minor effects.
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Affiliation(s)
- Nicholas Husak
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James Brewer Leonard
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Department of Pharmacy Practice and Science, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
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10
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Tellone V, Rosignoli MT, Picollo R, Dragone P, Del Vecchio A, Comandini A, Radicioni M, Leuratti C, Calisti F. Effect of 3 Single Doses of Trazodone on QTc Interval in Healthy Subjects. J Clin Pharmacol 2020; 60:1483-1495. [PMID: 32488885 PMCID: PMC7586935 DOI: 10.1002/jcph.1640] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/16/2020] [Indexed: 11/18/2022]
Abstract
This study evaluated the effect of 3 doses of a trazodone hydrochloride 6% oral drops solution on the QT interval of healthy volunteers. Subjects were randomly assigned to receive a single dose of trazodone 20 mg, 60 mg, and 140 mg, moxifloxacin 400 mg, and trazodone‐matched placebo in 5 periods separated by 7‐day washouts, according to a double‐blind, crossover study design. Subjects were monitored continuously, and triplicate ECGs were extracted from baseline (predose) until 24 hours postdose. Blood samples for trazodone and moxifloxacin analyses were collected at the same time points. The concentration‐QTc relationship assessed on placebo‐adjusted change from baseline for Fridericia‐corrected QT (ΔΔQTcF) was the primary end point. ΔΔQTcF values of 4.5, 12.3, and 19.8 ms for the 20‐, 60‐, and 140‐mg doses were observed at the corresponding trazodone peak plasma concentrations. The upper bound of the 90%CI exceeded 10 ms for the 60‐ and the 140‐mg doses. Time‐matched analysis results were in line with these findings. No significant trazodone effect on heart rate or PR or QRS intervals and no clinically significant new morphological changes were present. In this moxifloxacin‐validated ECG trial, trazodone had a modest, dose‐dependent effect on cardiac repolarization, with no QTc prolongation observed with the 20‐mg dose and an effect exceeding the values set in E14 guideline with the 60‐ and 140‐mg doses. The effect on cardiac repolarization is unlikely to represent a clinical risk for ventricular proarrhythmia, but caution should be used with concomitant use of other medications that prolong QT or increase trazodone exposure.
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Campleman SL, Brent J, Pizon AF, Shulman J, Wax P, Manini AF. Drug-specific risk of severe QT prolongation following acute drug overdose. Clin Toxicol (Phila) 2020; 58:1326-1334. [PMID: 32252558 DOI: 10.1080/15563650.2020.1746330] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Severe QT prolongation (SQTP) has been identified as a strong predictor of adverse cardiovascular events in acute drug overdose, but drug-specific causes of SQTP in the setting of acute drug overdose remain unclear. We aimed to perform the most definitive study to date describing drug-specific risk of SQTP following acute drug overdose.Methods: This was a prospective multicenter cohort study at >50 hospital sites across the US using the ToxIC Registry between 2015 and 2018. Inclusion criteria were adults (≥18 years) receiving medical toxicology consultation for acute drug overdose. The primary outcome was SQTP, which was defined using the computer automated Bazett QT correction (QTc) on the ECG with the previously validated cut point of 500 milliseconds. Mean difference in QTc was also calculated for specific drugs. Drugs associated with SQTP were analyzed using multivariable logistic regression to control for known confounders of QT risk (age, sex, race, cardiac disease).Results: From 25,303 patients screened, 6473 met inclusion criteria with SQTP occurring in 825 (13%). Drugs associated with increased adjusted odds of SQTP included Class III antidysrhythmics (sotalol), sodium channel blockers (amitriptyline, diphenhydramine, doxepin, imipramine, nortriptyline), antidepressants (bupropion, citalopram, escitalopram, trazodone), antipsychotics (haloperidol, quetiapine), and the antiemetic serotonin antagonist ondansetron.Conclusions: This large US cohort describes drug-specific risk of SQTP following acute drug overdose. Healthcare providers caring for acute drug overdoses from any of these implicated drugs should pay close attention to cardiac monitoring for occurrence of SQTP.
