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Cerdà G, Julià-Torras J, González-Barboteo J, Romeo M, Calsina-Berna A. Polypharmacy and Reversible Drug Induced QT Prolongation in a Patient with Advanced Cancer: Case Report. J Pain Palliat Care Pharmacother 2024; 38:33-37. [PMID: 38180376 DOI: 10.1080/15360288.2023.2297218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024]
Abstract
QT prolongation is related to the development of ventricular arrhythmias such as Torsade de Pointes (TdP) that can lead to sudden cardiac death. Several drugs used in the treatment of patients with advanced cancer may induce QT prolongation due to their interference with cardiac ion channels. Some patients may be at higher risk if predisposing factors are present. Herein we present the case of a patient with advanced cancer under anti-tumor treatment with radical intention that developed a reversible drug-induced QT prolongation when simultaneously treated with methadone, haloperidol and fluoxetine that presented with chest pain and bradycardia. An approach to cancer patients at risk for drug-induced QT prolongation is discussed highlighting the need of a thorough medication review with a special focus in the patient with polypharmacy.
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Affiliation(s)
- Gabriela Cerdà
- Medical Oncology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - Margarita Romeo
- is with Medical Oncology Department, Institut Català d'Oncologia, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Agnès Calsina-Berna
- Research and Knowledge Group in Palliative Care of Institut Català d'Oncologia (GRICOPAL)
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Shojaei L, Ruzbahani M, Khajavian S, Shahsavari S, Tamasoki N, Rajabian M, Moradi F, Shahbazi F. Analysis of QTc Interval during Levofloxacin Prescription in Cardiac Patients with Pneumonia. Curr Drug Saf 2020; 15:111-116. [DOI: 10.2174/1574886315666200213112702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 11/22/2022]
Abstract
Background:
Medications induced QT prolongation could cause ventricular arrhythmia,
torsade de pointes, and death.
Objective:
The purpose of this study was to evaluate the magnitude of QTc interval prolongation as
a result of levofloxacin treatment in patients admitted to cardiology wards.
Methods:
This was a cross-sectional study conducted in the coronary care units and general wards
of the Imam Ali Heart Hospital in Kermanshah, Iran. The QTc interval was determined at baseline
and after 72 hours of levofloxacin administration. Changes in the QTc interval before and after the
levofloxacin prescription were determined.
Results:
The mean age of recruited patients was 63.26 ± 14.56 years. More than 80% of patients
who received levofloxacin experienced QTc prolongation. The QTc interval was increased significantly
after levofloxacin administration (15.68 ± 26.84 milliseconds) (p<0.001). These changes remained
significant after excluding medications with QTc lengthening properties (p<0.001).
Conclusion:
Treatment with levofloxacin in patients with heart disease increases the risk of QT
prolongation.
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Affiliation(s)
- Lida Shojaei
- Pharmaceutical Sciences Research Center, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Ruzbahani
- Imam Ali cardiovascular Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shiva Khajavian
- Imam Ali cardiovascular Hospital, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Soodeh Shahsavari
- School of Allied Medical Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Negin Tamasoki
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mina Rajabian
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Farzaneh Moradi
- Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Foroud Shahbazi
- Pharmaceutical Sciences Research Center, School of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Gorelik E, Masarwa R, Perlman A, Rotshild V, Abbasi M, Muszkat M, Matok I. Fluoroquinolones and Cardiovascular Risk: A Systematic Review, Meta-analysis and Network Meta-analysis. Drug Saf 2020; 42:529-538. [PMID: 30368737 DOI: 10.1007/s40264-018-0751-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Several fluoroquinolone antibiotics have been associated with cardiac adverse effects, leading to the withdrawal of some of these agents from the market. Cardiac side effects such as QT prolongation and torsades de pointes (TdP) have also been observed with fluoroquinolones currently on the market. In order to evaluate the cardiac risk of fluoroquinolones as a class, and the comparative risk for each individual drug, we conducted a systematic review, meta-analysis, and network meta-analysis. METHODS MEDLINE, EMBASE and the Cochrane Library were searched, up to March 2018, for randomized controlled trials, cohort studies, and case-control studies that investigated the association between fluoroquinolone treatment and the risk of cardiovascular events and cardiovascular mortality. We followed the PRISMA 2009 guidelines for data selection and extraction. Outcomes were pooled using random effects models. Direct and indirect comparisons in network meta-analysis were performed using frequentist methods. RESULTS Thirteen studies were included in our analyses. Fluoroquinolone use was associated with a statistically significant 85% increase in the risk for arrhythmia (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.22-2.81) and 71% increase in the risk for cardiovascular mortality (OR 1.71; 95% CI 1.39-2.09). Moxifloxacin ranked most likely to have the highest risk for arrhythmia (P-score 0.99) and for cardiovascular mortality (P-score 0.95) by network meta-analysis. CONCLUSIONS Our findings show a significant association between fluoroquinolone use and an increased risk for arrhythmia and cardiovascular mortality. Moxifloxacin ranked with the highest probability for cardiovascular adverse events. Further study is required to determine how to reduce the risk for fluoroquinolone-associated cardiac toxicity.
