Psychiatric Pharmacy Essentials: QT Prolonging Medications

QTc prolongation is a cardiac rhythm disorder that serves as a surrogate marker for the risk of developing Torsades de Pointes (TdP). Though TdP is a relatively rare event, it is a serious and life-threatening polymorphic ventricular tachycardia. QTc prolongation is a more common occurrence that can be congenital or acquired (medication-induced). Many psychotropic medications are known to prolong the QT, so as psychiatric pharmacists, it is imperative that we are familiar with risk reduction, management and monitoring of QTc prolongation.

  • Where can I find reliable information regarding drug-specific QT prolongation risk?1
  • Many of my patients are on QT prolonging medications and/or have QTc prolongation, how do I clinically evaluate their risk for TdP?2-5
  • Are there any QTc prolongation medication management guidelines available?6
  • Are there differences between the amounts of QTc prolongation among antidepressants and antipsychotics? Can the TdP risk be stratified differently? 7-14

References

  1. CredibleMeds: [Weblink]. Website sponsored by the Arizona Center for Education and Research on Therapeutics (AzCERT). The site provides a searchable database of medications that define varying categories of risk of QT prolongation and information for the public and healthcare professionals. Full access requires registration.
  2. LePointe NA. Unraveling torsades de pointes: implications for clinical practice.   Presented at the CPNP annual meeting (2015).  [Weblink]
  3. Tisdale J. QTc interval prolongation: Clinical relevance, prevention, and management. Presented at the CPNP annual meeting (2018).  [Weblink]
  4. Daniel NM, Walsh K, Leach H, Stummer L. Implementation of a QTc-interval monitoring protocol by pharmacists to decrease cardiac risk in at-risk patients in an acute care inpatient psychiatric facility. Ment Health Clin. 2019;9(2):82-87. DOI: 10.9740/mhc.2019.03.082. PubMed PMID: 30842915; PubMed Central PMCID: PMC6398356.
  5. Vogel SM, Mican LM, Smith TL. Donepezil-induced QTc prolongation: A case report. Ment Health Clin. 2019;9(3):128-132. DOI: 10.9740/mhc.2019.05.128. PubMed PMID: 31123660; PubMed Central PMCID: PMC6513057.
  6. Effects of medications on the QTc interval-charts and general discussions. CPNP Shared Resource. Last Updated: 08/31/2017. [Weblink]
  7. McClelland J and Mathys M (2016) Evaluation of QTc prolongation and dosage effect with citalopram. Mental Health Clinician. 2016; 6(4): 165-70.  [Weblink]
  8. Castro VM, Clements CC, Murphy SN, Gainer VS, Fava M, Weilburg JB, et al. QT interval and antidepressant use: a cross sectional study of electronic health records. BMJ. 2013;346:f288. DOI: 10.1136/bmj.f288. PubMed PMID: 23360890; PubMed Central PMCID: PMC3558546.
  9. Girgis SJ, Maroney ME, and Liu MT (2016) Evaluation of the use of electrocardiogram monitoring in patients on psychotropic medications that have a risk of QT prolongation. Mental Health Clinician: 2016; 6(4): 171-7.  [Weblink]
  10. Beach SR, Celano CM, Noseworthy PA, Januzzi JL, Huffman JC. QTc prolongation, torsades de pointes, and psychotropic medications. Psychosomatics. 2013;54(1):1-13. DOI: 10.1016/j.psym.2012.11.001. PubMed PMID: 23295003.
  11. Beach SR, Celano CM, Sugrue AM, Adams C, Ackerman MJ, Noseworthy PA, et al. QT Prolongation, Torsades de Pointes, and Psychotropic Medications: A 5-Year Update. Psychosomatics. 2018;59(2):105- 122. DOI: 10.1016/j.psym.2017.10.009. PubMed PMID: 29275963.
  12. Wenzel-Seifert K, Wittmann M, Haen E. QTc prolongation by psychotropic           drugs and the risk of Torsade de Pointes. Dtsch Arztebl Int. 2011;108(41):687-93.    [Pubmed]
  13. Zareba W, Lin DA. Antipsychotic drugs and QT interval prolongation. Psychiatr Q. 2003;74(3):291-306.  [Pubmed]
  14. Haddad PM, Anderson IM. Antipsychotic-related QTc prolongation, torsade de pointes and sudden death. Drugs. 2002;62(11):1649-71. DOI: 10.2165/00003495-200262110-00006. PubMed PMID: 12109926.