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Lester RM, Engel C, van Haarst AD, Paglialunga S. Should You Run a Dedicated TQT Study? Sponsor and Regulatory Considerations on Substitution Pathways to Assess QT Liability. Clin Pharmacol Ther 2024; 116:42-51. [PMID: 38698592 DOI: 10.1002/cpt.3284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Cardiac safety regulatory guidance for drug development has undergone several monumental shifts over the past decade as technological advancements, analysis models and study best practices have transformed this landscape. Once, clinical proarrhythmic risk assessment of a new chemical entity (NCE) was nearly exclusively evaluated in a dedicated thorough QT (TQT) study. However, since the introduction of the International Council for Harmonisation (ICH) E14/S7B Q&A 5.1 and 6.1 TQT substitutions, drug developers are offered an alternative pathway to evaluate proarrhythmic risk during an ascending dose study in healthy volunteers or during a powered patient study, respectively. In addition, the findings as well as the manner in which nonclinical studies are conducted (i.e., utilizing best practices) can dictate the need for a positive control in the clinical study and/or affect the labeling outcome. Drug sponsors are now faced with the option of pursuing a dedicated TQT study or requesting a TQT substitution. Potential factors influencing the choice of pathway include the NCE mechanism of action, pharmacokinetic properties, and safety profile, as well as business considerations. This tutorial will highlight the regulatory framework for integrated arrhythmia risk prediction models to outline drug safety, delineate potential reasons why a TQT substitution request may be rejected and discuss when a standalone TQT is recommended.
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Fan W, Liu H, Shen Y, Hong K. The Association of Proton Pump Inhibitors and QT Interval Prolongation in Critically Ill Patients. Cardiovasc Drugs Ther 2024; 38:517-525. [PMID: 36625987 DOI: 10.1007/s10557-023-07425-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Drug-induced QT interval prolongation has been reported to be related to life-threatening polymorphic ventricular tachycardia (torsade de pointes). Proton pump inhibitors (PPIs) are prescribed widely for hospitalized patients; the QT interval prolongation and torsade de pointes caused by PPIs were reported. We conducted a study to determine the association between PPI treatment and QT interval prolongation in critically ill patients. METHODS This study included patients with electrocardiography (ECG) reports from the Medical Information Mart for Intensive Care III database (MIMIC-III). Patients younger than 18 years, missing baseline laboratories and with QT interval prolongation before intensive care unit (ICU) admission were excluded. The end point was the diagnosis of QT interval prolongation reported by ECG. RESULTS This study included 24,512 ICU patients. Of them, 11,327 patients were treated with PPIs, 4181 with histamine 2 receptor antagonists (H2RAs) and 6351 without acid suppression therapy (non-AST); the incidence of QT interval prolongation were 8.5%, 3.3% and 3.4% respectively. After adjustment for demographics, electrolytes, comorbidities and medications, PPIs were associated a higher risk of QT interval prolongation compared with H2RAs (OR 1.66, 95% CI 1.36 - 2.03) and non-AST (OR 1.54, 95% CI 1.31 - 1.82), while there was not significant difference between H2RAs and non-AST (OR 0.93, 95% CI 0.73 - 1.17). In the propensity score matching population, the results were consistent. Pantoprazole (OR 2.14, 95% CI 1.52 - 3.03) and lansoprazole (OR 1.80, 95% CI: 1.18 - 2.76) showed a higher QT prolongation risk than omeprazole. Several drugs caused higher QT prolongation risk when used in combination with PPIs. CONCLUSION In ICU patients, the association between PPI prescription and increased risk of QT interval prolongation was independent of known QT-prolonging factors; pantoprazole and lansoprazole had a higher risk compared with omeprazole. The combination of PPIs and other QT-prolonging drugs should be avoided.
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Affiliation(s)
- Weiguo Fan
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, NO 1 Mingde Road, Nanchang, Jiangxi, China
| | - Hualong Liu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, NO 1 Mingde Road, Nanchang, Jiangxi, China
| | - Yang Shen
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China
- Department of Genetic Medicine, the Second Affiliated Hospital of Nanchang University, NO 1 Mingde Road, Nanchang, Jiangxi, China
| | - Kui Hong
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, NO 1 Mingde Road, Nanchang, Jiangxi, China.
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China.
- Department of Genetic Medicine, the Second Affiliated Hospital of Nanchang University, NO 1 Mingde Road, Nanchang, Jiangxi, China.
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Cross MR, Savitz ST, Sangaralingham LR, So EL, Ackerman MJ, Noseworthy PA. Sudden Cardiac Death or Ventricular Arrythmia in Patients Taking Levetiracetam or Oxcarbazepine. Neurology 2024; 102:e209177. [PMID: 38560823 DOI: 10.1212/wnl.0000000000209177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 01/05/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Levetiracetam is a widely used antiseizure medication. Recent concerns have been raised regarding the potential prolongation of the QT interval by levetiracetam and increased risk of sudden cardiac death. This could have profound implications for patient safety and for prescribing practice. This study assessed the potential association of levetiracetam with cardiac outcomes related to QT interval prolongation. We compared outcomes of patients taking levetiracetam with those taking oxcarbazepine as a comparator medication that has not been associated with prolongation of the QT interval. METHODS The sample included patients who were newly prescribed levetiracetam or oxcarbazepine from January 31, 2010, to December 31, 2019, using administrative claims data from the OptumLabs Data Warehouse (OLDW). The analysis focused on a combined endpoint of sudden cardiac death or ventricular arrythmia, which are both linked to QT interval prolongation. We used a new user design and selected oxcarbazepine as an active comparator with levetiracetam to minimize bias. We used propensity score weighting to balance the levetiracetam and oxcarbazepine cohorts and then performed weighted Cox regressions to evaluate the association of levetiracetam with the combined endpoint. RESULTS We identified 104,655 enrollees taking levetiracetam and 39,596 enrollees taking oxcarbazepine. At baseline, enrollees taking levetiracetam were older, more likely to have diagnosed epilepsy, and more likely to have diagnosed comorbidities including hypertension, cerebrovascular disease, and coronary artery disease. In the main analysis, we found no significant difference between levetiracetam and oxcarbazepine in the rate of the combined endpoint for the Cox proportional hazards model (hazard ratio [HR] 0.79, 95% CI 0.42-1.47) or Cox regression with time-varying characteristics (HR 0.78, 95% CI 0.41-1.50). DISCUSSION When compared with oxcarbazepine, levetiracetam does not correlate with increased risk of ventricular arrythmia and sudden cardiac death. Our finding does not support the concern for cardiac risk to indicate restriction of levetiracetam use nor the requirement of cardiac monitoring when using it. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that sudden cardiac death and ventricular arrythmia are not more frequent in patients older than 17 years newly prescribed levetiracetam, compared with those prescribed oxcarbazepine.
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Affiliation(s)
- Madeline R Cross
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Samuel T Savitz
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Elson L So
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Michael J Ackerman
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
| | - Peter A Noseworthy
- From the Department of Neurology (M.R.C.), Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (S.T.S.), Division of Health Care Delivery Research (L.R.S., P.A.N.), Division of Epilepsy, Department of Neurology (E.L.S.), and Department of Cardiovascular Diseases (M.J.A., P.A.N.), Mayo Clinic, Rochester, MN
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Lopez-Medina AI, Campos-Staffico AM, A Chahal CA, Volkers I, Jacoby JP, Berenfeld O, Luzum JA. Genetic risk factors for drug-induced long QT syndrome: findings from a large real-world case-control study. Pharmacogenomics 2024; 25:117-131. [PMID: 38506312 DOI: 10.2217/pgs-2023-0229] [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] [Indexed: 03/21/2024] Open
Abstract
Aim: Drug-induced long QT syndrome (diLQTS), an adverse effect of many drugs, can lead to sudden cardiac death. Candidate genetic variants in cardiac ion channels have been associated with diLQTS, but several limitations of previous studies hamper clinical utility. Materials & methods: Thus, the purpose of this study was to assess the associations of KCNE1-D85N, KCNE2-I57T and SCN5A-G615E with diLQTS in a large observational case-control study (6,083 self-reported white patients treated with 27 different high-risk QT-prolonging medications; 12.0% with diLQTS). Results: KCNE1-D85N significantly associated with diLQTS (adjusted odds ratio: 2.24 [95% CI: 1.35-3.58]; p = 0.001). Given low minor allele frequencies, the study had insufficient power to analyze KCNE2-I57T and SCN5A-G615E. Conclusion: KCNE1-D85N is a risk factor for diLQTS that should be considered in future clinical practice guidelines.
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Grants
- F32 HL162231, K08 HL146990, R01-HL156961, R21-EB032661, R21-HL153694, T32 TR004371 CSR NIH HHS
- F32 HL162231, K08 HL146990, R01-HL156961, R21-EB032661, R21-HL153694, T32 TR004371 CSR NIH HHS
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Affiliation(s)
- Ana I Lopez-Medina
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Choudhary Anwar A Chahal
- Center for Inherited Cardiovascular Diseases, WellSpan Health, Lancaster, PA, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Isabella Volkers
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Juliet P Jacoby
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Omer Berenfeld
- Center for Arrhythmia Research, Departments of Internal Medicine - Cardiology, Biomedical Engineering, & Applied Physics, University of Michigan, Ann Arbor, MI, USA
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Donegan DM, Pivonello R, Stigliano A, Lardo P, Kearney T, Mezősi E, Ghigo E, Giordano R, Mariash CN, Feelders RA, Donaldson K, Darpo B, Xue H, Custodio JM, Hand AL, Moraitis AG. Relacorilant, a Selective Glucocorticoid Receptor Modulator in Development for the Treatment of Patients With Cushing Syndrome, Does Not Cause Prolongation of the Cardiac QT Interval. Endocr Pract 2024; 30:11-18. [PMID: 37805100 DOI: 10.1016/j.eprac.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVE To assess the effect of relacorilant, a selective glucocorticoid receptor modulator under investigation for the treatment of patients with endogenous hypercortisolism (Cushing syndrome [CS]), on the heart rate-corrected QT interval (QTc). METHODS Three clinical studies of relacorilant were included: (1) a first-in-human, randomized, placebo-controlled, ascending-dose (up to 500 mg of relacorilant) study in healthy volunteers; (2) a phase 1 placebo- and positive-controlled thorough QTc (TQT) study of 400 and 800 mg of relacorilant in healthy volunteers; and (3) a phase 2, open-label study of up to 400 mg of relacorilant administered daily for up to 16 weeks in patients with CS. Electrocardiogram recordings were taken, and QTc change from baseline (ΔQTc) was calculated. The association of plasma relacorilant concentration with the effect on QTc in healthy volunteers was assessed using linear mixed-effects modeling. RESULTS Across all studies, no notable changes in the electrocardiogram parameters were observed. At all time points and with all doses of relacorilant, including supratherapeutic doses, ΔQTc was small, generally negative, and, in the placebo-controlled studies, similar to placebo. In the TQT study, placebo-corrected ΔQTc with relacorilant was small and negative, whereas placebo-corrected ΔQTc with moxifloxacin positive control showed rapid QTc prolongation. These results constituted a negative TQT study. The model-estimated slopes of the concentration-QTc relationship were slightly negative, excluding an association of relacorilant with prolonged QTc. CONCLUSION At all doses studied, relacorilant consistently demonstrated a lack of QTc prolongation in healthy volunteers and patients with CS, including in the TQT study. Ongoing phase 3 studies will help further establish the overall benefit-risk profile of relacorilant.