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Affiliation(s)
- Einat Gorelik
- Division of Clinical Pharmacy, School of Pharmacy, The Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, 9112001, Jerusalem, Israel.,Department of Pharmacovigilance, Ministry of Health, Jerusalem, Israel
| | - Reem Masarwa
- Division of Clinical Pharmacy, School of Pharmacy, The Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, 9112001, Jerusalem, Israel
| | - Amichai Perlman
- Division of Clinical Pharmacy, School of Pharmacy, The Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, 9112001, Jerusalem, Israel
| | - Victoria Rotshild
- Division of Clinical Pharmacy, School of Pharmacy, The Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, 9112001, Jerusalem, Israel
| | - Momen Abbasi
- The Department of Medicine, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Mordechai Muszkat
- The Department of Medicine, Hadassah University Hospital, Mt. Scopus, Jerusalem, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, School of Pharmacy, The Institute for Drug Research, Faculty of Medicine, The Hebrew University of Jerusalem, 9112001, Jerusalem, Israel.
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Alrwisan AA, Wei YJ, Brumback BA, Antonelli PJ, Winterstein AG. Concomitant Use of Quinolones and Stimulants and the Risk of Adverse Cardiovascular Symptoms: A Retrospective Cohort Study. Pharmacotherapy 2019; 39:1167-1178. [DOI: 10.1002/phar.2343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Adel A. Alrwisan
- Pharmaceutical Outcomes and Policy College of Pharmacy University of Florida Gainesville Florida
- Saudi Food and Drug Authority Riyadh Saudi Arabia
| | | | | | | | - Almut G. Winterstein
- Saudi Food and Drug Authority Riyadh Saudi Arabia
- Department of Epidemiology College of Public Health and Health Professions and College of Medicine University of Florida Gainesville Florida
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Brunetti L, Lee SM, Nahass RG, Suh D, Miao B, Bucek J, Kim D, Kim OK, Suh DC. The risk of cardiac events in patients who received concomitant levofloxacin and amiodarone. Int J Infect Dis 2018; 78:50-56. [PMID: 30385404 DOI: 10.1016/j.ijid.2018.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/22/2018] [Accepted: 10/24/2018] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Levofloxacin and amiodarone are both known to prolong the QT interval. This study was conducted to estimate the risk of cardiac events in patients receiving concomitant levofloxacin and amiodarone. METHODS The study included patients who were admitted to a large academic community medical center from 1/2012 to 12/2015 and received both levofloxacin and amiodarone at some point during their hospitalization. Patients received concomitant or non-concomitant levofloxacin and amiodarone during hospitalization. The primary outcome was the occurrence of cardiac events during therapy. The secondary outcome was the proportion of patients with an electrocardiogram performed before and after initiation of therapy. Odds ratios for cardiac events were calculated using a multivariable logistic regression model with and without adjusting for the study variables. The concomitant group was further evaluated for predictors of the primary outcome using multivariable logistic regression. RESULTS This study included 240 patients, 164 (68.3%) of whom received concomitant levofloxacin and amiodarone. Concomitant medication therapy was associated with a greater than six-fold increased risk of cardiac events after adjusting for the study variables (Odds Ratio=6.20; 95% Confidence Interval=1.34-28.62). CONCLUSIONS Patients receiving concomitant amiodarone and levofloxacin experienced a five-fold increase in cardiac events compared to patients given either medication alone.
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Affiliation(s)
- Luigi Brunetti
- Rutgers University School of Pharmacy, Piscataway, NJ, USA; RWJ Barnabas Health-Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA
| | - Seung-Mi Lee
- Rutgers University School of Pharmacy, Piscataway, NJ, USA; Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Ronald G Nahass
- Rutgers University School of Pharmacy, Piscataway, NJ, USA; RWJ Barnabas Health-Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA
| | - David Suh
- Columbia University School of Public Health, New York, NY, USA
| | - Benjamin Miao
- Rutgers University School of Pharmacy, Piscataway, NJ, USA
| | - John Bucek
- RWJ Barnabas Health-Robert Wood Johnson University Hospital Somerset, Somerville, NJ, USA
| | - Dongwon Kim
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Ok-Kyu Kim
- Chung-Ang University College of Pharmacy, Seoul, South Korea
| | - Dong-Churl Suh
- Chung-Ang University College of Pharmacy, Seoul, South Korea.
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Stock EM, Zeber JE, McNeal CJ, Banchs JE, Copeland LA. Psychotropic Pharmacotherapy Associated With QT Prolongation Among Veterans With Posttraumatic Stress Disorder. Ann Pharmacother 2018; 52:838-848. [DOI: 10.1177/1060028018769425] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: In 2012, the Food and Drug Administration issued Drug Safety Communications on several drugs associated with QT prolongation and fatal ventricular arrhythmias. Among these was citalopram, a selective serotonin reuptake inhibitor (SSRI) approved for depression and commonly used for posttraumatic stress disorder (PTSD). Evaluation of the risk for QT prolongation among other psychotropic drugs for individuals with PTSD remains limited. Objective: Explore psychotropic drugs associated with QT prolongation among veterans with PTSD. Methods: Patients in the Veterans Health Administration in 2006-2009 with PTSD and QT prolongation (176 cases) were matched 1:4 on age, gender, visit date and setting, and physical comorbidity. Classification trees assessed QT prolongation risk among prescribed medications (n=880). Results: Receipt of any drug with known risk of QT prolongation varied by group (23% QT cases vs 15% control, p<0.01). Psychotropic medications conferring significant risks included ziprasidone (3% vs 1%, p=0.02) and buspirone (6% vs 2%, p=0.01). Increased risk was not observed for the SSRIs, citalopram and fluoxetine. Classification trees found that sotalol and amitriptyline carried greater risk among cardiac patients and methadone, especially if prescribed with quetiapine, among noncardiac patients. Per adjusted survival model, patients with QT prolongation were at increased risk for death (hazard ratio=1.60; 95% CI=1.04-2.44). Conclusions: Decision models are particularly advantageous when exploring nonlinear relationships or nonadditive interactions. These findings may potentially affect clinical decision-making concerning treatment for PTSD. For patients at higher risk of QT prolongation, antidepressants other than amitriptyline should be considered. Medications for comorbid conditions should also be closely monitored for heightened QT prolongation risk.
