While it can occur spontaneously in the congenital form, there is a wide array of drugs that have been implicated in the prolongation of the qt interval. Qt prolongers with a mean effect of less than 10 ms were labeled with either no or a minimum safety warning in the fda labeling. Drugs home qt prolonging medications there are a number of medications that can prolong the qt interval, which could lead to a dangerous irregular heart rhythm. Total 28 distinct qt prolonging drugs were used in cancer patients. Pharmacokinetic interactions inhibiting the clearance of qtc prolonging drugs may result in increased effect. Long qt syndrome is an inherited heart rhythm problem where the heart muscle takes longer than normal to recharge between beats. Therefore sotalol is often initiated in an inpatient setting with ecg monitoring to observe for excessive qt prolongation and proarrhythmia, especially when the drug. Drugs by themselves can cause them in patients with underlying risk to be discussed, and also in the setting of polypharmacy. Table 3 shows the highly prevalent n 5 qt prolonging drugs used in various types of cancer, such. If drugs are used for covid19 outside a clinical trial, the infectious.
In terms of practical use, when a pts qtc is getting too long, im looking for a way to know which meds are the most offensive and therefore the ones to reducestop. A lot of patients at my work place are taking medications that have high risk of qt prolongation. Total 993 qt prolonging drugs were identified in 92. Prolongation of the qt c interval is either acquired or due to a congenital long qt c syndrome table 1.
Ecg library basics waves, intervals, segments and clinical interpretation. To give insight into which drugs are commonly associated with intoxications, a ranking was made of the number of information requests concerning these types of drugs. Before initiating a qt prolonging drug, patients should be assessed for other risk factors and any modifiable risk factors should be corrected coadministration of a qt prolonging drug, especially with other qt prolonging drugs and or hepatic cytochrome p450 isoenzyme inhibitors which interfere with qt prolonging drugs should be avoided. The most common reason for removing a prescription drug from the u. Determine general approach to patient from table 1 avoid.
A list of the risk factors for tdp can be seen in table 1. Approach to patient prescribed qt prolonging drugs. An analysis in a large cohort of geriatric patients article pdf available in plos one 115. Over the past 20 years, several drugs, including terfenadine, astemizole, cisapride and grepafloxacin, have been withdrawn from the canadian market as a result of causing deaths.
The costeffectiveness of thorough qtqtc tqt studies. Drugs that cause qt prolongation antiarrhythmic agents. Qt prolongation is an established side effect of antiarrhythmic. In the 1990s, nonsedating antihistamines were found to prolong the qt interval and, subsequently, many drugs in other classes have been identified.
Terfenadine, cisapride, astemizole do you remember these drugs. Conditional risk of tdp these drugs are associated with tdp but only under certain conditions of their use e. Commonly used examples of this include drugs such as macrolide antibiotics and antifungals which inhibit the cyp3a4 enzyme. Consideration should be given to dose reduction of qt prolonging drugs or changing to an alternative nonqt prolonging drug. Click on a drug and see if the fdaapproved label recommends ecg monitoring. Includes searchable lists of drugs categorized by their potential to cause qt prolongation and torsades qt drug lists, the international registry for druginduced arrhythmias qt registry, educational resources, etc. Arizona center for education and research on therapeutics. Frequency, characteristics and risk factors of qt interval. The problem has become increasingly urgent as more qt prolonging drugs have entered the market. This prolongs the action potential and lengthens the qt interval. Acquired lqts usually results from undesired qt prolongation and potential for qttriggered arrhythmias by either qtprolonging disease states, qtprolonging medications, or qtprolonging.
More than 50 commonly prescribed medications can lead to druginduced long qt syndrome lqts and serious heart rhythm abnormalities known as cardiac arrhythmias. Drugs associated with qt prolongation, qtc prolongation. A sensitivity analysis demonstrated that monitoring 30% of users which would prevent 80% of sudden cardiac deaths is still not costeffective considerations. Dec 01, 2017 consideration should be given to dose reduction of qt prolonging drugs or changing to an alternative non qt prolonging drug.