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Affiliation(s)
- Diane M Donegan
- Division of Endocrinology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università "Federico II" di Napoli, Naples, Italy
| | - Antonio Stigliano
- Endocrinology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Pina Lardo
- Endocrinology, Sant'Andrea University Hospital, Sapienza University of Rome, Rome, Italy
| | - Tara Kearney
- Department of Endocrinology, Salford Royal Foundation Trust, Salford, Manchester, United Kingdom
| | - Emese Mezősi
- 1st Department of Internal Medicine, Clinical Center, University of Pecs, Pecs, Hungary
| | - Ezio Ghigo
- Division of Endocrinology, Diabetology and Metabolism, University of Turin, Turin, Italy
| | - Roberta Giordano
- Department of Biological and Clinical Sciences, University of Turin, Turin, Italy
| | - Cary N Mariash
- Division of Endocrinology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Richard A Feelders
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | | | | | - Austin L Hand
- Corcept Therapeutics Incorporated, Menlo Park, California
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Jefman Efendi Marzuki HY, Nafrialdi N, Sawitri N, Sugiri YJ, Gusti Agung Ayu Putu Sri Darmayani I, Ascobat P. Comparison of QTc interval changes in drug-resistant tuberculosis patients on delamanid-containing regimens versus shorter treatment regimens. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:181-190. [PMID: 38701163 DOI: 10.3233/jrs-230024] [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] [Indexed: 05/05/2024]
Abstract
BACKGROUND Delamanid (DLM) is a relatively new drug for drug-resistant tuberculosis (DR-TB) that has been used in Indonesia since 2019 despite its limited safety data. DLM is known to inhibit hERG potassium channel with the potential to cause QT prolongation which eventually leads to Torsades de pointes (TdP). OBJECTIVE This study aims to analyse the changes of QTc interval in DR-TB patients on DLM regimen compared to shorter treatment regimens (STR). METHODS A retrospective cohort was implemented on secondary data obtained from two participating hospitals. The QTc interval and the changes in QTc interval from baseline (ΔQTc) were assessed every 4 weeks for 24 weeks. RESULTS The maximum increased of QTc interval and ΔQTc interval were smaller in the DLM group with mean difference of 18,6 (95%CI 0.3 to 37.5) and 31.6 milliseconds (95%CI 14.1 to 49.1) respectively. The proportion of QTc interval prolongation in DLM group were smaller than STR group (RR=0.62; 95%CI 0.42 to 0.93). CONCLUSION This study has shown that DLM regimens are less likely to increase QTc interval compared to STR. However, close monitoring of the risk of QT interval prolongation needs to be carried out upon the use of QT interval prolonging antituberculoid drugs.
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Affiliation(s)
- H Y Jefman Efendi Marzuki
- Program Pendidikan Dokter Spesialis Farmakologi Klinik, FK UI, Jakarta, Indonesia
- Fakultas Kedokteran Universitas Surabaya, Surabaya, Indonesia
| | | | - Neni Sawitri
- Rumah Sakit Paru M. Goenawan Partowidigdo, Gadog Cisarua, Indonesia
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Topletz-Erickson AR, Mayor JG, Liu HT, Abdulrasool LI, Endres CJ. Effect of Tucatinib on Cardiac Repolarization in Healthy Volunteers. Drugs R D 2023; 23:411-419. [PMID: 37751113 PMCID: PMC10676329 DOI: 10.1007/s40268-023-00440-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Tucatinib is a selective tyrosine kinase inhibitor of the human epidermal growth factor receptor 2 (HER2) approved to treat metastatic HER2-positive breast and colorectal cancers. The International Council for Harmonisation of Technical Requirements for Human Use (ICH) E14 guideline mandates that new drugs are assessed for potential effects on cardiac repolarization through electrocardiogram (ECG) evaluation in a QT/corrected QT (TQT) study. METHODS We evaluated the effect of tucatinib on cardiac repolarization in healthy volunteers in a phase I, randomized, partially double-blind, placebo-and positive-controlled three-period crossover study. The primary endpoint was the placebo-corrected change from baseline in QT interval values, corrected for heart rate using Fridericia's method (ΔΔQTcF). RESULTS After achieving steady-state tucatinib exposures with 300 mg twice daily, the observed ΔΔQTcF ranged from -2.9 msec at 2 hours post-dose to 0 msec at 4 hours post-dose. The upper bound of the 90% confidence interval (CI) was below 5 ms at all post-dose timepoints. Assay sensitivity was confirmed as the lower bound of the 90% CI and was >5 ms following moxifloxacin dosing. As the mean ΔΔQTcF of tucatinib was predicted to be - 1.80 ms (90% CI - 3.90, 0.30) at clinically relevant tucatinib concentrations (511 ng/mL), an effect of tucatinib on QTcF exceeding 10 ms was excluded within observed ranges of tucatinib (up to ~1000 ng/mL). Tucatinib had no clinically relevant effect on heart rate or cardiac conduction. The safety profile of tucatinib was manageable after multiple doses. CONCLUSION Tucatinib had no clinically relevant effects on studied ECG parameters. This study constitutes a clearly negative TQT study per ICH E14 guidance. CLINICAL TRIAL REGISTRATION This trial (NCT03777761) was registered on 17 December 2018.
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Affiliation(s)
- Ariel R Topletz-Erickson
- Clinical Pharmacology and Pharmacometrics, Seagen Inc., 21823 30th Drive SE, Bothell, WA, 98021, USA
| | - JoAl G Mayor
- Clinical Development, Seagen Inc., Bothell, WA, USA
| | - Hsu-Tai Liu
- Global Safety Risk Management, Seagen Inc., Bothell, WA, USA
| | | | - Christopher J Endres
- Clinical Pharmacology and Pharmacometrics, Seagen Inc., 21823 30th Drive SE, Bothell, WA, 98021, USA.
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Liu X, Wang Y, Fang J, Chen R, Sun Y, Tang S, Wang M, Kan H, Li T, Chen D. Plastic additive components of PM 2.5 increase corrected QT interval: Screening for exposure markers based on airborne exposome. PNAS NEXUS 2023; 2:pgad397. [PMID: 38047040 PMCID: PMC10691654 DOI: 10.1093/pnasnexus/pgad397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 11/06/2023] [Indexed: 12/05/2023]
Abstract
The impact of industrial chemical components of ambient fine particles (e.g. PM2.5) on cardiovascular health has been poorly explored. Our study reports for the first time the associations between human exposure to complex plastic additive (PA) components of PM2.5 and prolongation of heart rate-corrected QT (QTC) interval by employing a screening-to-validation strategy based on a cohort of 373 participants (136 in the screening set and 237 in the validation set) recruited from 7 communities across China. The high-throughput airborne exposome framework revealed ubiquitous occurrences of 95 of 224 target PAs in PM2.5, totaling from 66.3 to 555 ng m-3 across the study locations. Joint effects were identified for 9 of the 13 groups of PAs with positive associations with QTC interval. Independent effect analysis also identified and validated tris(2-chloroisopropyl) phosphate, di-n-butyl/diisobutyl adipate, and 3,5-di-tert-butyl-4-hydroxybenzaldehyde as the key exposure markers for QTC interval prolongation and changes of selected cardiovascular biomarkers. Our findings highlight the important contributions of airborne industrial chemicals to the risks of cardiovascular diseases and underline the critical need for further research on the underlying mechanisms, toxic modes of action, and human exposure risks.
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Affiliation(s)
- Xiaotu Liu
- School of Environment and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 511443, China
| | - Yanwen Wang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Jianlong Fang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Renjie Chen
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education and NHC Key Lab of Health Technology Assessment, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai 200032, China
| | - Yue Sun
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Shuqin Tang
- School of Environment and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 511443, China
| | - Minghao Wang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Haidong Kan
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education and NHC Key Lab of Health Technology Assessment, Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai 200032, China
| | - Tiantian Li
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Da Chen
- School of Environment and Guangdong Key Laboratory of Environmental Pollution and Health, Jinan University, Guangzhou 511443, China
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Tong E, Wu Q, Chen Y, Liu Z, Zhang M, Zhu Y, Wu K, Pan J, Jiang J. The Efficacy and Safety of Bedaquiline in the Treatment of Pulmonary Tuberculosis Patients: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2023; 12:1389. [PMID: 37760686 PMCID: PMC10525131 DOI: 10.3390/antibiotics12091389] [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: 07/12/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Bedaquiline (BDQ) has been designated as a Group A drug by the World Health Organization (WHO) for the management of multi-drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). This systematic review and meta-analysis aim to evaluate the efficacy and safety of BDQ-containing regimens for the treatment of patients with pulmonary TB. METHODS PubMed (MEDLINE), Elton B. Stephens Company (EBSCO) database, the Cochrane Register of Controlled Trials, and the China National Knowledge Infrastructure (CNKI) database were initially searched on 15 June 2022 and again on 20 March 2023. We included randomized controlled trials (RCTs) and non-randomized studies (NRSs) that administered BDQ to TB patients. The outcomes of interest were as follows: (1) efficacy, including the rate of sputum culture conversion at 8 weeks, 24 weeks, and during follow-up, as well as the rates of completion cure, death, treatment failure, and loss at follow-up and at the end of the treatment; and (2) safety, which encompassed the incidences of cardiotoxicity, hepatotoxicity, and grade 3-5 adverse events during the treatment period. RESULTS A total of 29 articles were included in this meta-analysis, representing 23,358 individuals. Patients who were treated with BDQ were compared with patients who were not exposed to BDQ. The use of BDQ-containing regimens demonstrated improved rates of sputum conversion in RCTs at 24 weeks (RR = 1.27, 95% CI: 1.10 to 1.46) and during follow-up (RR = 1.33, 95% CI: 1.06 to 1.66). Additionally, BDQ-containing regimens showed increased cure rates (RR = 1.60, 95% CI: 1.13 to 2.26) and decreased failure rates (RR = 0.56, 95% CI: 0.56 to 0.88). In NRSs, BDQ-containing regimens improved the sputum culture conversion rate during follow-up (RR = 1.53, 95% CI: 1.07 to 2.20), increased the rate of cure (RR = 1.86, 95% CI: 1.23 to 2.83), reduced deaths from all causes (RR = 0.68, 95% CI: 0.48 to 0.97), and reduced failure rates (RR = 0.57, 95% CI: 0.46 to 0.71). However, the use of BDQ-containing regimens was associated with increased incidences of cardiotoxicity (RR = 4.54, 95% CI: 1.74 to 11.87) and grade 3-5 adverse events (RR = 1.42, 95% CI: 1.17 to 1.73) in RCTs. NRSs also showed an association between BDQ-containing regimens and cardiotoxicity (RR = 6.00, 95% CI: 1.32 to 27.19). No significant differences were observed between intervention groups and control groups with respect to other outcomes. CONCLUSIONS Data from both RCTs and NRSs support the efficacy of BDQ for the treatment of pulmonary tuberculosis. However, the use of BDQ is associated with a higher incidence of cardiotoxicity and serious adverse events. Comparative data on efficacy and safety are limited, and further confirmation is required, due to potential bias and discrepancies in the available studies.