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Affiliation(s)
- Eileen M. Stock
- Cooperative Studies Program Coordinating Center, VA Maryland Health Care System, Perry Point, MD, USA
| | - John E. Zeber
- Central Texas Veterans Health Care System, Temple, TX, USA
- Center for Applied Health Research, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M Health Science Center, Bryan, TX, USA
| | - Catherine J. McNeal
- Texas A&M Health Science Center, Bryan, TX, USA
- Department of Cardiology, Baylor Scott & White Health, Temple, TX, USA
| | - Javier E. Banchs
- Department of Electrophysiology and Pacing, Baylor Scott & White Health, Temple, TX, USA
| | - Laurel A. Copeland
- Center for Applied Health Research, Baylor Scott & White Health, Temple, TX, USA
- Texas A&M Health Science Center, Bryan, TX, USA
- VA Central Western Massachusetts, Leeds, MA, USA
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7
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Beach SR, Celano CM, Sugrue AM, Adams C, Ackerman MJ, Noseworthy PA, Huffman JC. QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update. PSYCHOSOMATICS 2018; 59:105-122. [DOI: 10.1016/j.psym.2017.10.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 10/11/2017] [Accepted: 10/17/2017] [Indexed: 12/31/2022]
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Wei A, Peng J, Gu Z, Li J. QTc prolongation and torsades de pointes due to a coadministration of fluoxetine and amiodarone in a patient with implantable cardioverter-defibrillator: Case report and review of the literature. Medicine (Baltimore) 2017; 96:e9071. [PMID: 29245320 PMCID: PMC5728935 DOI: 10.1097/md.0000000000009071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Drug-induced prolongation of the corrected QT interval (QTc) may lead to serious and potentially life-threatening ventricular tachyarrhythmia, such as torsades de pointes (Tdp), which is worthy of clinical attention. Here, we report 1 case of Tdp after a coadministration of fluoxetine and amiodarone. PATIENT CONCERNS A 62-year-old Chinese male who placed with the implanted cardioverter-defibrillator (ICD) appeared the QTc prolongation and Tdp after the concurrent administration of fluoxetine and amiodarone. DIAGNOSES Torsades de pointes (Tdp). INTERVENTIONS The patient was treated with magnesium and potassium immediately. Her ICD-brady pacing mode was reprogrammed to 90 bpm. Meanwhile, both of fluoxetine and amiodarone were discontinued. OUTCOMES The further episodes of Tdp were prevented. After a few days, the QTc gradually decreased without clinically significant arrhythmias. LESSONS The present case demonstrates that a potential drug-drug interaction (DDI) may lead to a life-threatening drug adverse reaction (ADR) especially in special subjects. Therefore, clinicians should closely monitor the electrocardiogram (ECG) when QTc-prolonging agents are given to patients with cardiac abnormalities, and avoid combining 2 QTc-prolonging drugs.
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Affiliation(s)
- Anhua Wei
- Department of Pharmacy, Tongji Hospital
| | - Jinlan Peng
- Department of Endocrinology, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Zhichun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Juan Li
- Department of Pharmacy, Tongji Hospital
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Khan Q, Ismail M, Haider I, Khan F. Prevalence of QT interval prolonging drug-drug interactions (QT-DDIs) in psychiatry wards of tertiary care hospitals in Pakistan: a multicenter cross-sectional study. Int J Clin Pharm 2017; 39:1256-1264. [PMID: 28895028 DOI: 10.1007/s11096-017-0532-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/05/2017] [Indexed: 02/03/2023]
Abstract
Background QT prolongation and associated arrhythmias, torsades de pointes (TdP), are considerable negative outcomes of many antipsychotic and antidepressant agents frequently used by psychiatric patients. Objective To identify the prevalence, levels, and predictors of QT prolonging drug-drug interactions (QT-DDIs), and AZCERT (Arizona Center for Education and Research on Therapeutics) classification of drugs involved in QT-DDIs. Setting Psychiatry wards of three major tertiary care hospitals of Khyber-Pakhtunkhwa, Pakistan. Method This was a multicenter cross-sectional study. Micromedex DrugReax was used for identification of QT-DDIs. TdP risks were identified by the AZCERT classification. Multivariate logistic regression analysis was performed to identify predictors of QT-DDIs. Main outcome measure Prevalence of QT-DDIs (overall, age-wise and gender-wise) and their levels of severity and documentation; AZCERT classes of drugs involved in QT-DDIs; and odds ratios for predictors of QT-DDIs. Results Of 600 patients, 58.5% were female. Median age was 25 years (IQR = 20-35). Overall 51.7% patients had QT-DDIs. Of total 698 identified QT-DDIs, most were of major-severity (98.4%) and fair-documentation (93.7%). According to the AZCERT classification, 36.4% of the interacting drugs were included in list-1 (known risk of TdP), 26.9% in list-2 (possible risk of TdP) and 27.5% in list-3 (conditional risk of TdP). Drugs commonly involved in QT-DDI were olanzapine (n = 146), haloperidol (138), escitalopram (122), risperidone (91), zuclopenthixol (87), quetiapine (n80) and fluoxetine (74). In multivariate logistic regression analysis, QT-DDIs were significantly associated with 6-7 prescribed medications (p = 0.04) and >7 medications (p = 0.03). Similarly, there was significant association of occurrence of QT-DDIs with 2-3 QT drugs (p < 0.001) and >3 QT drugs (p < 0.001). Conclusion A considerable number of patients are exposed to QT-DDIs in psychiatry. There is a need to implement protocol for monitoring the outcomes of QT-DDIs.