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Affiliation(s)
- Sharan L Campleman
- Toxicology Investigators Consortium, American College of Medical Toxicology, Phoenix, AZ, USA
| | - Jeffery Brent
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anthony F Pizon
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Joshua Shulman
- Division of Medical Toxicology, Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Paul Wax
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Alex F Manini
- Division of Medical Toxicology, Department of Emergency Medicine, Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
BACKGROUND Trazodone is widely used in the treatment of depression, anxiety, and insomnia. It is thought to have a safe cardiac profile due to the relative lack of anticholinergic effects. Publications about cardiac toxicities of trazodone are scant. CASE REPORT A 55-year-old woman presented with acute disorder of consciousness secondary to an intentional trazodone overdose. She was found to have seizure activity without cerebral edema. The initial electrocardiogram was unremarkable, with a normal QTc interval. She eventually developed QTc prolongation that evolved into ventricular tachycardia, and then into a transient right bundle-branch block, left anterior fascicular block, and variable degrees of atrioventricular nodal blocks at 12-24 h after ingestion. She then developed generalized tonic-clonic seizures, cardiogenic shock, and respiratory arrest. She was intubated and treated with antiepileptics, norepinephrine, and dopamine infusion. QTc interval prolongation gradually resolved and the various forms of heart block did not recur after at 24-36 h. She did not require transcutaneous pacing, and was successfully extubated with intact neurological function. CONCLUSIONS Fatal arrhythmias can occur in trazodone overdose. Close monitoring and supportive care are crucial for patient survival.
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Affiliation(s)
- Kyaw Khaing Soe
- Department of Medical Education, Dignity Health St. Mary Medical Center, Long Beach, CA, USA
| | - Mark Young Lee
- Section of Cardiology, Department of Internal Medicine, Dignity Health St. Mary Medical Center, Long Beach, CA, USA.,Department of Cardiology and Electrophysiology, Long Beach Memorial Medical Center, Long Beach, CA, USA
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Belinskaia DA, Belinskaia MA, Barygin OI, Vanchakova NP, Shestakova NN. Psychotropic Drugs for the Management of Chronic Pain and Itch. Pharmaceuticals (Basel) 2019; 12:ph12020099. [PMID: 31238561 PMCID: PMC6631469 DOI: 10.3390/ph12020099] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022] Open
Abstract
Clinical observations have shown that patients with chronic neuropathic pain or itch exhibit symptoms of increased anxiety, depression and cognitive impairment. Such patients need corrective therapy with antidepressants, antipsychotics or anticonvulsants. It is known that some psychotropic drugs are also effective for the treatment of neuropathic pain and pruritus syndromes due to interaction with the secondary molecular targets. Our own clinical studies have identified antipruritic and/or analgesic efficacy of the following compounds: tianeptine (atypical tricyclic antidepressant), citalopram (selective serotonin reuptake inhibitor), mianserin (tetracyclic antidepressant), carbamazepine (anticonvulsant), trazodone (serotonin antagonist and reuptake inhibitor), and chlorprothixene (antipsychotic). Venlafaxine (serotonin-norepinephrine reuptake inhibitor) is known to have an analgesic effect too. The mechanism of such effect of these drugs is not fully understood. Herein we review and correlate the literature data on analgesic/antipruritic activity with pharmacological profile of these compounds.
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Affiliation(s)
- Daria A Belinskaia
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, pr. Torez 44, St. Petersburg 194223, Russia.
| | - Mariia A Belinskaia
- International Centre for Neurotherapeutics, Dublin City University, Glasnevin, Dublin 9, Ireland.
| | - Oleg I Barygin
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, pr. Torez 44, St. Petersburg 194223, Russia.
| | - Nina P Vanchakova
- Department of Pedagogy and Psychology, Faculty of Postgraduate Education, First Pavlov State Medical University, L'va Tolstogo str. 6-8, St. Petersburg 197022, Russia.
| | - Natalia N Shestakova
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Russian Academy of Sciences, pr. Torez 44, St. Petersburg 194223, Russia.