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Affiliation(s)
- Enyu Tong
- School of Public Health, Hangzhou Normal University, Hangzhou 311100, China
| | - Qian Wu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Yiming Chen
- School of Public Health, Hangzhou Normal University, Hangzhou 311100, China
| | - Zhengwei Liu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Mingwu Zhang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Yelei Zhu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Kunyang Wu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Junhang Pan
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Jianmin Jiang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
- Key Lab of Vaccine, Prevention and Control of Infectious Disease of Zhejiang Province, Hangzhou 310051, China
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10
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Khan Z. Polypharmacy-Induced Long QT Syndrome in a Patient With Newly Diagnosed Acute Myeloid Leukaemia: A Case Report. Cureus 2023; 15:e36914. [PMID: 37143491 PMCID: PMC10153016 DOI: 10.7759/cureus.36914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Long QT syndrome is a type of disease caused by ion channels in the heart not working properly. It is a rare condition that can affect up to one in 2000 people. Many people with this condition do not develop any symptoms; however, this can lead to heart rhythm abnormality, known as torsades de pointes, and can sometimes be fatal. The cause of this condition is often inherited; however, it can also be triggered by certain medications. But the latter tends to affect those who already tend to develop this condition. The medications causing this condition include antiarrhythmics, antibiotics, antihistamines, antiemetics, antidepressants, antipsychotics, and many more. In this case report, we will be discussing a 63-year-old female who developed long QT syndrome as a result of the multiple drug therapy which is associated with long QT syndrome. Our patient was admitted to the hospital with dyspnoea, fatigue, and weight loss and was diagnosed with acute myeloid leukaemia. The patient was commenced on several medications leading to a prolonged QTc interval which resolved after stopping the culprit medications.
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11
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Lee J, Lester R, O'Reilly T, Lowe ER, Slatkin NE, Franklin H, Israel RJ. A Randomized, Double-Blind, Parallel Design Thorough QT Study With a Nested Crossover to Compare the Cardiac Safety of Amiselimod With Placebo and Positive Control in Healthy Volunteers. Clin Pharmacol Drug Dev 2023; 12:236-248. [PMID: 36708138 DOI: 10.1002/cpdd.1210] [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: 03/03/2022] [Accepted: 11/28/2022] [Indexed: 01/29/2023]
Abstract
This double-blind study evaluated the cardiac safety of amiselimod. Healthy adults (n = 190) were randomized (2:1:1) to receive (1) oral placebo (day -1), followed by oral amiselimod (days 1-26), which was upwardly titrated from 0.4 to 1.6 mg once daily to achieve steady-state concentrations comparable with 0.4 (therapeutic) and 0.8 mg (supratherapeutic) once daily, and placebo (day 27); (2) placebo (day -1), oral moxifloxacin 400 mg (day 1; positive control), followed by placebo (days 1-27); or (3) placebo (days -1 to 26), followed by moxifloxacin 400 mg (day 27). No participant had a corrected QT interval by Fredericia (QTcF) >500 milliseconds or a change from baseline (dQTcF) >60 milliseconds. The upper limits of the 90%CIs for the differences in least-squares mean difference in dQTcF between amiselimod and placebo on days 13 and 26 were <10 milliseconds. Area under the concentration-time curve from 0 to 23.5 hours after dosing and maximum plasma concentration of amiselimod and amiselimod-P (active metabolite) at steady-state concentrations for the 0.8-mg dose on day 26 were approximately double that observed with the 0.4-mg dose on day 13. All adverse events were mild to moderate in severity, and no deaths occurred. Amiselimod did not have any clinically relevant effect on the QTcF interval.
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Affiliation(s)
- Jimin Lee
- Bausch Health US, LLC, Bridgewater, New Jersey, USA
| | | | | | - Ezra R Lowe
- Bausch Health US, LLC, Bridgewater, New Jersey, USA
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12
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Räsänen E, Pukkila T, Kanniainen M, Miettinen M, Duda R, Kim J, Solanpää J, Aalto-Setälä K, Potapov I. Accurate QT correction method from transfer entropy. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2022; 4:1-8. [PMID: 36865582 PMCID: PMC9972000 DOI: 10.1016/j.cvdhj.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background The QT interval in the electrocardiogram (ECG) is a fundamental risk measure for arrhythmic adverse cardiac events. However, the QT interval depends on the heart rate and must be corrected accordingly. The present QT correction (QTc) methods are either simple models leading to under- or overcorrection, or impractical in requiring long-term empirical data. In general, there is no consensus on the best QTc method. Objective We introduce a model-free QTc method-AccuQT-that computes QTc by minimizing the information transfer from R-R to QT intervals. The objective is to establish and validate a QTc method that provides superior stability and reliability without models or empirical data. Methods We tested AccuQT against the most commonly used QT correction methods by using long-term ECG recordings of more than 200 healthy subjects from PhysioNet and THEW databases. Results AccuQT overperforms the previously reported correction methods: the proportion of false-positives is reduced from 16% (Bazett) to 3% (AccuQT) for the PhysioNet data. In particular, the QTc variance is significantly reduced and thus the RR-QT stability is increased. Conclusion AccuQT has significant potential to become the QTc method of choice in clinical studies and drug development. The method can be implemented in any device recording R-R and QT intervals.
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Affiliation(s)
- Esa Räsänen
- Computational Physics Laboratory, Tampere University, Tampere, Finland,Address reprint requests and correspondence: Dr Esa Räsänen, Computational Physics Laboratory, Tampere University, P.O. Box 692, FI-33014, Tampere, Finland.
| | - Teemu Pukkila
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Matias Kanniainen
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Minna Miettinen
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Rostislav Duda
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Jiyeong Kim
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Janne Solanpää
- Computational Physics Laboratory, Tampere University, Tampere, Finland
| | - Katriina Aalto-Setälä
- Faculty of Medicine and Health Technology, BioMediTech, Tampere University, Tampere, Finland,Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Ilya Potapov
- Computational Physics Laboratory, Tampere University, Tampere, Finland
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13
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Mulla W, Murninkas M, Levi O, Etzion Y. Incorrectly corrected? QT interval analysis in rats and mice. Front Physiol 2022; 13:1002203. [PMID: 36304573 PMCID: PMC9595597 DOI: 10.3389/fphys.2022.1002203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
QT interval, a surrogate measure for ventricular action potential duration (APD) in the surface ECG, is widely used to identify cardiac abnormalities and drug safety. In humans, cardiac APD and QT interval are prominently affected by heart rate (HR), leading to widely accepted formulas to correct the QT interval for HR changes (QT corrected - QTc). While QTc is widely used in the clinic, the proper way to correct the QT interval in small mammals such as rats and mice is not clear. Over the years, empiric correction formulas were developed for rats and mice, which are widely used in the literature. Recent experimental findings obtained from pharmacological and direct pacing experiments in unanesthetized rodents show that the rate-adaptation properties are markedly different from those in humans and the use of existing QTc formulae can lead to major errors in data interpretation. In the present review, these experimental findings are summarized and discussed.
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Affiliation(s)
- Wesam Mulla
- Cardiac Arrhythmia Research Laboratory, Department of Physiology and Cell Biology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Regenerative Medicine and Stem Cell Research Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- *Correspondence: Wesam Mulla, ; Yoram Etzion,
| | - Michael Murninkas
- Cardiac Arrhythmia Research Laboratory, Department of Physiology and Cell Biology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Regenerative Medicine and Stem Cell Research Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Or Levi
- Cardiac Arrhythmia Research Laboratory, Department of Physiology and Cell Biology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Regenerative Medicine and Stem Cell Research Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yoram Etzion
- Cardiac Arrhythmia Research Laboratory, Department of Physiology and Cell Biology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Regenerative Medicine and Stem Cell Research Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- *Correspondence: Wesam Mulla, ; Yoram Etzion,
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14
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Giraud EL, Ferrier KRM, Lankheet NAG, Desar IME, Steeghs N, Beukema RJ, van Erp NP, Smolders EJ. The QT interval prolongation potential of anticancer and supportive drugs: a comprehensive overview. Lancet Oncol 2022; 23:e406-e415. [DOI: 10.1016/s1470-2045(22)00221-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/05/2022] [Accepted: 04/05/2022] [Indexed: 10/14/2022]
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15
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QTc intervals are not prolonged in former ELBW infants at pre-adolescent age. Pediatr Res 2022; 92:848-852. [PMID: 34857877 DOI: 10.1038/s41390-021-01877-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/01/2021] [Accepted: 11/13/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Whether preterm birth is associated with cardiac conduction or repolarization abnormalities in later life is still poorly explored, with conflicting data on QTc prolongation in former extreme low birth weight (ELBW, <1000 g) infants. METHODS Twelve lead electrocardiograms (ECG) at rest, collected in the PREMATurity as predictor of children's Cardiovascular-renal Health (PREMATCH) study in former ELBW cases and term controls during pre-adolescence (8-14 years) were analyzed on corrected QT time (QTc, Bazett) and QT dispersion (QTd). ECG findings were compared between groups (Mann-Whitney), and associations with clinical and biochemical findings were explored (Spearman). In ELBW cases, associations between QTc and perinatal characteristics (at birth, neonatal stay) were explored (Mann-Whitney, Spearman). RESULTS QTc and QTd were similar between 93 ELBW cases and 87 controls [409 (range 360-465) versus 409 (337-460); 40 (0-100) versus 39 (0-110)] ms. Age, height, weight, or body mass index were not associated with the QTc interval, while female sex (median difference 11.4 ms) and lower potassium (r = -0.26) were associated with longer QTc interval. We could not observe any significant association between QTc interval and perinatal characteristics. CONCLUSIONS There were no differences in QTc or QTd between ELBW and term controls in ECGs at rest in pre-adolescents. IMPACT This study aimed to assess the differences in QTc and QTd intervals between extreme low birth weight infants (ELBW) and term controls in electrocardiographic measurements at rest during pre-adolescence. This analysis confirmed the absence of significant differences in QTc or QTd findings between ELBW cases and term controls, while female sex and lower potassium were associated with a prolonged QTc interval. These data suggest that QTc screening strategies-including for pharmacovigilance-should not differentiate between former ELBW cases and term controls. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02147457.
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16
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False Negative ECG Device Results May Increase the Risk of Adverse Events in Clinical Oncology Trials. Ther Innov Regul Sci 2022; 56:667-676. [PMID: 35471562 PMCID: PMC9135776 DOI: 10.1007/s43441-022-00405-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/07/2022] [Indexed: 12/03/2022]
Abstract
Background Sites participating in clinical trials may not have the expertise and infrastructure to accurately measure cardiac intervals on 12-lead ECGs and rely heavily on the automated ECG device generated results for clinical decision-making. Methods Using a dataset of over 260,000 ECGs collected in clinical oncology studies, we investigated the mean difference and the rate of false negative results between the digital ECG machine QTc and QRS measurements compared to those obtained by a centralized ECG core lab. Results The mean differences between the core lab and the automated algorithm QTcF and QRS measurements were + 1.8 ± 16.0 ms and − 1.0 ± 8.8 ms, respectively. Among the ECGs with a centralized QTcF value > 450 or > 470 ms, 39.5% and 47.8% respectively had a device reported QTcF value ≤ 450 ms or ≤ 470 ms. Among the ECGs with a centrally measured QTcF > 500 ms, 55.8% had a device reported value ≤ 500 ms. Automated QTcF measurements failed to detect a QTcF increase > 60 ms for 53.9% of the ECGs identified by the core lab. Automated measurements also failed to detect QRS prolongation, though to a lesser extent than failures to detect QTc prolongation. Among the ECGs with a centrally measured QRS > 110 or 120 ms, 7.9% and 7.3% respectively had a device reported QRS value ≤ 110 ms or ≤ 120 ms. Conclusion Relying on automated measurements from ECG devices for patient inclusion and treatment (dis)continuation decisions poses a potential risk to patients participating in oncology studies.