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Affiliation(s)
- Qasim Khan
- Department of Pharmacy, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan.,Department of Pharmacy, COMSATS Institute of Information Technology, Abbottabad, Pakistan
| | - Mohammad Ismail
- Department of Pharmacy, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan.
| | - Iqbal Haider
- Department of Medicine, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Fahadullah Khan
- Department of Pharmacy, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan
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10
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Truzzi JC, Silvinato A, Bernardo WM. Overactive bladder: pharmacological treatment. Rev Assoc Med Bras (1992) 2017; 63:197-202. [PMID: 28489120 DOI: 10.1590/1806-9282.63.03.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2016] [Indexed: 11/22/2022] Open
Affiliation(s)
- José Carlos Truzzi
- Sociedade Brasileira de Urologia. Universidade Federal de São Paulo. Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
| | - Antonio Silvinato
- Sociedade Brasileira de Urologia. Universidade Federal de São Paulo. Hospital Alemão Oswaldo Cruz, São Paulo, SP, Brazil
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Stancampiano FF, Palmer WC, Getz TW, Serra-Valentin NA, Sears SP, Seeger KM, Pagan RJ, Racho RG, Ray JC, Snipelisky DF, Mentel JJ, Diehl NN, Heckman MG. Rare Incidence of Ventricular Tachycardia and Torsades de Pointes in Hospitalized Patients With Prolonged QT Who Later Received Levofloxacin: A Retrospective Study. Mayo Clin Proc 2015; 90:606-12. [PMID: 25863416 DOI: 10.1016/j.mayocp.2015.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 02/09/2015] [Accepted: 02/16/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To determine the incidence of ventricular tachycardia and ventricular fibrillation in patients with prolonged corrected QT interval (QTc) who received levofloxacin through retrospective chart review at a tertiary care teaching hospital in the United States. PATIENTS AND METHODS We selected 1004 consecutive hospitalized patients with prolonged QTc (>450 ms) between October 9, 2009 and June 12, 2012 at our institution. Levofloxacin was administered orally and/or intravenously and adjusted to renal function in the inpatient setting. The primary outcome measure was sustained ventricular tachycardia recorded electrocardiographically. RESULTS With a median time from the start of levofloxacin use to hospital discharge (or death) of 4 days (range, 1-94 days), only 2 patients (0.2%; 95% CI, 0.0%-0.7%) experienced the primary outcome of sustained ventricular tachycardia after the initiation of levofloxacin use. CONCLUSION In this study, the short-term risk for sustained ventricular tachycardia in patients with a prolonged QTc who subsequently received levofloxacin was very rare. These results suggest that levofloxacin may be a safe option in patients with prolonged QTc; however, studies with longer follow-up are needed.
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Affiliation(s)
| | - William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL
| | - Trevor W Getz
- CRISP Investigative Research Program, Mayo Clinic, Jacksonville, FL
| | | | - Steven P Sears
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Ricardo J Pagan
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Ronald G Racho
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Jordan C Ray
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | | | - John J Mentel
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
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Serra R, Grande R, Butrico L, Rossi A, Settimio UF, Caroleo B, Amato B, Gallelli L, de Franciscis S. Chronic wound infections: the role of Pseudomonas aeruginosa and Staphylococcus aureus. Expert Rev Anti Infect Ther 2015; 13:605-13. [PMID: 25746414 DOI: 10.1586/14787210.2015.1023291] [Citation(s) in RCA: 380] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic leg ulcers affect 1-2% of the general population and are related to increased morbidity and health costs. Staphylococcus aureus and Pseudomonas aeruginosa are the most common bacteria isolated from chronic wounds. They can express virulence factors and surface proteins affecting wound healing. The co-infection of S. aureus and P. aeruginosa is more virulent than single infection. In particular, S. aureus and P. aeruginosa have both intrinsic and acquired antibiotic resistance, making clinical management of infection a real challenge, particularly in patients with comorbidity. Therefore, a correct and prompt diagnosis of chronic wound infection requires a detailed knowledge of skin bacterial flora. This is a necessary prerequisite for tailored pharmacological treatment, improving symptoms, and reducing side effects and antibiotic resistance.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology, Headquarters: University Magna Græcia of Catanzaro, Viale Europa 88100 Catanzaro, Italy
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13
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Lu ZK, Yuan J, Li M, Sutton SS, Rao GA, Jacob S, Bennett CL. Cardiac risks associated with antibiotics: azithromycin and levofloxacin. Expert Opin Drug Saf 2015; 14:295-303. [PMID: 25494485 PMCID: PMC4404501 DOI: 10.1517/14740338.2015.989210] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Azithromycin and levofloxacin have been shown to be efficacious in treating infections. The adverse drug events associated with azithromycin and levofloxacin were considered rare. However, the US FDA released warnings regarding the possible risk of QT prolongation with azithromycin and levofloxacin. AREAS COVERED Case reports/case series, observational studies and clinical trials assessing cardiovascular risks associated with azithromycin and levofloxacin were critically reviewed, including 15 case reports/series, 5 observational studies and 5 clinical trials that investigated the cardiac risks associated azithromycin and levofloxacin. EXPERT OPINION Results are discordant. Two retrospective studies utilizing large databases demonstrated an increased risk of cardiovascular death with azithromycin, when azithromycin was compared with amoxicillin. Two other retrospective studies found no difference in cardiovascular death associated with azithromycin and other antibiotics. For levofloxacin, the increased risk of cardiovascular death was only found in one retrospective study. Therefore, the risks and benefits of antibacterial therapies should be considered when making prescription decisions. This study should not preclude clinicians from avoiding azithromycin and levofloxacin. If a patient has an indication to receive an antibiotic and if azithromycin or levofloxacin is needed, it may be used, but the potential risks must be understood.
