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Restrepo JA, MacLean R, Celano CM, Huffman JC, Januzzi JL, Beach SR. The assessment of cardiac risk in patients taking lamotrigine; a systematic review. Gen Hosp Psychiatry 2022; 78:14-27. [PMID: 35763920 DOI: 10.1016/j.genhosppsych.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The Food and Drug Administration (FDA) warned about lamotrigine's arrhythmogenicity based on in vitro data. This systematic review investigates lamotrigine's effect on cardiac conduction and risk of sudden cardiac death (SCD) in individuals with and without cardiovascular disease. METHODS We searched Web of Science and PubMed from inception through August 2021. We included studies measuring electrocardiogram (ECG) changes, laboratory abnormalities, or SCD among patients taking lamotrigine. Studies examining sudden unexpected death in epilepsy were excluded for scope. Two reviewers assessed articles and extracted data. We used the Effective Public Healthcare Panacea Project tool to evaluate confidence in evidence. RESULTS Eight randomized controlled trials, 9 nonrandomized observational studies, and 24 case reports were identified, with >3054 total participants, >1606 of whom used lamotrigine. One randomized trial of older patients found an average QRS increase of 3.5 +/- 13.1 ms. Fifteen studies reported no changes in ECG parameters. Case reports documented QRS widening (13), Brugada syndrome (6), QTc prolongation (1) and SCD (2), though many ingested toxic quantities of lamotrigine and/or other medications. CONCLUSIONS Evidence is insufficient to support the breadth of the FDA warning concerning lamotrigine's cardiac risk. Lamotrigine at therapeutic doses may be associated with modest, non-dangerous QRS widening.
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Affiliation(s)
- Judith A Restrepo
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
| | - Rachel MacLean
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Christopher M Celano
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jeffery C Huffman
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Medicine, Harvard Medical School, Boston, MA, USA; Baim Institute for Clinical Research, 930 Commonwealth Avenue #3, Boston, MA 02215, United States of America
| | - Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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Gupta S, Guleria RS, Szabo YZ. MicroRNAs as biomarker and novel therapeutic target for posttraumatic stress disorder in Veterans. Psychiatry Res 2021; 305:114252. [PMID: 34739954 PMCID: PMC8857765 DOI: 10.1016/j.psychres.2021.114252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/04/2021] [Accepted: 10/23/2021] [Indexed: 12/16/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a common psychiatric disorder for military Veterans, characterized by hyperarousal, intrusive thoughts, flashbacks, hypervigilance, and distress after experiencing traumatic events. Some of the known physiological effects of PTSD include hypothalamic-pituitary-adrenal (HPA)-axis imbalance, a cortical function resulting in neuronal deficit and changes in behavior. Moreover, excessive discharge of inflammatory molecules and a dysregulated immune system are implicated in the pathophysiology of PTSD. Due to complex nature of this disorder, the biological underpinnings of PTSD remain inexplicable. Investigating novel biomarkers to understanding the pathogenesis of PTSD may reflect the underlying molecular network for therapeutic use and treatment. Circulatory microRNAs (miRNAs) and exosomes are evolving biomarkers that have shown a key role in psychiatric and neurological disorders including PTSD. Given the unique nature of combat trauma, as well as evidence that a large portion of Veterans do not benefit from frontline treatments, focus on veterans specifically is warranted. In the present review, we delineate the identification and role of several miRNAs in PTSD among veterans. An association of miRNA with HPA-axis regulation through FKBP5, a key modulator in PTSD is discussed as an emerging molecule in psychiatric diseases. We conclude that miRNAs may be used as circulatory biomarker detection in Veterans with PTSD.
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Affiliation(s)
- Sudhiranjan Gupta
- VISN 17 Center of Excellence for Research on Returning War Veterans, Biomarkers & Genetics Core, Central Texas Veterans Health Care System, 4800 Memorial Drive (151C), Waco, TX, 76711, USA.
| | - Rakeshwar S. Guleria
- VISN 17 Center of Excellence for Research on Returning War Veterans, Biomarkers & Genetics Core, Central Texas Veterans Health Care System, 4800 Memorial Drive (151C), Waco, Texas, 76711
| | - Yvette Z. Szabo
- VISN 17 Center of Excellence for Research on Returning War Veterans, Biomarkers & Genetics Core, Central Texas Veterans Health Care System, 4800 Memorial Drive (151C), Waco, Texas, 76711
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Neurological Disorders and Risk of Arrhythmia. Int J Mol Sci 2020; 22:ijms22010188. [PMID: 33375447 PMCID: PMC7795827 DOI: 10.3390/ijms22010188] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 01/08/2023] Open
Abstract
Neurological disorders including depression, anxiety, post-traumatic stress disorder (PTSD), schizophrenia, autism and epilepsy are associated with an increased incidence of cardiovascular disorders and susceptibility to heart failure. The underlying molecular mechanisms that link neurological disorders and adverse cardiac function are poorly understood. Further, a lack of progress is likely due to a paucity of studies that investigate the relationship between neurological disorders and cardiac electrical activity in health and disease. Therefore, there is an important need to understand the spatiotemporal behavior of neurocardiac mechanisms. This can be advanced through the identification and validation of neurological and cardiac signaling pathways that may be adversely regulated. In this review we highlight how dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, autonomic nervous system (ANS) activity and inflammation, predispose to psychiatric disorders and cardiac dysfunction. Moreover, antipsychotic and antidepressant medications increase the risk for adverse cardiac events, mostly through the block of the human ether-a-go-go-related gene (hERG), which plays a critical role in cardiac repolarization. Therefore, understanding how neurological disorders lead to adverse cardiac ion channel remodeling is likely to have significant implications for the development of effective therapeutic interventions and helps improve the rational development of targeted therapeutics with significant clinical implications.