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17
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Landry IS, Boyd P, Aluri J, Darpo B, Xue H, Brown R, Reyderman L, Lai R. E2027 Cardiac Safety Evaluation With Concentration-Response Modeling of ECG Data to Inform Dose Selection in Studies in Patients With Dementia With Lewy Bodies. Alzheimer Dis Assoc Disord 2022; 36:208-214. [PMID: 35622456 DOI: 10.1097/wad.0000000000000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 03/08/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND E2027 is a novel, highly selective and potent inhibitor of phosphodiesterase 9 in development for dementia with Lewy bodies. Cardiac safety assessments for emerging agents are essential to avoid drug-induced QT interval prolongation, which may predispose individuals to potentially fatal ventricular arrhythmias. To evaluate the cardiac safety of E2027 and to inform dose selection for the phase 2 study of E2027 in dementia with Lewy bodies, we evaluated concentration-response modeling of pooled electrocardiogram data. PATIENTS AND METHODS A post hoc concentration-QTc analysis evaluated potential QT effects using data from 2 randomized, double-blind studies in healthy subjects: a single ascending dose (SAD) study and a multiple ascending dose (MAD) study. Daily E2027 doses ranged from 5 to 1200 mg. RESULTS A linear mixed-effects model was used to establish the relationship between plasma concentrations of E2027 and change from the baseline of QTcF (ΔQTcF). A significant but shallow relationship was observed in the estimated slope of the concentration-ΔQTcF: 0.002 ms/ng/mL (90% confidence interval: 0.0007-0.0031) with a small, nonsignificant treatment effect-specific intercept of -0.6 ms. Based on this pooled concentration-QTc analysis, an effect on the QTcF interval >10 ms can be excluded up to E2027 plasma concentrations of ∼3579 ng/mL, corresponding to a dose at least 4-fold larger than the 50 mg phase 2 dose. CONCLUSION This pooled post hoc analysis evaluating cardiac safety of E2027 demonstrated that clinically concerning QTcF prolongation and related cardiac complications are highly unlikely with proposed E2027 doses planned for phase 2.
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Ayo Bivigou E, Manomba Boulingui C, Bouraima A, Allognon C, Akagha Konde C, Atsame G, Kinga A, Boguikouma JB, Kouna Ndouongo P, Bouyou Akotet MK. Early Alterations of QTc in Patients with COVID-19 Treated with Hydroxychloroquine or Chloroquine in Libreville, Gabon. Clin Pract 2022; 12:482-490. [PMID: 35892438 PMCID: PMC9326533 DOI: 10.3390/clinpract12040052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/26/2022] [Accepted: 05/29/2022] [Indexed: 12/04/2022] Open
Abstract
The objective of this study was to analyze the effect of hydroxychloroquine or chloroquine associated with azithromycin on the QTc interval in Gabonese patients treated for COVID-19. METHODS This was an observational study conducted from April to June 2020, at the Libreville University Hospital Center in Gabon. Patients admitted for COVID-19 and treated with hydroxychloroquine or chloroquine, each combined with azithromycin were included. The QTc interval was measured upon admission and 48 h after starting treatment. The primary endpoint was QTc prolongation exceeding 60 ms and/or a QTc value exceeding 500 ms at 48 h. RESULTS Data from 224 patients, 102 (45.5%) who received hydroxychloroquine and 122 treated with chloroquine, were analyzed. The median baseline QTc was 396 (369-419) ms. After 48 h of treatment, 50 (22.3%) patients had a significant prolongation of QTc. This tended to be more frequent in patients treated with chloroquine (n = 33; 27.0%) than in those treated with hydroxychloroquine (n = 17; 16.7%) (p = 0.06). QTc prolongation exceeding 60 ms was found in 48 (21.3%) patients, while 11 patients had a (4.9%) QTc exceeding 60 ms at admission and exceeding 500 ms after 48 h. CONCLUSION Early QTc prolongation is frequent in COVID-19 patients treated with hydroxychloroquine or chloroquine in association with azithromycin.
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Affiliation(s)
- Elsa Ayo Bivigou
- Cardiology Department, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (E.A.B.); (A.B.); (C.A.); (C.A.K.); (A.K.)
| | - Charlene Manomba Boulingui
- Department of Medicine, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (C.M.B.); (G.A.); (J.B.B.); (P.K.N.)
| | - Aridath Bouraima
- Cardiology Department, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (E.A.B.); (A.B.); (C.A.); (C.A.K.); (A.K.)
| | - Christian Allognon
- Cardiology Department, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (E.A.B.); (A.B.); (C.A.); (C.A.K.); (A.K.)
| | - Christelle Akagha Konde
- Cardiology Department, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (E.A.B.); (A.B.); (C.A.); (C.A.K.); (A.K.)
| | - Gabrielle Atsame
- Department of Medicine, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (C.M.B.); (G.A.); (J.B.B.); (P.K.N.)
| | - Armel Kinga
- Cardiology Department, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (E.A.B.); (A.B.); (C.A.); (C.A.K.); (A.K.)
| | - Jean B. Boguikouma
- Department of Medicine, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (C.M.B.); (G.A.); (J.B.B.); (P.K.N.)
| | - Philomène Kouna Ndouongo
- Department of Medicine, University Hospital of Libreville, Libreville P.O. Box 18231, Gabon; (C.M.B.); (G.A.); (J.B.B.); (P.K.N.)
| | - Marielle K. Bouyou Akotet
- Department of Basic Sciences, Faculty of Medicine, Université des Sciences de la Santé, Libreville BP 4009, Gabon
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Krishnatry AS, Hanze E, Bergsma T, Dhar A, Prohn M, Ferron‐Brady G. Exposure-response analysis of adverse events associated with molibresib and its active metabolites in patients with solid tumors. CPT Pharmacometrics Syst Pharmacol 2022; 11:556-568. [PMID: 34648693 PMCID: PMC9124358 DOI: 10.1002/psp4.12724] [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: 05/12/2021] [Revised: 09/03/2021] [Accepted: 09/13/2021] [Indexed: 11/15/2022] Open
Abstract
Molibresib (GSK525762) is an investigational orally bioavailable small-molecule bromodomain and extraterminal (BET) protein inhibitor for the treatment of advanced solid tumors. In the first-time-in-human BET115521 study of molibresib in patients with solid tumors, thrombocytopenia was the most frequent treatment-related adverse event (AE), QT prolongation was an AE of special interest based on preclinical signals, and gastrointestinal (GI) AEs (nausea, vomiting, diarrhea, and dysgeusia) were often observed. The aims of this analysis were the following: (i) develop a population pharmacokinetic (PK)/pharmacodynamic (PD) model capable of predicting platelet time courses in individual patients after administration of molibresib and identify covariates of clinical interest; (ii) evaluate the effects of molibresib (and/or its two active metabolites [GSK3529246]) exposure on cardiac repolarization by applying a systematic modeling approach using high-quality, intensive, PK time-matched 12-lead electrocardiogram measurements; (iii) evaluate the exposure-response (ER) relationship between molibresib and/or GSK3529246 exposures and the occurrence of Grade 2 or higher GI AEs. Overall, the PK/PD model (including a maximal drug effect model and molibresib concentration) adequately described platelet counts following molibresib treatment and was used to simulate the impact of molibresib dosing on thrombocytopenia at different doses and regimens. ER analyses showed no clinically meaningful QT interval prolongation with molibresib at up to 100 mg q.d., and no strong correlation between molibresib exposure and the occurrence of Grade 2 or higher GI AEs. The models described here can aid dosing/schedule and drug combination strategies and may support a thorough QT study waiver request for molibresib.
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Affiliation(s)
- Anu Shilpa Krishnatry
- Clinical Pharmacology Modelling and SimulationGlaxoSmithKlineCollegevillePennsylvaniaUSA
| | - Eva Hanze
- qPharmetra LLCNijmegenthe Netherlands
| | | | - Arindam Dhar
- Epigenetics Research UnitGlaxoSmithKlineCollegevillePennsylvaniaUSA
| | | | - Geraldine Ferron‐Brady
- Clinical Pharmacology Modelling and SimulationGlaxoSmithKlineCollegevillePennsylvaniaUSA
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Darpo B, Sager PT, Xue H, Kamin M. A Phase 1 Clinical Study Evaluating the Effects of Cenobamate on the QT Interval. Clin Pharmacol Drug Dev 2022; 11:523-534. [PMID: 35182037 DOI: 10.1002/cpdd.1077] [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: 07/19/2021] [Accepted: 12/27/2021] [Indexed: 11/12/2022]
Abstract
Cenobamate is an antiseizure medication for uncontrolled focal seizures. This thorough QT study assessed the effects of therapeutic and supratherapeutic cenobamate doses (maximum recommended dose, 400 mg/day) on correct QT interval (QTc) in healthy adults (N = 108) randomly assigned to 1 of 3 treatments: (A) cenobamate (days 1-63) up-titrated by 50-mg increments weekly to a 200 mg/day therapeutic dose (day 35) and then by 100 mg weekly to a 500 mg/day supratherapeutic dose (day 63), with placebo-moxifloxacin (days -1 and 64); (B) moxifloxacin 400 mg (day -1; positive control), placebo-cenobamate (days 1-63), and placebo-moxifloxacin (day 64); and (C) placebo-moxifloxacin (day -1), placebo-cenobamate (days 1-64), and moxifloxacin 400 mg (day 64). The primary end point was baseline-adjusted, placebo-corrected QTc (ΔΔQTcF; corrected for heart rate [HR] by Fridericia's method) with cenobamate 200 and 500 mg/day. Baseline electrocardiographic parameters were balanced across groups. Mean ΔΔQTcF was negative throughout for cenobamate doses (largest: day 35, -10.8 milliseconds; day 63, -18.4 milliseconds). Based on concentration-QTc analysis, ∆∆QTcF effect was predicted as -9.85 and -17.14 milliseconds at mean peak plasma levels of therapeutic (200 mg/day; 23.06 μg/mL) and supratherapeutic (500 mg/day; 63.96 μg/mL) doses. Cenobamate had no clinically relevant prolonging effect on electrocardiographic parameters (eg, PR, QRS); HR effects were similar to placebo. Cenobamate showed slight dose-related shortening of QTc, but to a degree not known to be clinically relevant (no reductions ≤340 milliseconds). Cenobamate had no clinically relevant effects on HR or electrocardiographic parameters and no QTc-prolonging effect at therapeutic/supratherapeutic doses. Cenobamate is contraindicated in patients with short-QT syndrome and caution should be used when coadministering with drugs that shorten QT interval.