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Affiliation(s)
- Zhiqiang Kevin Lu
- University of South Carolina, South Carolina College of Pharmacy, Clinical Pharmacy and Outcomes Sciences Department , 715 Sumter Street, CLS Building, Room 311G, Columbia, SC 29208 , USA +1 803 777 2653 ; +1 803 777 2820 ;
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14
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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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Beach SR, Celano CM, Noseworthy PA, Januzzi JL, Huffman JC. QTc prolongation, torsades de pointes, and psychotropic medications. PSYCHOSOMATICS 2013; 54:1-13. [PMID: 23295003 DOI: 10.1016/j.psym.2012.11.001] [Citation(s) in RCA: 200] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 10/31/2012] [Accepted: 11/01/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Prolongation of the corrected QT (QTc) interval is a key issue for patients who receive psychotropic medications. Such patients may have baseline clinical risk factors for QTc prolongation, and many psychotropic medications may further prolong this interval. This has great clinical relevance, as QTc prolongation is linked with dangerous arrhythmias, especially torsades de pointes (TdP). METHODS We summarize current literature regarding appropriate methods of calculating the QTc interval, the association of the QTc interval with TdP, and risk factors for QTc prolongation. We then review connections between psychiatric medications and QTc prolongation, with a specific focus on antidepressants and antipsychotics. RESULTS QTc interval prolongation is an established, though imperfect, risk marker for TdP. There are no well-controlled studies that assess the risk of TdP associated with psychotropic agents. There are limited data that selective serotonin reuptake inhibitors (SSRIs) as a class are linked to QTc prolongation; citalopram appears more likely than others to induce this phenomenon. Among antipsychotics, thioridazine remains the agent most associated with QTc prolongation; intravenous haloperidol also appears to carry an increased risk. Of the atypical antipsychotics, ziprasidone appears most likely to prolong the QTc interval. CONCLUSIONS The majority of patients in need of psychotropic medications display few risk factors for QTc prolongation and should be considered to be at low risk for TdP. The frequency of cardiac monitoring for patients receiving psychiatric medications should be individually determined, based on the prescribed agent(s) and additional risk factors for TdP.
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Abstract
OBJECTIVE To report QT prolongation potential in selective serotonin reuptake inhibitors (SSRIs) in order to advise clinicians on safe use of SSRIs other than citalopram in light of citalopram warnings. DATA SOURCES Primary literature and case reports were identified through a systematic search. Data from drug manufacturers, package inserts, and the ArizonaCERT database were also utilized. STUDY SELECTION AND DATA EXTRACTION English-language studies and case reports were included. DATA SYNTHESIS Studies demonstrate possible dose-related clinically significant QT prolongation with escitalopram. Fluoxetine, fluvoxamine, and sertraline at traditional doses demonstrate a lack of clinically significant increases in QTc in the majority of studies. Further, paroxetine monotherapy shows a lack of clinically significant QTc prolongation in all studies. However, case reports or reporting tools still link these SSRIs with QTc prolongation. Fluoxetine, escitalopram, and sertraline used in post-acute coronary syndrome patients did not demonstrate risk of QTc prolongation. CONCLUSION For clinicians who choose not to use citalopram due to recent Food and Drug Administration (FDA) recommendations, other antidepressants within this class may be considered. When citalopram is not utilized based on risk factors for TdP, use of escitalopram is not likely the safest alternative. Based on current literature, fluoxetine, fluvoxamine, and sertraline appear to have similar, low risk for QT prolongation, and paroxetine appears to have the lowest risk. However, there are significant limitations in interpreting the studies, including varying definitions of significant QT prolongation. Therefore, choice of an alternative SSRI should be based on individual risk factors for arrhythmias and other patient-specific factors.
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Affiliation(s)
- Kylee A Funk
- University of Michigan Health System, Ann Arbor, MI, USA
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Veerman CC, Verkerk AO, Blom MT, Klemens CA, Langendijk PNJ, van Ginneken ACG, Wilders R, Tan HL. Slow delayed rectifier potassium current blockade contributes importantly to drug-induced long QT syndrome. Circ Arrhythm Electrophysiol 2013; 6:1002-9. [PMID: 23995305 DOI: 10.1161/circep.113.000239] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Drug-induced long QT syndrome is generally ascribed to inhibition of the cardiac rapid delayed rectifier potassium current (IKr). Effects on the slow delayed rectifier potassium current (IKs) are less recognized. Triggered by a patient who carried the K422T mutation in KCNQ1 (encoding the α-subunit of the IKs channel), who presented with excessive QT prolongation and high serum levels of norfluoxetine, we investigated the effects of fluoxetine and its metabolite norfluoxetine on IKs. METHODS AND RESULTS ECG data from mutation carriers and noncarriers revealed that the K422T mutation per se had mild clinical effects. Patch clamp studies, performed on HEK293 cells, showed that heterozygously expressed K422T KCNQ1/KCNE1 channels had a positive shift in voltage dependence of activation and an increase in deactivation rate. Fluoxetine and its metabolite norfluoxetine both inhibited KCNQ1/KCNE1 current, with norfluoxetine being the most potent. Moreover, norfluoxetine increased activation and deactivation rates. Computer simulations of the effects of norfluoxetine on IKs and IKr demonstrated significant action potential prolongation, to which IKs block contributed importantly. Although the effects of the mutation per se were small, additional IKs blockade by norfluoxetine resulted in more prominent QTc prolongation in mutation carriers than in noncarriers, demonstrating synergistic effects of innate and drug-induced IKs blockade on QTc prolongation. CONCLUSIONS IKs blockade contributes importantly to drug-induced long QT syndrome, especially when repolarization reserve is reduced. Drug safety tests might have to include screening for IKs blockade.