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Kahl KG. Direct and indirect effects of psychopharmacological treatment on the cardiovascular system. Horm Mol Biol Clin Investig 2018; 36:hmbci-2018-0054. [PMID: 30427780 DOI: 10.1515/hmbci-2018-0054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/27/2018] [Indexed: 12/11/2022]
Abstract
Background Severe mental disorders, i.e. psychotic disorders, unipolar and bipolar disorders are associated with increased morbidity and mortality from cardiovascular and metabolic disorders. The underlying cause of this association is complex and comprises disorder specific alterations such as dysfunctions of immunological and hormonal systems, body-composition changes and health associated behaviors (smoking, sedentary lifestyle, alcohol intake and treatment compliance). Furthermore, some psychopharmacological drugs may exert unwanted side effects that impact the cardiovascular system. Methods This paper reviews studies concerning commonly used antidepressant and antipsychotics drugs with a particular focus on direct and indirect cardiovascular side effects. Results Newer antidepressant drugs have a favorable cardiovascular safety profile compared to tricyclic antidepressants. However, QTc prolongation, increased blood pressure and potentially higher risks of bleeding have been observed in some newer antidepressants. Some second generation (atypical) antipsychotics have raised concern because of indirect cardiovascular, metabolic side effects such as weight gain and disturbances in lipid and glucose metabolism. Conclusions Psychiatrists need to be aware of potential direct and indirect cardiovascular side effects and to include them in the risk/benefit assessment when choosing a specific individualized treatment.
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Affiliation(s)
- Kai G Kahl
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Center of Mental Health, Hannover Medical School (MHH), Carl-Neuberg-Str. 1, 30625 Hannover, Germany, Phone: + 49 511 5322495.,Working Group on Polypharmacy, AGNP, Munich, Germany
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Abstract
CLINICAL FEATURES We present a case of a middle-aged man admitted to an inpatient detoxification facility for withdrawal of intranasal heroin, alprazolam, and ethanol. The patient was placed on methadone and chlordiazepoxide tapers. Ondansetron and trazodone were prescribed as needed for symptom control. On the third hospital day, the patient was found unresponsive with blood glucose of 40 mg/dL. He had no history of glucose dysregulation. The patient was pronounced dead shortly thereafter. Methadone overdose was ruled the cause of death. THERAPEUTIC CHALLENGES There have been studies linking methadone with glucose dysregulation. Hypoglycemia can induce changes in the electrical system in the heart, including lengthening QT interval, lengthening repolarization, and causing ST wave changes. In addition, there have been studies linking methadone treatment to QT interval prolongation and torsade de pointes. Ondansetron and trazodone have both been associated with cardiac conduction abnormalities. SOLUTION We recommend initial blood glucose and cardiac monitoring in patients taking methadone 40 mg daily or higher.
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Atli O, Kilic V, Baysal M, Kilic G, Gormus G, Ucarcan S, Korkut B, Ilgin S. Assessment of trazodone-induced cardiotoxicity after repeated doses in rats. Hum Exp Toxicol 2018; 38:45-55. [PMID: 29774748 DOI: 10.1177/0960327118769717] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Trazodone (TRZ) is an antidepressant drug commonly used in the treatment of depression, anxiety, and insomnia. Although some studies demonstrated the adverse effects of TRZ related to cardiovascular system, the conflicting results were observed in these studies. Therefore, we aimed to investigate the cardiac adverse effects of TRZ in rats at repeated doses in our study. In accordance with this purpose, TRZ was administered orally to rats at 5, 10, and 20 mg/kg doses for 28 days. Electrocardiogram records, serum aspartate aminotransferase (AST), lactate dehydrogenase, creatine kinase-myoglobin band, cardiac troponin-T (cTn-T) levels, DNA damage in cardiomyocytes, and histologic view of heart tissues were evaluated. In addition, glutathione (GSH) and malondialdehyde (MDA) levels were measured to determine the oxidative status of cardiac tissue after TRZ administration. Heart rate was decreased, PR interval was prolonged, and QRS and T amplitudes were decreased in 20 mg/kg TRZ-administered group compared to the control group. Serum AST and cTn-T levels were significantly increased in 10 and 20 mg/kg TRZ-administered rats with respect to control rats. DNA damage was significantly increased in these groups. Additionally, degenerative histopathologic findings were observed in TRZ-administered groups. Although there was no difference in MDA levels between groups, GSH levels were significantly decreased in 10 and 20 mg/kg TRZ-administered groups compared to the control group. Our results have shown that TRZ induced cardiotoxicity in rats dose-dependently. It is assumed that oxidative stress related to GSH depletion may be accompanied by these adverse effects.