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Andersen FD, Simonsen U, Andersen CU. Quetiapine and other antipsychotics combined with opioids in legal autopsy cases: A random finding or cause of fatal outcome? Basic Clin Pharmacol Toxicol 2020; 128:66-79. [PMID: 33245632 DOI: 10.1111/bcpt.13480] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 01/16/2023]
Abstract
Opioid poisoning is a frequent cause of death in drug addicts and occurs with opioid treatment. Quetiapine is often found in forensic autopsies and may increase the risk of fatal opioid poisoning by enhancing sedation, respiratory depression, hypotension and QT prolongation. We systematically searched for studies of acute toxicity of quetiapine or other antipsychotics combined with morphine or methadone. Case reports describing toxicity of quetiapine combined with morphine or methadone were also included. We retrieved one human study that observed pharmacokinetic interaction between quetiapine and methadone, and 16 other human studies. Fourteen investigated the combination of droperidol and morphine in treatment doses, and some indicated an additive sedative effect. Five animal studies with acepromazine in combination with morphine or methadone were located and indicated an additive effect on sedation and hypotension. Six forensic case reports in which death could have been caused solely by quetiapine, the opioid, or other drugs were found. Thus, acute toxicity of quetiapine combined with morphine or methadone has not been studied. Because of quetiapine's effects on alpha-adrenoceptors, muscarinic and histamine receptors, human ether-a-go-go-channels and methadone kinetics, we suggest further research to clarify if the indicated additive effects of opioids and droperidol or acepromazine are also true for quetiapine.
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Affiliation(s)
| | - Ulf Simonsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Charlotte Uggerhøj Andersen
- Department of Forensic Medicine, Aarhus University, Aarhus, Denmark.,Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
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Measurement and Management of QT Interval Prolongation for General Physicians. J Gen Intern Med 2020; 35:865-873. [PMID: 31654357 PMCID: PMC7080915 DOI: 10.1007/s11606-019-05477-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/24/2019] [Accepted: 10/02/2019] [Indexed: 02/08/2023]
Abstract
One of the more challenging aspects of ECG interpretation is measurement and interpretation of the QT interval. This interval represents the time taken for the ventricles to completely repolarise after activation. Abnormal prolongation of the QT interval can lead to torsades de pointes, a form of potentially life-threatening polymorphic ventricular tachycardia (VT). Detection of a prolonged QT interval is essential as this can be a reversible problem, particularly in the context of the use of a variety of commonly prescribed medications in the hospital setting. Automated ECG printouts cannot be relied upon to diagnose QT interval prolongation; thus, the onus is on the clinician to identify it. This is a difficult task, as the normal QT interval is typically measured relative to the heart rate. Therefore, the QT interval often requires "correction" for the current heart rate, in order to correctly stratify the risk of torsades de pointes. A wealth of correctional formulae have been derived, but none has proven superior. We present an approach to the ECG in this context, and a step-by-step guide to manually measuring and correcting the QT interval, and an approach to management in common hospital-based clinical scenarios.
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Thind M, Rodriguez I, Kosari S, Turner JR. How to Prescribe Drugs With an Identified Proarrhythmic Liability. J Clin Pharmacol 2019; 60:284-294. [DOI: 10.1002/jcph.1551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/10/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Munveer Thind
- Lankenau Institute for Medical Research Philadelphia Pennsylvania USA
| | - Ignacio Rodriguez
- Novartis Pharmaceutical Corporation East Hanover New Jersey USA
- Cardiac Safety Research Consortium Duke Clinical Research Institute Durham North Carolina USA
| | - Sam Kosari
- Discipline of Pharmacy, Faculty of Health University of Canberra Bruce Australian Capital Territory Australia
| | - J. Rick Turner
- Cardiac Safety Research Consortium Duke Clinical Research Institute Durham North Carolina USA
- The American College of Clinical Pharmacology Rockville Maryland USA
- Department of Pharmacy Practice Campbell University College of Pharmacy & Health Sciences Buies Creek North Carolina USA
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