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Affiliation(s)
- Christiaan C Veerman
- Heart Center, and Departments of Anatomy, Embryology, and Physiology, Cardiology, Hospital Pharmacy, Academic Medical Center, University of Amsterdam, the Netherlands; and Department of Hospital Pharmacy, Reinier de Graaf Group Hospitals, Delft, the Netherlands
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Zhou H. Population-Based Assessments of Clinical Drug-Drug Interactions: Qualitative Indices or Quantitative Measures? J Clin Pharmacol 2013; 46:1268-89. [PMID: 17050792 DOI: 10.1177/0091270006294278] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Population-based assessments of drug-drug interactions have become more common since the introduction and acceptance of the population pharmacokinetic approach. Unlike traditional methods, population-based studies provide clinically relevant results that can be applied directly to a target patient population. Furthermore, population-based studies do not demand the traditional requirements of intensive pharmacokinetic sampling, rigorous inpatient stays, or stringent assessment schedules. As such, the population-based approach can effectively be used to confirm known drug-drug interactions and further characterize anticipated interactions. A prospectively designed analysis can also reveal drug-drug interactions that might otherwise have gone undetected with traditional methods. Ultimately, these results could help to alleviate clinicians' concerns about using widely marketed drugs in combination therapies and also reduce patients' risk of experiencing unacceptable side effects. This article intends to provide a balanced overview of the population-based approach and its merits, drawbacks, and potential utility in the assessment of drug-drug interactions during clinical drug development.
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Affiliation(s)
- Honghui Zhou
- Pharmacokinetics, Modeling & Simulation, Clinical Pharmacology & Experimental Medicine, Centocor Research & Development, Malvern, PA 19087, USA
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Absi M, Ghareeb H, Khalil A, Ruegg UT. The effect of levofloxacin and moxifloxacin on cardiovascular functions of rats with streptozotocin-induced diabetes. Diab Vasc Dis Res 2013; 10:65-71. [PMID: 22621918 DOI: 10.1177/1479164112445755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Fluoroquinolone antibiotics cause rare, but clinically important, adverse events including hyperglycaemia and hypoglycaemia. The present study focuses on the possible effect of levofloxacin and moxifloxacin on the cardiovascular functions of rats with type I diabetes. Both antibiotics caused bradycardia. Levofloxacin but not moxifloxacin caused hypoglycaemia in diabetic rats and an increase in amplitude of the ST segment revealed by electrocardiogram (ECG) analysis of isolated hearts. In pressurized mesenteric arteries, levofloxacin did not affect the endothelium-derived hyperpolarising factor (EDHF) pathway or its main components, the small-conductance Ca(2+) activated potassium (SK(Ca)) and intermediate-conductance Ca(2+) activated potassium (IK(Ca)) channels. In moxifloxacin-treated rats, an increase in the EDHF response was observed, which was largely attributed to SK(Ca)-activation. In conclusion, levofloxacin and moxifloxacin use appeared to vary but with no evidence of impairment of the cardiovascular function. However, it is still possible that these antibiotics may produce different effects if there are co-morbidities and therefore their use must be with care.
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Affiliation(s)
- Mais Absi
- Pharmacology and Toxicology Department, Aleppo University, Syria.
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Pugi A, Longo L, Bartoloni A, Rossolini GM, Mugelli A, Vannacci A, Lapi F. Cardiovascular and metabolic safety profiles of the fluoroquinolones. Expert Opin Drug Saf 2011; 11:53-69. [PMID: 21958023 DOI: 10.1517/14740338.2011.624512] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Certain fluoroquinolones share similar indications of use. A comparison among Cardiovascular and metabolic (i.e., dysglycemia) safety profiles of the fluoroquinolones might be particularly useful for the prescribers' decision-making process as well as to hypothesize future researcher purposes. AREAS COVERED A literature search was conducted using keywords apt to identify information on safety profile of the fluoroquinolones. Publications concerned with descriptive and etiological surveys were manually reviewed. EXPERT OPINION Cardiac alterations and blood glucose impairments might be associated with any fluoroquinolone. However, the benefit/risk profile of these agents could be stratified for the single compounds. Several predisposing factors, such as diabetes, heart illnesses and their related pharmacotherapies, might exacerbate the risk of potentially serious adverse events. In this context, the opportunity of the more appropriate choice among different fluoroquinolones could be applicable.
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Affiliation(s)
- Alessandra Pugi
- University of Florence, Department of Pharmacology, Viale Pieraccini 6, 50139, Florence, Italy.