The cancer patients were frequently encountered with antiemetics n 571, proton pump inhibitors 145, antimicrobials 126, anticancer drugs 51 and antineoplastic agents 30 which carried the potential for qt prolongation table 2. Produced by nhs greater glasgow and clyde medicines. All medicines both those prescribed by your doctor and any you buy over the counter must be checked, as some can increase the risk of sudden death. Three drugs with large qt effects and adverse clinical outcomes were approved.
Why do i need to know about druginduced long qt syndrome. Many medicines have not been tested for this risk in patients, especially those with congenital long qt syndrome. Women and certain susceptible people are more prone to prolongation of the qt c interval. Many commonly used drugs can prolong the qt c interval, especially if used in combination with other substances which affect their metabolism. Possible risk of qt prolongationtdp substantial evidence supports the conclusion that these drugs can cause qt prolongation but there is insufficient evidence at this time that these drugs, when used as directed in official labeling, are associated with a risk of causing tdp. Numerous medications that may cause tdp are available for use in clinical practice, and include drugs for management of cardiovascular diseases, primarily arrhythmias, but also noncardiovascular agents from multiple classes, including antiinfectives. Concomitant administration of drugs that inhibit the cytochrome p450 especially imidazole antifungals, macrolide antibiotics or those that can prolong the qt interval or drugs that cause electrolyte disturbance should be avoided. Table 3 shows the highly prevalent n 5qt prolonging drugs used in various types of cancer, such. Do they generally have the same theoretical maximal effect in vivo, or does this vary.
Ecg a to z by diagnosis ecg interpretation in clinical context. Drugs that prolong the qt interval andor induce torsades. Known risk of tdp kr, possible risk of tdp pr or have a conditional risk of tdp cr. Drugs causing qt prolongation litfl medical blog ecg. A qtc interval 500 ms is clinically significant and likely to confer an increased risk of arrhythmia. Risk assessment of druginduced qt prolongation request pdf. Qt prolongation is a measure of delayed ventricular repolarisation, which means the heart muscle takes longer than normal to recharge between beats.
Long qt syndrome is uncommon, affecting about 1 in every 2,000 people. In addition, these medications should be prescribed with caution in patients who have underlying risk factors, such as cardiac disorders. Predicting the potential significance of these interactions is difficult as data are lacking. All three drugs have been added to the list of drugs to avoid in patients with congenital long qt syndrome if at all possible. Drugs that have qt prolonging effects should not exceed recommended dosing range, as druginduced arrhythmia is often a result of high drug concentrations. How does the full exposureresponse curves look with different qtc prolonging drugs. The cancer patients were frequently encountered with antiemetics n 571, proton pump inhibitors 145, antimicrobials 126, anticancer drugs 51 and antineoplastic agents 30 which carried the potential for qt. Meulenbelt1,2,4 1national poisons information centre nvic, university medical centre utrecht, utrecht, the netherlands, department of 2intensive care medicine and 3emergency medicine, university medical. Jan 01, 2005 the most common reason for removing a prescription drug from the u. A major theme of these studies is prophylactic treatment of predominantly healthy, asymptomatic health care workers for the purpose of preventing covid19 infection, cumulatively enrolling over 170,000 participants.
The dangers of qtc interval prolongation and medications. These qtprolonging medications include methadone, certain antibiotics, cyclobenzaprine, and. High risk, generally avoid qt drug combination ekg monitoring. Pharmacodynamic interactions may be even more difficult to predict. Share your experience with the drugs to avoid list short 5 question survey. Is there a general pattern of sum qtc effects of two qtcprolonging drugs. In some people, this can cause fainting or fits seizures. The magnitude of the change will depend on a number of variables. Some qt prolonging medications include amoxapine, ranolazine, and certain arrhythmia drugs. These risk factors include female sex, structural heart damage myocardial infarction, heart failure, valvular disease or cardiomyopathy, hypokalemia, multiple qt prolonging drugs or agents. Most drugs known to cause qt prolongation block the rapid component of the delayed rectifier potassium channel. Updated jan 2016 qt prolonging drugs lists can fit these three criteria. Prolonged qtc interval 500 ms in males and females. Check qtc interval on 12lead ekg prior to giving qt prolonging drugs zofran, azithromycin, haldol, sotalol.