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Affiliation(s)
- O Atli
- 1 Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Anadolu University, Eskisehir, Turkey
| | - V Kilic
- 2 Department of Biology, Faculty of Science, Anadolu University, Eskisehir, Turkey
| | - M Baysal
- 1 Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Anadolu University, Eskisehir, Turkey
| | - G Kilic
- 2 Department of Biology, Faculty of Science, Anadolu University, Eskisehir, Turkey
| | - G Gormus
- 1 Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Anadolu University, Eskisehir, Turkey
| | - S Ucarcan
- 2 Department of Biology, Faculty of Science, Anadolu University, Eskisehir, Turkey
| | - B Korkut
- 1 Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Anadolu University, Eskisehir, Turkey
| | - S Ilgin
- 1 Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Anadolu University, Eskisehir, Turkey
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Jalily Hasani H, Ganesan A, Ahmed M, Barakat KH. Effects of protein-protein interactions and ligand binding on the ion permeation in KCNQ1 potassium channel. PLoS One 2018; 13:e0191905. [PMID: 29444113 PMCID: PMC5812580 DOI: 10.1371/journal.pone.0191905] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 01/12/2018] [Indexed: 12/23/2022] Open
Abstract
The voltage-gated KCNQ1 potassium ion channel interacts with the type I transmembrane protein minK (KCNE1) to generate the slow delayed rectifier (IKs) current in the heart. Mutations in these transmembrane proteins have been linked with several heart-related issues, including long QT syndromes (LQTS), congenital atrial fibrillation, and short QT syndrome. Off-target interactions of several drugs with that of KCNQ1/KCNE1 ion channel complex have been known to cause fatal cardiac irregularities. Thus, KCNQ1/KCNE1 remains an important avenue for drug-design and discovery research. In this work, we present the structural and mechanistic details of potassium ion permeation through an open KCNQ1 structural model using the combined molecular dynamics and steered molecular dynamics simulations. We discuss the processes and key residues involved in the permeation of a potassium ion through the KCNQ1 ion channel, and how the ion permeation is affected by (i) the KCNQ1-KCNE1 interactions and (ii) the binding of chromanol 293B ligand and its derivatives into the complex. The results reveal that interactions between KCNQ1 with KCNE1 causes a pore constriction in the former, which in-turn forms small energetic barriers in the ion-permeation pathway. These findings correlate with the previous experimental reports that interactions of KCNE1 dramatically slows the activation of KCNQ1. Upon ligand-binding onto the complex, the energy-barriers along ion permeation path are more pronounced, as expected, therefore, requiring higher force in our steered-MD simulations. Nevertheless, pulling the ion when a weak blocker is bound to the channel does not necessitate high force in SMD. This indicates that our SMD simulations have been able to discern between strong and week blockers and reveal their influence on potassium ion permeation. The findings presented here will have some implications in understanding the potential off-target interactions of the drugs with the KCNQ1/KCNE1 channel that lead to cardiotoxic effects.
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Affiliation(s)
- Horia Jalily Hasani
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Aravindhan Ganesan
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Marawan Ahmed
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Khaled H. Barakat
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta, Canada
- Li Ka Shing Institute of Virology, University of Alberta, Edmonton, Alberta, Canada
- Li Ka Shing Applied Virology Institute, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
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Humanity in a Dish: Population Genetics with iPSCs. Trends Cell Biol 2017; 28:46-57. [PMID: 29054332 DOI: 10.1016/j.tcb.2017.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 12/17/2022]
Abstract
Induced pluripotent stem cells (iPSCs) are powerful tools for investigating the relationship between genotype and phenotype. Recent publications have described iPSC cohort studies of common genetic variants and their effects on gene expression and cellular phenotypes. These in vitro quantitative trait locus (QTL) studies are the first experiments in a new paradigm with great potential: iPSC-based functional population genetic studies. iPSC collections from large cohorts are currently under development to facilitate the next wave of these studies, which have the potential to discover the effects of common genetic variants on cellular phenotypes and to uncover the molecular basis of common genetic diseases. Here, we describe the recent advances in this developing field, and provide a road map for future in vitro functional population genetic studies and trial-in-a-dish experiments.
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Effects of psychopharmacological treatment with antidepressants on the vascular system. Vascul Pharmacol 2017; 96-98:11-18. [DOI: 10.1016/j.vph.2017.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/23/2017] [Indexed: 02/08/2023]
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