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Park MY, Kim EY, Lee YH, Kim W, Kim KS, Sheen SS, Lim HS, Park RW. Analysis of Relationship between Levofloxacin and Corrected QT Prolongation Using a Clinical Data Warehouse. Healthc Inform Res 2011; 17:58-66. [PMID: 21818458 PMCID: PMC3092995 DOI: 10.4258/hir.2011.17.1.58] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 03/25/2011] [Indexed: 01/08/2023] Open
Abstract
Objective The aim of this study was to examine whether or not levofloxacin has any relationship with QT prolongation in a real clinical setting by analyzing a clinical data warehouse of data collected from different hospital information systems. Methods Electronic prescription data and medical charts from 3 different hospitals spanning the past 9 years were reviewed, and a clinical data warehouse was constructed. Patients who were both administrated levofloxacin and given electrocardiograms (ECG) were selected. The correlations between various patient characteristics, concomitant drugs, corrected QT (QTc) prolongation, and the interval difference in QTc before and after levofloxacin administration were analyzed. Results A total of 2,176 patients from 3 different hospitals were included in the study. QTc prolongation was found in 364 patients (16.7%). The study revealed that age (OR 1.026, p < 0.001), gender (OR 0.676, p = 0.007), body temperature (OR 1.267, p = 0.024), and cigarette smoking (OR 1.641, p = 0.022) were related with QTc prolongation. After adjusting for related factors, 12 drugs concomitant with levofloxacin were associated with QTc prolongation. For patients who took ECGs before and after administration of levofloxacin during their hospitalization (n = 112), there was no significant difference in QTc prolongation. Conclusions The age, gender, body temperature, cigarette smoking and various concomitant drugs might be related with QTc prolongation. However, there was no definite causal relationship or interaction between levofloxacin and QTc prolongation. Alternative surveillance methods utilizing the massive accumulation of electronic medical data seem to be essential to adverse drug reaction surveillance in future.
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Affiliation(s)
- Man Young Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Korea
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Briasoulis A, Agarwal V, Pierce WJ. QT Prolongation and Torsade de Pointes Induced by Fluoroquinolones: Infrequent Side Effects from Commonly Used Medications. Cardiology 2011; 120:103-10. [DOI: 10.1159/000334441] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 10/10/2011] [Indexed: 11/19/2022]
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Raschi E, Poluzzi E, Zuliani C, Muller A, Goossens H, De Ponti F. Exposure to antibacterial agents with QT liability in 14 European countries: trends over an 8-year period. Br J Clin Pharmacol 2009; 67:88-98. [PMID: 19076158 PMCID: PMC2668089 DOI: 10.1111/j.1365-2125.2008.03319.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 11/24/2008] [Accepted: 10/02/2008] [Indexed: 01/18/2023] Open
Abstract
AIMS (i) To classify antibacterial agents with QT liability on the basis of the available evidence, and (ii) to assess trends in their consumption over an 8-year period (1998-2005) in 14 European countries. METHODS Current published evidence on QT liability of antibiotics was retrieved through MEDLINE search and joined to official warnings from regulatory agencies. Each drug was classified according to an already proposed algorithm based on the strength of evidence: from group A (any evidence) to group E (clinical reports of torsades de pointes and warnings on QT liability). Consumption data were provided by the European Surveillance of Antibacterial Consumption (ESAC) project and were expressed as defined daily doses per 1000 inhabitants per day (DID). RESULTS Among 21 detected compounds, nine [six fluoroquinolones (FQs) and three macrolides (MACs)] belonged to group E. Use of group E drugs ranged from 1.3 (Sweden) to 4.1 DID (Italy) in 1998 and from 1.2 (Sweden) to 6.5 DID (Italy) in 2005. Significant exposure was observed in Italy and Spain (6.5 and 3.8 DID, respectively, in 2005). Only Denmark, Sweden and UK showed a slight decrease in use. Exposure to clarithromycin increased in 10 out of 14 countries, with a marked increment in Italy (3 DID in 2005). CONCLUSIONS Notwithstanding regulatory measures, in 2005 there was still significant exposure to antibacterials with strong evidence of QT liability and, in most countries, it was even increased. This warrants further investigation of appropriateness of use and suggests closer monitoring of group E drugs. Physicians should be aware when prescribing them to susceptible patients.
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Affiliation(s)
- Emanuel Raschi
- Department of Pharmacology, University of Bologna, Bologna, Italy
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Wille SMR, Cooreman SG, Neels HM, Lambert WEE. Relevant Issues in the Monitoring and the Toxicology of Antidepressants. Crit Rev Clin Lab Sci 2008; 45:25-89. [DOI: 10.1080/10408360701713112] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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McNally P, McNicholas F, Oslizlok P. The QT interval and psychotropic medications in children: recommendations for clinicians. Eur Child Adolesc Psychiatry 2007; 16:33-47. [PMID: 16944043 DOI: 10.1007/s00787-006-0573-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/26/2006] [Indexed: 11/29/2022]
Abstract
The use of psychotropic medications in children has increased significantly in the last few years. There have been several case reports of sudden death in children taking specific psychotropic medications. Fears that these deaths might have been caused by ventricular arrhythmias have been enhanced by reports of electrocardiographic abnormalities, including prolongation of the QTc interval, in patients taking these medications. Several factors including genetic susceptibility, pre-existing cardiac disease, abnormalities of drug clearance and concomitant use of other medications known to affect the QTc interval can increase the susceptibility of the heart to conduction abnormalities. This article discusses the potential of particular psychotropic drugs to prolong the QTc interval in children, and examines other factors that may contribute to conduction abnormalities. We aim to provide clear clinical recommendations for the prescription of these drugs and the monitoring of children taking them.
