QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients

Reilly, Jacqueline; Ayis, Salma; Ferrier, I. Nicol; Jones, S. J.; Thomas, Simon

doi:10.1016/s0140-6736(00)02035-3

Cited by 539 publications

(396 citation statements)

References 20 publications

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“…Lithium can increase the risk of abnormal QT prolongation or T‐wave abnormalities,834 an impact more pronounced with age, as almost 60% of older patients on lithium maintenance therapy have ECG abnormalities 835. Several antipsychotics, including risperidone, olanzapine, ziprasidone and asenapine, are also associated with arrhythmias, QTc prolongation, and other cardiovascular adverse events.…”

Section: Safety and Monitoringmentioning

confidence: 99%

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

et al. 2018

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The Canadian Network for Mood and Anxiety Treatments (CANMAT) previously published treatment guidelines for bipolar disorder in 2005, along with international commentaries and subsequent updates in 2007, 2009, and 2013. The last two updates were published in collaboration with the International Society for Bipolar Disorders (ISBD). These 2018 CANMAT and ISBD Bipolar Treatment Guidelines represent the significant advances in the field since the last full edition was published in 2005, including updates to diagnosis and management as well as new research into pharmacological and psychological treatments. These advances have been translated into clear and easy to use recommendations for first, second, and third‐ line treatments, with consideration given to levels of evidence for efficacy, clinical support based on experience, and consensus ratings of safety, tolerability, and treatment‐emergent switch risk. New to these guidelines, hierarchical rankings were created for first and second‐ line treatments recommended for acute mania, acute depression, and maintenance treatment in bipolar I disorder. Created by considering the impact of each treatment across all phases of illness, this hierarchy will further assist clinicians in making evidence‐based treatment decisions. Lithium, quetiapine, divalproex, asenapine, aripiprazole, paliperidone, risperidone, and cariprazine alone or in combination are recommended as first‐line treatments for acute mania. First‐line options for bipolar I depression include quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine. While medications that have been shown to be effective for the acute phase should generally be continued for the maintenance phase in bipolar I disorder, there are some exceptions (such as with antidepressants); and available data suggest that lithium, quetiapine, divalproex, lamotrigine, asenapine, and aripiprazole monotherapy or combination treatments should be considered first‐line for those initiating or switching treatment during the maintenance phase. In addition to addressing issues in bipolar I disorder, these guidelines also provide an overview of, and recommendations for, clinical management of bipolar II disorder, as well as advice on specific populations, such as women at various stages of the reproductive cycle, children and adolescents, and older adults. There are also discussions on the impact of specific psychiatric and medical comorbidities such as substance use, anxiety, and metabolic disorders. Finally, an overview of issues related to safety and monitoring is provided. The CANMAT and ISBD groups hope that these guidelines become a valuable tool for practitioners across the globe.

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Section: Safety and Monitoringmentioning

confidence: 99%

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

et al. 2018

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“…In psychiatric patients, therapeutic doses of TCAs lengthen the QTc interval independently of the presence of cardiovascular disease, but the clinical importance of this observation is unknown. 40 To minimize the risk of arrhythmia, electrocardiogram (ECG) screening is recommended before treatment with TCAs is initiated in patients older than 40 years. 12 On the basis of observations in the late 1980s, mortality after myocardial infarction (MI) is increased with use of type 1A antiarrhythmic agents.…”

Section: Cardiovascular Considerations Of Pharmacotherapy For Npmentioning

confidence: 99%

Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities

Haanpää¹,

Gourlay

Kent

et al. 2010

Mayo Clinic Proceedings

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The efficacy of drugs for neuropathic pain has been established in randomized controlled trials that have excluded patients with comorbid conditions and those taking complex medications. However, patients with neuropathic pain frequently present with complex histories, making direct application of this evidence problematic. Treatment of neuropathic pain needs to be individualized according to the cause of the pain, concomitant diseases, medications, and other individual factors. Tricyclic antidepressants (TCAs), gabapentinoids, selective noradrenergic reuptake inhibitors, and topical lidocaine are the first-line choices; if needed, combination therapy may be used. When a new drug is added, screening for potential drug interactions is recommended. The TCAs have anticholinergic adverse effects and may cause orthostatic hypotension. They should be avoided or used cautiously in patients with cardiac conduction disturbances or arrhythmias. Patients who lack cytochrome P450 2D6 isoenzyme activity are prone to adverse effects of TCAs and venlafaxine and have a weaker analgesic response to tramadol. A combination of several serotoninergic drugs may lead to serotonin syndrome. Risk of gastrointestinal tract bleeding is increased in patients taking selective serotonin reuptake inhibitors or venlafaxine, especially when combined with nonsteroidal anti-inflammatory drugs. Dose adjustment may be needed in patients with renal or hepatic impairment. Depending on the drug, the dose is reduced or the dosage interval lengthened. Slow titration and careful follow-up are needed. No drug is absolutely safe during pregnancy and lactation. Particular care must be exercised during the first trimester when drug dose should be as low as possible. Individual weighing of benefits and risks should guide therapeutic decisions.Mayo Clin Proc. 2010;85(3)(suppl):S15-S25 ADR = adverse drug reaction; BP = blood pressure; CKD = chronic kidney disease; CYP = cytochrome P450; ECG = electrocardiogram; EM = extensive metabolizer; GFR = glomerular filtration rate; MI = myocardial infarction; NP = neuropathic pain; NSAID = nonsteroidal anti-inflammatory drug; OR = odds ratio; PM = poor metabolizer; RCT = randomized controlled trial; SNRI = selective noradrenergic reuptake inhibitor; TCA = tricyclic antidepressant; UM = ultrarapid metabolizer From Rehabilitation ORTON,