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Affiliation(s)
| | - Philip T Sager
- Cardiovascular Research Institute and Department of Medicine, Stanford University, Palo Alto, California, USA
| | | | - Marc Kamin
- SK Life Science, Inc., Paramus, New Jersey, USA
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Yazdanpanah MH, Naghizadeh MM, Sayyadipoor S, Farjam M. The best QT correction formula in a non-hospitalized population: the Fasa PERSIAN cohort study. BMC Cardiovasc Disord 2022; 22:52. [PMID: 35172723 PMCID: PMC8851728 DOI: 10.1186/s12872-022-02502-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 02/08/2022] [Indexed: 01/08/2023] Open
Abstract
Background QT interval as an indicator of ventricular repolarization is a clinically important parameter on an electrocardiogram (ECG). QT prolongation predisposes individuals to different ventricular arrhythmias and sudden cardiac death. The current study aimed to identify the best heart rate corrected QT interval for a non-hospitalized Iranian population based on cardiovascular mortality.
Methods Using Fasa PERSIAN cohort study data, this study enrolled 7071 subjects aged 35–70 years. Corrected QT intervals (QTc) were calculated by the QT interval measured by Cardiax® software from ECGs and 6 different correction formulas (Bazett, Fridericia, Dmitrienko, Framingham, Hodges, and Rautaharju). Mortality status was checked using an annual telephone-based follow-up and a minimum 3-year follow-up for each participant. Bland–Altman, QTc/RR regression, sensitivity analysis, and Cox regression were performed in IBM SPSS Statistics v23 to find the best QT. Also, for calculating the upper and lower limits of normal of different QT correction formulas, 3952 healthy subjects were selected. Results In this study, 56.4% of participants were female, and the mean age was 48.60 ± 9.35 years. Age, heart rate in females, and QT interval in males were significantly higher. The smallest slopes of QTc/RR analysis were related to Fridericia in males and Rautaharju followed by Fridericia in females. Thus, Fridericia’s formula was identified as the best mathematical formula and Bazett’s as the worst in males. In the sensitivity analysis, however, Bazett’s formula had the highest sensitivity (23.07%) among all others in cardiac mortality. Also, in the Cox regression analysis, Bazett’s formula was better than Fridericia’s and was identified as the best significant cardiac mortality predictor (Hazard ratio: 4.31, 95% CI 1.73–10.74, p value = 0.002). Conclusion Fridericia was the best correction formula based on mathematical methods. Bazett’s formula despite its poorest performance in mathematical methods, was the best one for cardiac mortality prediction. Practically, it is suggested that physicians use QTcB for a better evaluation of cardiac mortality risk. However, in population-based studies, QTcFri might be the one to be used by researchers. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-022-02502-2.
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Affiliation(s)
- Mohammad Hosein Yazdanpanah
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Ibn-Sina Square, P.O. Box: 74616-86688, Fasa, Fars, Iran.,Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Naghizadeh
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Ibn-Sina Square, P.O. Box: 74616-86688, Fasa, Fars, Iran
| | | | - Mojtaba Farjam
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Ibn-Sina Square, P.O. Box: 74616-86688, Fasa, Fars, Iran.
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22
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Allegaert K, Salaets T, Ward RM, Annaert P, Smits A. QTc Intervals Are Prolonged in Late Preterm and Term Neonates during Therapeutic Hypothermia but Normalize Afterwards. CHILDREN (BASEL, SWITZERLAND) 2021; 8:1153. [PMID: 34943349 PMCID: PMC8700422 DOI: 10.3390/children8121153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 12/05/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are anecdotal reports on reversible QTc prolongation during therapeutic hypothermia (TH) for moderate to severe neonatal encephalopathy after asphyxia. As the QTc interval is a relevant biomarker for pharmacovigilance during medication development, a structured search and review on published neonatal QTc values to generate reference values is warranted to facilate medication development in this specific population. METHODS A structured search and literature assessment (PubMed, Embase, and Google Scholar) with 'Newborn/Infant, QT and hypothermia' was conducted (October 2021). Retrieved individual values were converted to QTc (Bazett) over postnatal age (day 1-7). RESULTS We retrieved 94 QTc intervals (during TH (n = 50, until day 3) or subsequent normothermia (n = 44, day 4-7)) in 33 neonates from 6 publications. The median (range) of QTc intervals during TH was 508 (430-678), and 410 (317-540) ms afterwards (difference 98 ms, or +28 ms/°C decrease). Four additional cohorts (without individual QTc intervals) confirmed the pattern and magnitude of the effect of body temperature on the QTc interval. CONCLUSIONS We highlighted a relevant non-maturational covariate (°C dependent TH) and generated reference values for the QTc interval in this specific neonatal subpopulation. This knowledge on QTc during TH should be considered and integrated in neonatal medication development.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium;
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium;
- Department of Clinical Pharmacy, Erasmus MC, Postbus 2040, 3000 GA Rotterdam, The Netherlands
| | - Thomas Salaets
- Division of Pediatric Cardiology, Department of Pediatrics, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Robert M. Ward
- Division of Neonatology and Clinical Pharmacology, Department of Pediatrics, University of Utah, Salt Lake City, UT 84132, USA;
| | - Pieter Annaert
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium;
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium;
- Neonatal Intensive Care Unit, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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23
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Huynh C, Brussee JM, Pouzol L, Fonseca M, Meyer Zu Schwabedissen HE, Dingemanse J, Sidharta PN. Target engagement of the first-in-class CXCR7 antagonist ACT-1004-1239 following multiple-dose administration in mice and humans. Biomed Pharmacother 2021; 144:112363. [PMID: 34794236 DOI: 10.1016/j.biopha.2021.112363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/06/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022] Open
Abstract
Antagonism of the chemokine receptor CXCR7 has shown promising effects in diverse disease areas through modulation of its ligands, CXCL11 and CXCL12. Preclinical data of the first-in-class CXCR7 antagonist, ACT-1004-1239, showed efficacy in animal models of multiple sclerosis and acute lung injury. In healthy humans, single-dose administration of ACT-1004-1239 revealed a favorable clinical profile. Here, we report the target engagement of ACT-1004-1239 in healthy mice and humans after multiple doses using CXCL11 and CXCL12 as biomarkers. In addition, safety/tolerability, concentration-QTc relationship, and pharmacokinetics (PK) were assessed in a randomized, double-blind, placebo-controlled Phase 1 clinical study. Multiple-dose ACT-1004-1239 dose-dependently increased CXCL12 plasma concentration across the investigated dose range in mice and humans (mice: 1-100 mg/kg b.i.d.; humans: 30-200 mg o.d.) when compared to vehicle/placebo demonstrating target engagement. Mouse and human PK/PD models predicted that CXCL12 concentration approached a plateau within these dose ranges. In humans, ACT-1004-1239 was rapidly absorbed (tmax: 1.75-3.01 h) and the terminal t1/2 was approximately 19 h. Steady-state conditions were reached by Day 3 with an accumulation index of 1.2. Female subjects had overall higher exposure compared to males. Multiple-dose ACT-1004-1239 was well tolerated up to 200 mg once daily in humans. There was no evidence of ACT-1004-1239-mediated QTc interval prolongation. Overall, multiple oral doses of ACT-1004-1239 showed target engagement with CXCR7 in healthy mice and humans, therefore, assessment of CXCL12 as translational tool for further investigations in patients is warranted. Favorable safety/tolerability and PK profiles allow for further clinical development.
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Affiliation(s)
- Christine Huynh
- Idorsia Pharmaceuticals Ltd, Department of Clinical Pharmacology, 4123 Allschwil, Switzerland; Biopharmacy, Department of Pharmaceutical Sciences, University of Basel, 4056 Basel, Switzerland.
| | - Janneke M Brussee
- Idorsia Pharmaceuticals Ltd, Department of Clinical Pharmacology, 4123 Allschwil, Switzerland
| | - Laetitia Pouzol
- Idorsia Pharmaceuticals Ltd, Department of Pharmacology Immunology, 4123 Allschwil, Switzerland
| | - Marlene Fonseca
- BlueClinical Phase 1, Hospital de Prelada, 4250-449 Porto, Portugal
| | | | - Jasper Dingemanse
- Idorsia Pharmaceuticals Ltd, Department of Clinical Pharmacology, 4123 Allschwil, Switzerland
| | - Patricia N Sidharta
- Idorsia Pharmaceuticals Ltd, Department of Clinical Pharmacology, 4123 Allschwil, Switzerland
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24
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Prediction of arrhythmia susceptibility through mathematical modeling and machine learning. Proc Natl Acad Sci U S A 2021; 118:2104019118. [PMID: 34493665 DOI: 10.1073/pnas.2104019118] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 01/08/2023] Open
Abstract
At present, the QT interval on the electrocardiographic (ECG) waveform is the most common metric for assessing an individual's susceptibility to ventricular arrhythmias, with a long QT, or, at the cellular level, a long action potential duration (APD) considered high risk. However, the limitations of this simple approach have long been recognized. Here, we sought to improve prediction of arrhythmia susceptibility by combining mechanistic mathematical modeling with machine learning (ML). Simulations with a model of the ventricular myocyte were performed to develop a large heterogenous population of cardiomyocytes (n = 10,586), and we tested each variant's ability to withstand three arrhythmogenic triggers: 1) block of the rapid delayed rectifier potassium current (IKr Block), 2) augmentation of the L-type calcium current (ICaL Increase), and 3) injection of inward current (Current Injection). Eight ML algorithms were trained to predict, based on simulated AP features in preperturbed cells, whether each cell would develop arrhythmic dynamics in response to each trigger. We found that APD can accurately predict how cells respond to the simple Current Injection trigger but cannot effectively predict the response to IKr Block or ICaL Increase. ML predictive performance could be improved by incorporating additional AP features and simulations of additional experimental protocols. Importantly, we discovered that the most relevant features and experimental protocols were trigger specific, which shed light on the mechanisms that promoted arrhythmia formation in response to the triggers. Overall, our quantitative approach provides a means to understand and predict differences between individuals in arrhythmia susceptibility.
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25
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Cantet G, Berges A, O'Sullivan R, Cohen-Rabbie S, Dota C, Dubois V, Benoist GE, Tomkinson H, Rekić D, Parkinson J, Schalkwijk S. Concentration-QT modelling in early clinical oncology settings: Simulation evaluation of performance. Br J Clin Pharmacol 2021; 88:1010-1019. [PMID: 34416045 DOI: 10.1111/bcp.15047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 11/27/2022] Open
Abstract
AIMS Concentration-QT modelling (C-QTc) of first-in-human data has been rapidly adopted as the primary evaluation of QTc interval prolongation risk. Here, we evaluate the performance of C-QTc in early oncology settings (i.e., patients, no placebo or supratherapeutic dose, 3 + 3 designs). METHODS C-QTc performance was evaluated across three oncology scenarios using a simulation-estimation approach: (scen1) typical dose-escalation testing six dose levels (n = 21); (scen2) small dose-escalation testing two dose levels (n = 9); (scen3) expansion cohorts at one dose level (n = 6-140). True ΔΔQTc effects ranged from 3 ms ("no effect") to 20 ms ("large effect"). Performance was assessed based on the upper limit of the ΔQTc two-sided 90% CI against a threshold of 10 or 20 ms. RESULTS The performance against the 10 ms threshold was limited based on C-QTc data from typical dose escalation (scen1) and acceptable performance was observed only for relatively large expansions (n ≥ 45; scen3). Performance against the 20 ms threshold was acceptable based on C-QTc data from a typical dose escalation (scen1) or dose expansion cohort n > 10 (scen3). In general, pooling C-QTc data from dose escalation and expansion cohorts substantially improved the performance and reduced the ΔQTc 90% CI width. CONCLUSION C-QTc performance appeared limited using a 10 ms threshold, but acceptable against a 20 ms threshold. Selection of threshold may be informed by the benefit-risk balance in a specific disease area. Acceptable precision (i.e., confidence intervals) of the estimated ΔQTc, regardless of its magnitude, can be facilitated by pooling data from dose escalation and expansion cohorts.