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Affiliation(s)
- Paul McNally
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 12, Ireland
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Falagas ME, Rafailidis PI, Rosmarakis ES. Arrhythmias associated with fluoroquinolone therapy. Int J Antimicrob Agents 2007; 29:374-9. [PMID: 17241772 DOI: 10.1016/j.ijantimicag.2006.11.011] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Revised: 11/17/2006] [Accepted: 11/17/2006] [Indexed: 11/27/2022]
Abstract
Fluoroquinolones are widely used and well tolerated antibacterial agents. However, prolongation of the QT interval is an adverse effect associated with the use of fluoroquinolones. According to the available case reports and clinical studies, moxifloxacin carries the greatest risk of QT prolongation from all available quinolones in clinical practice and it should be used with caution in patients with predisposing factors for Torsades de pointes (Tdp). Although gemifloxacin, levofloxacin and ofloxacin are associated with a lower risk of QT prolongation compared with moxifloxacin, they should also be used with caution in patients with risk factors for QT prolongation. Ciprofloxacin appears to be associated with the lowest risk for QT prolongation and the lowest rate of Tdp. The overall risk of Tdp is small with the use of fluoroquinolones. Clinicians can minimise that risk by avoiding prescriptions of multiple medications associated with QT interval prolongation, especially in high-risk patients.
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Affiliation(s)
- Matthew E Falagas
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 15123 Marousi, Athens, Greece.
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Rajamani S, Eckhardt LL, Valdivia CR, Klemens CA, Gillman BM, Anderson CL, Holzem KM, Delisle BP, Anson BD, Makielski JC, January CT. Drug-induced long QT syndrome: hERG K+ channel block and disruption of protein trafficking by fluoxetine and norfluoxetine. Br J Pharmacol 2006; 149:481-9. [PMID: 16967046 PMCID: PMC2014667 DOI: 10.1038/sj.bjp.0706892] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND AND PURPOSE Fluoxetine (Prozac) is a widely prescribed drug in adults and children, and it has an active metabolite, norfluoxetine, with a prolonged elimination time. Although uncommon, Prozac causes QT interval prolongation and arrhythmias; a patient who took an overdose of Prozac exhibited a prolonged QT interval (QTc 625 msec). We looked for possible mechanisms underlying this clinical finding by analysing the effects of fluoxetine and norfluoxetine on ion channels in vitro. EXPERIMENTAL APPROACH We studied the effects of fluoxetine and norfluoxetine on the electrophysiology and cellular trafficking of hERG K+ and SCN5A Na+ channels heterologously expressed in HEK293 cells. KEY RESULTS Voltage clamp analyses employing square pulse or ventricular action potential waveform protocols showed that fluoxetine and norfluoxetine caused direct, concentration-dependent, block of hERG current (IhERG). Biochemical studies showed that both compounds also caused concentration-dependent reductions in the trafficking of hERG channel protein into the cell surface membrane. Fluoxetine had no effect on SCN5A channel or HEK293 cell endogenous current. Mutations in the hERG channel drug binding domain reduced fluoxetine block of IhERG but did not alter fluoxetine's effect on hERG channel protein trafficking. CONCLUSIONS AND IMPLICATIONS Our findings show that both fluoxetine and norfluoxetine at similar concentrations selectively reduce IhERG by two mechanisms, (1) direct channel block, and (2) indirectly by disrupting channel protein trafficking. These two effects are not mediated by a single drug binding site. Our findings add complexity to understanding the mechanisms that cause drug-induced long QT syndrome.
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Affiliation(s)
- S Rajamani
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - L L Eckhardt
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - C R Valdivia
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - C A Klemens
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - B M Gillman
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - C L Anderson
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - K M Holzem
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - B P Delisle
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - B D Anson
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
| | - J C Makielski
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
- Department of Physiology, University of Wisconsin-Madison Madison, WI, USA
| | - C T January
- Department of Medicine, University of Wisconsin-Madison Madison, WI, USA
- Department of Physiology, University of Wisconsin-Madison Madison, WI, USA
- Author for correspondence:
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Hancox JC, Mitcheson JS. Combined hERG channel inhibition and disruption of trafficking in drug-induced long QT syndrome by fluoxetine: a case-study in cardiac safety pharmacology. Br J Pharmacol 2006; 149:457-9. [PMID: 16967047 PMCID: PMC2014673 DOI: 10.1038/sj.bjp.0706890] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Drug-induced prolongation of the rate-corrected QT interval (QTCI) on the electrocardiogram occurs as an unwanted effect of diverse clinical and investigational drugs and carries a risk of potentially fatal cardiac arrhythmias. hERG (human ether-à-go-go-related gene) is the gene encoding the alpha-subunit of channels mediating the rapid delayed rectifier K+ current, which plays a vital role in repolarising the ventricles of the heart. Most QTCI prolonging drugs can inhibit the function of recombinant hERG K+ channels, consequently in vitro hERG assays are used widely as front-line screens in cardiac safety-testing of novel chemical entities. In this issue, Rajamani and colleagues report a case of QTCI prolongation with the antidepressant fluoxetine and correlate this with a dual effect of the drug and of its major metabolite norfluoxetine on hERG channels. Both compounds were found to produce an acute inhibition of the hERG channel by pharmacological blockade, but in addition they also were able to disrupt the normal trafficking of hERG protein to the cell membrane. Mutations to a key component of the drug binding site in the S6 region of the channel greatly attenuated channel block, but did not impair disruption of trafficking; this suggests that channel block and drug effects on trafficking were mediated by different mechanisms. These findings add to growing evidence for disruption of hERG channel trafficking as a mechanism for drug-induced long QT syndrome and raise questions as to possible limitations of acute screening methods in the assessment of QTcI prolonging liability of drugs in development.
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Affiliation(s)
- J C Hancox
- Department of Physiology and Cardiovascular Research Laboratories, School of Medical Sciences, University Walk, Bristol, UK.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2005. [DOI: 10.1002/pds.1030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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