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“…9,10 Warner et al 11 demonstrated higher rates of QT abnormalities in patients with schizophrenia than in controls and a distinct association with the use of antipsychotics (P Ͻ 0.05). Reilly et al 12 found increasing age (P ϭ 0.04) and use of typical antipsychotics such as thioridazine (P ϭ 0.001) and droperidol (P ϭ 0.004) to be risk factors for QT prolongation. It has been shown that ∼25% of patients using antipsychotics demonstrate abnormal QT-interval prolongation, which can increase the risk of serious ventricular arrhythmias.…”

Section: Introductionmentioning

confidence: 99%

“…It has been shown that ∼25% of patients using antipsychotics demonstrate abnormal QT-interval prolongation, which can increase the risk of serious ventricular arrhythmias. 12,13 Although there is no direct evidence linking QT prolongation with the risk of torsades de pointes, QT prolongation has been consistently identified as an important predictor of sudden death in patients with schizophrenia. 14 The published literature includes numerous case reports of torsades de pointes and sudden death in patients taking thioridazine, haloperidol, risperidone, and other antipsychotics.…”

Section: Introductionmentioning

confidence: 99%

Analysis of West Virginia medicaid claims data for the prevalence of medical conditions and use of drugs likely to cause QT prolongation in patients with schizophrenia

Kalsekar¹,

Makela

Moeller

2003

Current Therapeutic Research

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Background: An important concern with antipsychotic drugs used for the treatment of schizophrenia is the prolongation of the QT interval on the electrocardiogram. Concomitant use of other QT-prolonging drugs and the presence of certain medical conditions may lead to excessive QT prolongation and subsequent cardiac arrhythmias.Objective: The aim of this study was to assess the utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation in a large population of patients with schizophrenia in practice settings.Methods: The study was conducted using West Virginia Medicaid claims data for patients aged 18 to 64 years with Ն1 medical claim for schizophrenia between January 1, 1997, and December 31, 1999. A comprehensive list of drugs and medical conditions causing QT prolongation was obtained from the literature. The drugs were identified in the prescription claims data using their specific National Drug Classification codes. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, were used to identify the medical conditions as described in the medical claims files. Descriptive statistics on utilization of drugs and prevalence of medical conditions were reported and demographic differences were examined.Results: The final sample consisted of 1699 patients with schizophrenia. The mean (SD) age was 40.8 (11.35) years (range, 18-63 years); 55% of the patients were women. A total of 76.9% of patients utilized Ն1 nonantipsychotic QTprolonging drug in a year, with a mean (SD) of 2.1 (1.3) such drugs used per patient per year. A total of 15.9% of patients with schizophrenia had Ն1 medical condition associated with QT prolongation. Patients with Ն1 such medical condition had a mean (SD) of 1.2 (0.57) conditions potentially causing QT prolongation. The number of nonantipsychotic QT-prolonging prescriptions filled and the prevalence of medical conditions leading to QT prolongation were found to be significantly higher for women (both P Ͻ 0.001) and patients aged 34 to 64 years (both P Ͻ 0.001). Conclusions:In this study, a high utilization of QT-prolonging drugs and the prevalence of medical conditions causing QT prolongation were found. These results merit assessment of predisposing risk factors, such as concurrent use of other QT-prolonging drugs and the presence of cardiovascular and other conditions associated with QT prolongation, before prescribing antipsychotics, especially in women and older patients with schizophrenia. (Curr Ther Res Clin Exp. 2003;64:538-550)

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QTc-interval abnormalities and psychotropic drug therapy in psychiatric patients

Cited by 539 publications

References 20 publications

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder

Treatment Considerations for Patients With Neuropathic Pain and Other Medical Comorbidities

Analysis of West Virginia medicaid claims data for the prevalence of medical conditions and use of drugs likely to cause QT prolongation in patients with schizophrenia

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