Magnitude of qt effects for approved drugs was large. A prolonged qtc interval 500 ms is clinically significant and likely to confer an increased risk of arrhythmia. Possible risk of qt prolongation tdp substantial evidence supports the conclusion that these drugs can cause qt prolongation but there is insufficient evidence at this time that these drugs, when used as directed in official labeling, are associated with a risk of causing tdp. Druginduced qt prolongation an overview sciencedirect. Risk assessment of druginduced qt prolongation australian. Nov 06, 2017 a lot of patients at my work place are taking medications that have high risk of qt prolongation. Some people with long qt syndrome dont have any symptoms. Drugs home qtprolonging medications there are a number of medications that can prolong the qt interval, which could lead to a dangerous irregular heart rhythm. Covid19, clinical trials and qtprolonging prophylactic. There is an increased risk for the development of torsades. Grapefruit juice can increase the risk of druginduced qt c prolongation by inhibiting the metabolism of amiodarone. There are three mechanisms by which drugs can interact and increase the risk of qt prolongation. May 01, 2020 in the 1990s, nonsedating antihistamines were found to prolong the qt interval and, subsequently, many drugs in other classes have been identified. Prevention and management of druginduced qt prolongation.
Woosley, md, phd, president, azcert and sads scientific advisor. It is recommended to perform surveillance ekgs before and after initiation of qt prolonging drugs. Drugs are by far the commonest cause for an acquired long qt c interval. It is recommended to perform surveillance ekgs before and after initiation of qtprolonging drugs. Fda approvals are made on the basis of riskbenefit. Hypokalaemia and hypomagnesaemia can increase the risk of qt prolongation e. National medicines volume 21 information centre number 6. We have evaluated the available evidence for levomepromazine, an antipsychotic marketed in the eu and several other countries brand names. However, this was an average and the possibility of more extreme values. Check qtc interval on 12lead ekg prior to giving qt prolonging drugs zofran, azithromycin, haldol, sotalol print. An observational study from the netherlands showed that 3. Generic name, brand name, risk category, pharmacologic class, and. Druginduced qt prolongation the most common cause of acquired qt interval prolongation is use of drugs. Some of the qt c prolonging drugs withdrawn were associated with a qt c interval prolongation of only 510 ms in patient populations 9.
Since 1997, 6 drugs in 5 different clinical categories have been removed from the market due to their association with qt prolongation and tdp. Numerous medications that may cause tdp are available for use in clinical practice, and include drugs for management of cardiovascular diseases, primarily arrhythmias, but also noncardiovascular agents from. If so, examples imply that it may be less than additive. Class ia class ia antiarrthymic drugs work by blocking sodium and potassium channels. This part of the emedtv library lists other drugs that may increase the risk of qt prolongation and describes the seriousness of the condition. Anyone with a condition affecting the heart that can cause sudden cardiac death needs to take extra care with medicines. The dangers of qtc interval prolongation and medications used. Actually looking for something larger, w most all the meds psych and nonpsych producing qtc prolongation on the same chart. Aug 25, 2011 these risk factors include female sex, structural heart damage myocardial infarction, heart failure, valvular disease or cardiomyopathy, hypokalemia, multiple qt prolonging drugs or agents. These qt prolonging medications include methadone, certain antibiotics, cyclobenzaprine, and certain cancer medicines. Druginduced qt prolongation an overview sciencedirect topics. Currently 6 different drugs are listed on this website. It is an electrical disturbance which can be seen on an electrocardiogram ecg. Ecg exigency and cardiovascular curveball ecg clinical cases.
Acquired lqts usually results from undesired qt prolongation and potential for qttriggered arrhythmias by either qtprolonging disease states, qtprolonging medications, or qtprolonging antituberculous drugs. Pharmacists letter includes 12 issues every year, with brief articles about new meds and hot topics. Among them, the most prevalent were ondansetron n278, metoclopramide 152, tropisetron 9, ciprofloxacin 90, omeprazole 87, capecitabine 46 and oxaliplatin 30. Recently there have been warnings relating to drug induced qt prolongation for three commonly used drugs citalopram, domperidone and ondansetron.
829 507 1314 1307 1404 1312 1010 1369 1461 796 727 1296 1296 1172 1436 1284 1511 1277 701 1627 1460 1645 84 135 1018 13 982 1400 822 669 1462 1185 1264 280 592 184 152 530 1376 173 1001