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Affiliation(s)
- Gael Cantet
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Alienor Berges
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK.,Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline, UK
| | - Rhianna O'Sullivan
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Sarit Cohen-Rabbie
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Corina Dota
- Cardiovascular Safety Centre of Excellence, CMO, Oncology R&D, Gothenburg, Sweden
| | - Vincent Dubois
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | | | - Helen Tomkinson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Dinko Rekić
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Joanna Parkinson
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Gothenburg, Sweden
| | - Stein Schalkwijk
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology and Safety Sciences, R&D, AstraZeneca, Cambridge, UK.,Clinical Pharmacology Modelling and Simulation, GlaxoSmithKline, UK
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26
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Garg L, Fradley MG. QT prolongation and cancer therapeutics: a coming Tempest or Much Ado About Nothing? Eur Heart J 2021; 42:3929-3931. [PMID: 34387663 DOI: 10.1093/eurheartj/ehab483] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lohit Garg
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael G Fradley
- Section of Cardiac Electrophysiology, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Cardio-Oncology Center of Excellence, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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27
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Dopamine Receptor Antagonists for the Prevention and Treatment of Postoperative Nausea and Vomiting. J Perianesth Nurs 2021; 36:199-202. [PMID: 33812503 DOI: 10.1016/j.jopan.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 12/28/2020] [Indexed: 11/23/2022]
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28
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Lester RM. Update on ICH E14/S7B Cardiac Safety Regulations: The Expanded Role of Preclinical Assays and the "Double-Negative" Scenario. Clin Pharmacol Drug Dev 2021; 10:964-973. [PMID: 34331518 PMCID: PMC8456868 DOI: 10.1002/cpdd.1003] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/22/2021] [Indexed: 11/09/2022]
Abstract
For nearly 2 decades, regulators have adopted a harmonized approach to drug development, which has succeeded in bringing new pharmaceuticals to market without significant cardiac liability. Ushered in by technological advancements and better understanding of cellular electrophysiology, the initial paradigm detailed in the 2005 International Conference for Harmonization E14 and S7B documents has undergone evolutionary changes designed to streamline drug development and improve regulatory decision‐making and product labeling. The intent of this review is to summarize the new US Food and Drug Administration (FDA) Question and Answer update from August 2020 and key messaging from a subsequent FDA webinar describing best practices for preclinical and clinical data integration into a QT risk prediction model.
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29
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Ding J, Liu W, Guan H, Feng Y, Bao Y, Li H, Wang X, Zhou Z, Chen Z. Corrected QT interval in hospitalized patients with coronavirus disease 2019: Focus on drugs therapy. Medicine (Baltimore) 2021; 100:e26538. [PMID: 34260531 PMCID: PMC8284736 DOI: 10.1097/md.0000000000026538] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 06/15/2021] [Indexed: 12/22/2022] Open
Abstract
Corrected QT (QTc) interval prolongation has been associated with poor patient prognosis. In this study, we assessed the effects of different drugs and cardiac injury on QTc interval prolongation in patients with coronavirus disease 2019 (COVID-19).The study cohort consisted of 395 confirmed COVID-19 cases from the Wuhan Union Hospital West Campus. All hospitalized patients were treated with chloroquine/hydroxychloroquine (CQ/HCQ), lopinavir/ritonavir (LPV/r), quinolones, interferon, Arbidol, or Qingfei Paidu decoction (QPD) and received at least 1 electrocardiogram after drug administration.Fifty one (12.9%) patients exhibited QTc prolongation (QTc ≥ 470 ms). QTc interval prolongation was associated with COVID-19 severity and mortality (both P < .001). Administration of CQ/HCQ (odds ratio [OR], 2.759; 95% confidence interval [CI], 1.318-5.775; P = .007), LPV/r (OR, 2.342; 95% CI, 1.152-4.760; P = .019), and quinolones (OR, 2.268; 95% CI, 1.171-4.392; P = .015) increased the risk of QTc prolongation. In contrast, the administration of Arbidol, interferon, or QPD did not increase the risk of QTc prolongation. Notably, patients treated with QPD had a shorter QTc duration than those without QPD treatment (412.10 [384.39-433.77] vs 420.86 [388.19-459.58]; P = .042). The QTc interval was positively correlated with the levels of cardiac biomarkers (creatine kinase-MB fraction [rho = 0.14, P = .016], high-sensitivity troponin I [rho = .22, P < .001], and B-type natriuretic peptide [rho = 0.27, P < .001]).In conclusion, QTc prolongation was associated with COVID-19 severity and mortality. The risk of QTc prolongation was higher in patients receiving CQ/HCQ, LPV/r, and quinolones. QPD had less significant effects on QTc prolongation than other antiviral agents.
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30
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Al-Tweigeri T, Dent S, Al Sayed A, Mohty D, Suleman K, Ajarim D, Raef H, Echahidi N. Using the appropriate formula for QT measurement can save lives. Hematol Oncol Stem Cell Ther 2021; 15:79-82. [PMID: 34181897 DOI: 10.1016/j.hemonc.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/05/2021] [Indexed: 10/21/2022] Open
Abstract
CDK 4/6 inhibitors, in combination with endocrine therapy, are the standard of care for patients with endocrine-sensitive advanced breast cancer. This class of drug, however, is associated with QT prolongation, which serves as a surrogate marker for Torsades de Pointes (TdP), a cause of life-threatening ventricular arrhythmias and sudden cardiac death. The ICH E14 guidance document uses the Bazett formula for reporting of cardio-dynamic and safety ECG data in clinical trials. While there is substantial familiarity with the Bazett (QTcB) formula (QT/(RR) 1/2), the Fridericia (QTcF) formula (QT/(RR) 1/3 ) is preferred in the cancer population as it is often more accurate at heart rate extreme. Accordingly, the Fridericia formula is currently the standard adopted by the FDA when submitting QT data for review. At the King Faisal Specialist Hospital and Research Center, a total of 82 patients with advanced breast cancer, had a baseline ECG on day 1 before the initiation of ribociclib based therapy. Of the enrolled 82 patients, 19 (23%) were initially excluded from receiving ribociclib based due to a prolonged QTc >450ms, however, when the QTc-interval was manually measured and recalculated using Fridericia and Framingham formulae using MDCalC (https//:www.mdcalc.com),17 of 19 patients successfully received their treatment without any arrhythmogenic effects. Repeat ECG on day14, and day 1 of cycle 2 demonstrated that none of these patients had QTc exceeding 480 ms. Our data highlights the complexities of evaluating the QT interval in oncology patients and the utility of the Fridericia/Framingham formulae in this population. Given these findings, we recommend the adoption of the Fridericia or Framingham formulae for measurement of QTc in all cancer patients exposed to potentially QT-prolonging cancer therapy.
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Affiliation(s)
- Taher Al-Tweigeri
- Medical Oncology Section, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia.
| | - Susan Dent
- Division of Medical Oncology, Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Adher Al Sayed
- Medical Oncology Section, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Dania Mohty
- Heart Center Adult Cardiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Kausar Suleman
- Medical Oncology Section, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Dahish Ajarim
- Medical Oncology Section, Oncology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hussein Raef
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Najmeddine Echahidi
- Heart Center Adult Cardiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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31
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Community pharmacist use of mobile
ECG
to inform drug therapy decision making for patients receiving
QTc
prolonging medications. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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32
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Rubin GA, Desai AD, Chai Z, Wang A, Chen Q, Wang AS, Kemal C, Baksh H, Biviano A, Dizon JM, Yarmohammadi H, Ehlert F, Saluja D, Rubin DA, Morrow JP, Avula UMR, Berman JP, Kushnir A, Abrams MP, Hennessey JA, Elias P, Poterucha TJ, Uriel N, Kubin CJ, LaSota E, Zucker J, Sobieszczyk ME, Schwartz A, Garan H, Waase MP, Wan EY. Cardiac Corrected QT Interval Changes Among Patients Treated for COVID-19 Infection During the Early Phase of the Pandemic. JAMA Netw Open 2021; 4:e216842. [PMID: 33890991 PMCID: PMC8065381 DOI: 10.1001/jamanetworkopen.2021.6842] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Critical illness, a marked inflammatory response, and viruses such as SARS-CoV-2 may prolong corrected QT interval (QTc). OBJECTIVE To evaluate baseline QTc interval on 12-lead electrocardiograms (ECGs) and ensuing changes among patients with and without COVID-19. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 3050 patients aged 18 years and older who underwent SARS-CoV-2 testing and had ECGs at Columbia University Irving Medical Center from March 1 through May 1, 2020. Patients were analyzed by treatment group over 5 days, as follows: hydroxychloroquine with azithromycin, hydroxychloroquine alone, azithromycin alone, and neither hydroxychloroquine nor azithromycin. ECGs were manually analyzed by electrophysiologists masked to COVID-19 status. Multivariable modeling evaluated clinical associations with QTc prolongation from baseline. EXPOSURES COVID-19, hydroxychloroquine, azithromycin. MAIN OUTCOMES AND MEASURES Mean QTc prolongation, percentage of patients with QTc of 500 milliseconds or greater. RESULTS A total of 965 patients had more than 2 ECGs and were included in the study, with 561 (58.1%) men, 198 (26.2%) Black patients, and 191 (19.8%) aged 80 years and older. There were 733 patients (76.0%) with COVID-19 and 232 patients (24.0%) without COVID-19. COVID-19 infection was associated with significant mean QTc prolongation from baseline by both 5-day and 2-day multivariable models (5-day, patients with COVID-19: 20.81 [95% CI, 15.29 to 26.33] milliseconds; P < .001; patients without COVID-19: -2.01 [95% CI, -17.31 to 21.32] milliseconds; P = .93; 2-day, patients with COVID-19: 17.40 [95% CI, 12.65 to 22.16] milliseconds; P < .001; patients without COVID-19: 0.11 [95% CI, -12.60 to 12.81] milliseconds; P = .99). COVID-19 infection was independently associated with a modeled mean 27.32 (95% CI, 4.63-43.21) millisecond increase in QTc at 5 days compared with COVID-19-negative status (mean QTc, with COVID-19: 450.45 [95% CI, 441.6 to 459.3] milliseconds; without COVID-19: 423.13 [95% CI, 403.25 to 443.01] milliseconds; P = .01). More patients with COVID-19 not receiving hydroxychloroquine and azithromycin had QTc of 500 milliseconds or greater compared with patients without COVID-19 (34 of 136 [25.0%] vs 17 of 158 [10.8%], P = .002). Multivariable analysis revealed that age 80 years and older compared with those younger than 50 years (mean difference in QTc, 11.91 [SE, 4.69; 95% CI, 2.73 to 21.09]; P = .01), severe chronic kidney disease compared with no chronic kidney disease (mean difference in QTc, 12.20 [SE, 5.26; 95% CI, 1.89 to 22.51; P = .02]), elevated high-sensitivity troponin levels (mean difference in QTc, 5.05 [SE, 1.19; 95% CI, 2.72 to 7.38]; P < .001), and elevated lactate dehydrogenase levels (mean difference in QTc, 5.31 [SE, 2.68; 95% CI, 0.06 to 10.57]; P = .04) were associated with QTc prolongation. Torsades de pointes occurred in 1 patient (0.1%) with COVID-19. CONCLUSIONS AND RELEVANCE In this cohort study, COVID-19 infection was independently associated with significant mean QTc prolongation at days 5 and 2 of hospitalization compared with day 0. More patients with COVID-19 had QTc of 500 milliseconds or greater compared with patients without COVID-19.
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Affiliation(s)
- Geoffrey A. Rubin
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Amar D. Desai
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Zilan Chai
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Aijin Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Qixuan Chen
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Amy S. Wang
- Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Cameron Kemal
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Haajra Baksh
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Angelo Biviano
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jose M. Dizon
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Hirad Yarmohammadi
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Frederick Ehlert
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Deepak Saluja
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - David A. Rubin
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - John P. Morrow
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Uma Mahesh R. Avula
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jeremy P. Berman
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Alexander Kushnir
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Mark P. Abrams
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jessica A. Hennessey
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Pierre Elias
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Timothy J. Poterucha
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Christine J. Kubin
- Division of Infectious Disease, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Elijah LaSota
- Division of Infectious Disease, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Jason Zucker
- Division of Infectious Disease, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Magdalena E. Sobieszczyk
- Division of Infectious Disease, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Allan Schwartz
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Hasan Garan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Marc P. Waase
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Elaine Y. Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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Park JW, Kim KA, Park JY. Effect of Memantine on QT/QTc Interval in a Healthy Korean Population. Clin Pharmacol Drug Dev 2021; 10:1209-1215. [PMID: 33761171 DOI: 10.1002/cpdd.931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Studies on the effects of memantine on QT prolongation have yielded conflicting results. For a long time, memantine was reported to be a safe drug without QT prolongation; however, several case studies have reported memantine-induced QT prolongation in Alzheimer's patients. This study evaluated the relationship between memantine blood levels, and QT interval changes. Over a 2-week period, we orally administered 20 mg of memantine daily to achieve a steady state in 57 healthy Korean subjects. We measured and analyzed the QT interval and blood memantine concentrations simultaneously before and after treatment, as well as 2 weeks after the last dosing. Correlation analysis was done between blood memantine level and QT interval. No serious adverse events occurred during the study period. Repeated dosing of memantine did not show clinically significant QT interval changes after treatment. Regression analysis was performed based on the results; there was no statistical association between memantine blood level and QT prolongation. In conclusion, the results of the present study demonstrated no clinically significant changes in the QT interval with therapeutic blood levels of memantine.
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Affiliation(s)
- Jin-Woo Park
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyoung-Ah Kim
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Ji-Young Park
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
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Saponara S, Fusi F, Iovinelli D, Ahmed A, Trezza A, Spiga O, Sgaragli G, Valoti M. Flavonoids and hERG channels: Friends or foes? Eur J Pharmacol 2021; 899:174030. [PMID: 33727059 DOI: 10.1016/j.ejphar.2021.174030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 02/28/2021] [Accepted: 03/11/2021] [Indexed: 01/24/2023]
Abstract
The cardiac action potential is regulated by several ion channels. Drugs capable to block these channels, in particular the human ether-à-go-go-related gene (hERG) channel, also known as KV11.1 channel, may lead to a potentially lethal ventricular tachyarrhythmia called "Torsades de Pointes". Thus, evaluation of the hERG channel off-target activity of novel chemical entities is nowadays required to safeguard patients as well as to avoid attrition in drug development. Flavonoids, a large class of natural compounds abundantly present in food, beverages, herbal medicines, and dietary food supplements, generally escape this assessment, though consumed in consistent amounts. Continuously growing evidence indicates that these compounds may interact with the hERG channel and block it. The present review, by examining numerous studies, summarizes the state-of-the-art in this field, describing the most significant examples of direct and indirect inhibition of the hERG channel current operated by flavonoids. A description of the molecular interactions between a few of these natural molecules and the Rattus norvegicus channel protein, achieved by an in silico approach, is also presented.
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Affiliation(s)
- Simona Saponara
- Dipartimento di Scienze della Vita, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy
| | - Fabio Fusi
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy.
| | - Daniele Iovinelli
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy
| | - Amer Ahmed
- Dipartimento di Scienze della Vita, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy
| | - Alfonso Trezza
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy
| | - Ottavia Spiga
- Dipartimento di Biotecnologie, Chimica e Farmacia, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy
| | - Giampietro Sgaragli
- Dipartimento di Scienze della Vita, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy; Accademia Italiana della Vite e del Vino, via Logge degli Uffizi Corti 1, 50122, Florence, Italy
| | - Massimo Valoti
- Dipartimento di Scienze della Vita, Università degli Studi di Siena, via A. Moro 2, 53100, Siena, Italy
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Fung KW, Baye F, Kapusnik-Uner J, McDonald CJ. Using Medicare Data to Assess the Proarrhythmic Risk of Non-Cardiac Treatment Drugs that Prolong the QT Interval in Older Adults: An Observational Cohort Study. Drugs Real World Outcomes 2021; 8:173-185. [PMID: 33569737 PMCID: PMC7875170 DOI: 10.1007/s40801-021-00230-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction Serious cardiac arrhythmias caused by QT-prolonging drugs are difficult to predict based on physiological measurement and pre-approval clinical trials. Post-marketing surveillance and monitoring are important to generate safety data. Objectives To assess whether an observational study using Medicare claims data can detect the arrhythmogenic risk of QT-prolonging drugs. Methods We identified 17 QT-prolonging drugs with known risk of torsades des pointes (TdP) that were not used to treat cardiac arrhythmias. Amoxicillin and four serotonin-norepinephrine reuptake inhibitors (SNRIs) were used as controls. De-identified claims data of 1.2 million Medicare beneficiaries were accessed. Two separate Cox regressions were done for short-term and chronic-use drugs. The primary outcome was a composite of ventricular arrhythmias and/or sudden death, identified by ICD diagnostic codes. We explored the independent effect of each study drug on the outcomes. Other covariates included patient demographics, comorbidities, and known risk factors for drug-induced cardiac arrhythmia. Results We were able to detect increased risk in 14 of 17 study drugs (82.3%), and none of the control drugs. Among the fluoroquinolones, ciprofloxacin was the safest. Azithromycin and clarithromycin were relatively safe compared to erythromycin. Compared to SNRIs, both citalopram and escitalopram had increased risk, more so with escitalopram than citalopram. Comorbidities associated with increased risk included ischemic heart disease, electrolyte imbalance, bradycardia, acute myocardial infarction, heart failure, and chronic kidney and liver disease. Conclusion Medicare data can be utilized for post-marketing surveillance and monitoring of the proarrhythmic risk of QT-prolonging drugs in older adults. Supplementary Information The online version contains supplementary material available at 10.1007/s40801-021-00230-1.
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Affiliation(s)
- Kin Wah Fung
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, U.S. National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA.
| | - Fitsum Baye
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, U.S. National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
| | - Joan Kapusnik-Uner
- First Databank. Inc., San Francisco, CA, USA.,University of California, San Francisco, CA, USA
| | - Clement J McDonald
- Lister Hill National Center for Biomedical Communications, National Library of Medicine, U.S. National Institutes of Health, 8600 Rockville Pike, Bethesda, MD, 20894, USA
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Visone R, Ugolini GS, Cruz-Moreira D, Marzorati S, Piazza S, Pesenti E, Redaelli A, Moretti M, Occhetta P, Rasponi M. Micro-electrode channel guide (µECG) technology: an online method for continuous electrical recording in a human beating heart-on-chip. Biofabrication 2021; 13. [PMID: 33561845 DOI: 10.1088/1758-5090/abe4c4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/09/2021] [Indexed: 12/19/2022]
Abstract
Cardiac toxicity still represents a common adverse outcome causing drug attrition and post-marketing withdrawal. The development of relevant in vitro models resembling the human heart recently opened the path towards a more accurate detection of drug-induced human cardiac toxicity early in the drug development process. Organs-on-chip (OoC) have been proposed as promising tools to recapitulate in vitro the key aspects of the in vivo cardiac physiology and to provide a means to directly analyze functional readouts. In this scenario, a new device capable of continuous monitoring of electrophysiological signals from functional in vitro human hearts-on-chip is here presented. The development of cardiac microtissues was achieved through a recently published method to control the mechanical environment, while the introduction of a technology consisting in micro-electrode coaxial guides (µECG) allowed to conduct direct and non-destructive electrophysiology studies. The generated human cardiac microtissues exhibited synchronous spontaneous beating, as demonstrated by multi-point and continuous acquisition of cardiac field potential, and expression of relevant genes encoding for cardiac ion-channels. A proof-of-concept pharmacological validation on 3 drugs proved the proposed model to potentially be a powerful tool to evaluate functional cardiac toxicity.
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Affiliation(s)
- Roberta Visone
- Politecnico di Milano Dipartimento di Elettronica Informazione e Bioingegneria, Via Ponzio 34/5, Milano, Lombardia, 20133, ITALY
| | - Giovanni Stefano Ugolini
- Politecnico di Milano Dipartimento di Elettronica Informazione e Bioingegneria, Via Ponzio 34/5, Milano, Lombardia, 20133, ITALY
| | - Daniela Cruz-Moreira
- Politecnico di Milano Dipartimento di Elettronica Informazione e Bioingegneria, Via Ponzio 34/5, Milano, Lombardia, 20133, ITALY
| | - Simona Marzorati
- Translational Medicine, Accelera Srl, via Pasteur, Nerviano, Nerviano, MI, 20100, ITALY
| | - Stefano Piazza
- BiomimX Srl, Via Giovanni Durando 38/A, Milan, 20158, ITALY
| | | | - Alberto Redaelli
- Politecnico di Milano Dipartimento di Elettronica Informazione e Bioingegneria, Via Ponzio 34/5, Milano, Lombardia, 20133, ITALY
| | - Matteo Moretti
- Cell and Tissue Engineering Lab, IRCCS Galeazzi Orthopaedic Institute, via R Galeazzi 4, Milan, 20161, ITALY
| | - Paola Occhetta
- Politecnico di Milano Dipartimento di Elettronica Informazione e Bioingegneria, Via Ponzio 34/5, Milano, Lombardia, 20133, ITALY
| | - Marco Rasponi
- Politecnico di Milano Dipartimento di Elettronica Informazione e Bioingegneria, Via Ponzio 34/5, Milano, Lombardia, 20133, ITALY
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Rosenblum AL, Dremonas AC, Stockholm SC, Biondi NL. A Retrospective Analysis of Hospital Electrocardiogram Auto-Populated QT Interval Calculation. Cureus 2020; 12:e9317. [PMID: 32714713 PMCID: PMC7376804 DOI: 10.7759/cureus.9317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background The current electrocardiogram (ECG) standard for rate correction of the QT interval (QTc) is a power function known as the Bazett formula (QTcB). QTc formulae are either power functions or linear functions. QTcB is known to lack reliability, as heart rate (HR) rises from or falls below 60 beats per minute (bpm). The American Heart Association (AHA), the American College of Cardiology Foundation (ACCF), and the Heart Rhythm Society (HRS) have recommended using other formulae in place of QTcB since 2009. The Epic Electronic Health Record System (Epic Systems Corporation, Verona, WI) automatically populates the Fridericia formula (QTcFri) on hospital ECG reports without any provider calculation. Methods We aimed to retrospectively investigate the effect of QTcFri on one year of ECGs in the Epic Electronic Health Record (EHR) at a single tertiary care center. Inclusion criteria for ECG reports specified HR 60-120 bpm without QRS duration > 120 ms. Gathered data from Epic EHR ECG reports included patient age, sex, HR, QRS duration (QRSd), QT interval, QTcB, and QTcFri. EHR documented 61,946 ECG reports for the year, with 44,566 meeting criteria for inclusion. General statistical methods included range, median, mean, and standard deviation. Confidence intervals were assessed to maintain the fidelity of analysis. The normality of data distribution was assessed with Kolmogorov-Smirnov testing. The Wilcoxon rank-sum test was then performed to confirm a statistically significant difference between the Bazett and Fridericia formulae. The ∆QTc analysis was conducted on prolonged QTc (males > 450 ms; females > 460 ms) and severely prolonged QTc > 500 ms data subsets. A value of p<0.05 was interpreted as significant. Statistical analysis was performed using SPSS statistical software (IBM Statistics, v. 26; IBM Corp, Armonk, NY). Results The 44,566 ECG reports demonstrated 57% female gender and a mean age of 57 ± 17.5 years. The mean HR was 83 ± 14.7 bpm and the mean ∆QTc was 23 ± 12.9 ms shorter with QTcFri. Mean data showed minimal variation between sexes: age, heart rate, uncorrected QT, QTcB, QTcFri, and ∆QTc varied by less than 2%. Mean QRS varied by 4% between sexes. The Wilcoxon rank-sum test revealed 44,127 ranks with a negative difference, 0 ranks with a positive difference, and 439 ties, p <0.001 (99% CI: 22.5 ms, 23.0 ms). QTcB identified 37.4% (16665/44566) ECGs prolonged. Using QTcFri, 21% (9371/44566) of the total ECGs corrected to normal QTc (<450 ms (men) and 460 ms (women)). QTcFri use reduced the number of ECG reports with QTc > 500 ms by 57.3%. A total of 125 ECG reports, 117 females and eight males, corrected to normal gender-specific QTc with QTcFri. The mean decrease in QTc with the Fridericia formula when QTcB > 500 ms was 31 ± 14.5 ms (99% CI: 30.4 ms, 31.7 ms). Conclusion Our data from the Wilcoxon rank-sum analysis indicated that the EHR QTcFri analysis yields a statistically significant difference (p < 0.001) in QTc calculation of 22 ms over 44,566 ECG reports. The data showed a 21% reduction in inaccurately documented test results. The utilization of this resource will provide the most accurate and clinically relevant data to inform clinical decision-making. Accurate QT interval calculation will better inform downstream clinical decision-making through a wider scope of therapeutic intervention. This analysis is readily available to clinicians without calculation and its awareness will benefit patient care.
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Affiliation(s)
- Adam L Rosenblum
- Internal Medicine, Cape Fear Valley Health System, Fayetteville, USA.,Internal Medicine, Campbell University School of Osteopathic Medicine, Buies Creek, USA
| | - Ariana C Dremonas
- Internal Medicine, Cape Fear Valley Health System, Fayetteville, USA.,Internal Medicine, Campbell University School of Osteopathic Medicine, Buies Creek, USA
| | - Scott C Stockholm
- Internal Medicine, Cape Fear Valley Health System, Fayetteville, USA.,Internal Medicine, Campbell University School of Osteopathic Medicine, Buies Creek, USA
| | - Nicholas L Biondi
- Internal Medicine, Cape Fear Valley Health System, Fayetteville, USA.,Internal Medicine, Campbell University School of Osteopathic Medicine, Buies Creek, USA
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Srivastava S, Mennemeier M, Chaudhary JA. A Randomized Placebo Controlled Clinical Trial Demonstrating Safety & Efficacy of EnXtra ® in Healthy Adults. J Am Coll Nutr 2020; 40:224-236. [PMID: 32412358 DOI: 10.1080/07315724.2020.1753129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: The present randomized, placebo-controlled study aimed to assess the long-term safety and perceivable mental acuity benefits of EnXtra® in healthy individuals.Methods: Study participants were administered EnXtra® with or without caffeine for a period of 12 weeks. The cardiovascular safety was evaluated by assessing change in QT interval, blood pressure and heart rate. Further, other efficacy variables evaluated were change in perceived alertness and calmness by Bond and Lader mood scales, Sleep disturbance by Pittsburgh sleep quality Index and daytime sleepiness by Epworth sleepiness scale.Results: None of the study group showed any significant change in the ECG or haemodynamic parameters as compared to baseline (p > 0.05). Post consumption, alertness and calmness scores were significantly increased in the EnXtra®, and EnXtra® plus caffeine group (p < 0.001) as compared to placebo. Daytime sleep scores decreased in the EnXtra® group however change was not significant. Sleep quality remained undisturbed in all three arms.Conclusion: The findings demonstrated the psychostimulant efficacy of EnXtra® with no safety concerns on long-term usage.
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Affiliation(s)
- Shalini Srivastava
- Department of Clinical development, Enovate Biolife, Mumbai, Maharashtra, India
| | - Mark Mennemeier
- Neurobiology and Developmental Sciences, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Thioridazine Induces Cardiotoxicity via Reactive Oxygen Species-Mediated hERG Channel Deficiency and L-Type Calcium Channel Activation. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:3690123. [PMID: 32064022 PMCID: PMC6998749 DOI: 10.1155/2020/3690123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/01/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Abstract
Thioridazine (THIO) is a phenothiazine derivative that is mainly used for the treatment of psychotic disorders. However, cardiac arrhythmias especially QT interval prolongation associated with the application of this compound have received serious attention after its introduction into clinical practice, and the mechanisms underlying the cardiotoxicity induced by THIO have not been well defined. The present study was aimed at exploring the long-term effects of THIO on the hERG and L-type calcium channels, both of which are relevant to the development of QT prolongation. The hERG current (I hERG) and the calcium current (I Ca-L) were measured by patch clamp techniques. Protein levels were analyzed by Western blot, and channel-chaperone interactions were determined by coimmunoprecipitation. Reactive oxygen species (ROS) were determined by flow cytometry and laser scanning confocal microscopy. Our results demonstrated that THIO induced hERG channel deficiency but did not alter channel kinetics. THIO promoted ROS production and stimulated endoplasmic reticulum (ER) stress and the related proteins. The ROS scavenger N-acetyl cysteine (NAC) significantly attenuated hERG reduction induced by THIO and abolished the upregulation of ER stress marker proteins. Meanwhile, THIO increased the degradation of hERG channels via disrupting hERG-Hsp70 interactions. The disordered hERG proteins were degraded in proteasomes after ubiquitin modification. On the other hand, THIO increased I Ca-L density and intracellular Ca2+ ([Ca2+]i) in neonatal rat ventricular cardiomyocytes (NRVMs). The specific CaMKII inhibitor KN-93 attenuated the intracellular Ca2+ overload, indicating that ROS-mediated CaMKII activation promoted calcium channel activation induced by THIO. Optical mapping analysis demonstrated the slowing effects of THIO on cardiac repolarization in mouse hearts. THIO significantly prolonged APD50 and APD90 and increased the incidence of early afterdepolarizations (EADs). In human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs), THIO also resulted in APD prolongation. In conclusion, dysfunction of hERG channel proteins and activation of L-type calcium channels via ROS production might be the ionic mechanisms for QT prolongation induced by THIO.
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Wu J, Wang K, Chen Y, Yuan H, Li L, Zhang J. Concentration-response modeling of ECG data from early-phase clinical studies to assess QT prolongation risk of contezolid (MRX-I), an oxazolidinone antibacterial agent. J Pharmacokinet Pharmacodyn 2019; 46:531-541. [PMID: 31410633 DOI: 10.1007/s10928-019-09650-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 08/05/2019] [Indexed: 02/02/2023]
Abstract
The effects of contezolid (MRX-I, an oxazolidinone antibacterial agent) on cardiac repolarization were evaluated retrospectively using a population modeling approach in a Phase I study incorporating single ascending dose, multiple ascending dose, and food effect assessments. Linear mixed effect models were used to assess the relationships between MRX-I plasma concentrations and QT/QTc/∆QTc (baseline-adjusted), in which different correction methods for heart rate have been included. The upper bound of the one-sided 95% confidence interval (CI) for predicted ∆∆QTc was < 10 ms (ms) at therapeutic doses of MRX-I. Model performance/suitability was determined using diagnostic evaluations, which indicated rationality of one-stage concentration-QT model, as well as C-QT model suggested by Garnett et al. The finding demonstrated that MRX-I may have no clinical effects on the QT interval. Concentration-QT model may be an alternative to conventional thorough QT studies.
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Affiliation(s)
- Junzhen Wu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Kun Wang
- Certara Strategic Consulting China, Shanghai, 200122, China
| | - Yuancheng Chen
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China.,Phase I Unit, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong Yuan
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Li Li
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China.,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China.,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Jing Zhang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China. .,Key Laboratory of Clinical Pharmacology of Antibiotics, National Health and Family Planning Commission, Shanghai, China. .,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China. .,Phase I Unit, Huashan Hospital, Fudan University, Shanghai, China.
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Exposure-response analysis of drug-induced QT interval prolongation in telemetered monkeys for translational prediction to human. J Pharmacol Toxicol Methods 2019; 99:106606. [PMID: 31255745 DOI: 10.1016/j.vascn.2019.106606] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The preclinical in vivo assay for QT prolongation is critical for predicting torsadogenic risk, but still difficult to extrapolate to humans. This study ran preclinical tests in cynomolgus monkeys on seven QT reference drugs containing the drugs used in the IQ-CSRC clinical trial and applied exposure-response (ER) analysis to the data to investigate the potential for translational information on the QT effect. METHODS In each of six participating facilities in the J-ICET project, telemetered monkeys were monitored for 24 h following administration of vehicle or 3 doses of test drugs, and pharmacokinetic profiles at the same doses were evaluated separately. An individual rate-corrected QT interval (QTca) was derived and the vehicle-adjusted change in QTca from baseline (∆∆QTca) was calculated. Then the relationship of concentration to QT effect was evaluated by ER analysis. RESULTS For QT-positive drugs in the IQ-CSRC study (dofetilide, dolasetron, moxifloxacin, ondansetron, and quinine) and levofloxacin, the slope of the total concentration-QTca effect was significantly positive, and the QT-prolonging effect, taken as the upper bound of the confidence interval for predicted ∆∆QTca, was confirmed to exceed 10 ms. The ER slope of the negative drug levocetirizine was not significantly positive and the QTca effect was below 10 ms at observed peak exposure. DISCUSSION Preclinical QT assessment in cynomolgus monkeys combined with ER analysis could identify the small QT effect induced by several QT drugs consistently with the outcomes in humans. Thus, the ER method should be regarded as useful for translational prediction of QT effects in humans.
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