Psychiatric Pharmacy Essentials: QT Prolonging Medications

QT 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. QT prolongation is a more common occurrence that can be congenital or acquired (medication-induced). Many psychotropic medications are known to prolong the QT interval, so as psychiatric pharmacists, it is imperative that we are familiar with risk reduction, management, and monitoring of QT 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 QT prolongation, how do I clinically evaluate their risk for TdP?2-5
  • Are there any QT prolongation medication management guidelines available?6-8
  • Are there differences between the amounts of QT prolongation among antidepressants and antipsychotics? Can the TdP risk be stratified differently?9-18

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, et al. 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. [Weblink]
  5. Vandael E, Vandenberk B, Vandenberghe J, et al. Development of a risk score for QTc-prolongation: the RISQ-PATH study. Int J Clin Pharm. 2017;39(2):424-432. [PubMed]
  6. Drew BJ, Ackerman MJ, Funk M, Gibler WB, Kligfield P, Menon V, et al. Prevention of torsade de pointes in hospital settings: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. Circulation. 2010;121(8):1047-60. DOI: 10.1161/CIRCULATIONAHA.109.192704. PubMed PMID: 20142454; PubMed Central PMCID: PMC3056123.
  7. Effects of medications on the QTc interval-charts and general discussions. CPNP Shared Resource. Last Updated: 08/31/2017. [Weblink]
  8. Funk MC, Beach SR, Bostwick JR et al. APA resource document on QTc prolongation and psychotropic medications. Am J Psychiatry 2020;177(3):273-274. [PubMed]
  9. McClelland J, Mathys M. Evaluation of QTc prolongation and dosage effect with citalopram. Ment Health Clin. 2016;6(4):165-70. [Weblink]
  10. Castro VM, Clements CC, Murphy SN et al. QT interval and antidepressant use: a cross-sectional study of electronic health records. BMJ. 2013;346. [PubMed]
  11. Girgis SJ, Maroney ME, and Liu MT. Evaluation of the use of electrocardiogram monitoring in patients on psychotropic medications that have a risk of QT prolongation. Ment Health Clin. 2016;6(4):171-7. [Weblink]
  12. 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.
  13. 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.
  14. Zareba W, Lin DA. Antipsychotic drugs and QT interval prolongation. Psychiatr Q. 2003;74(3):291-306.  [Pubmed]
  15. 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.
  16. Funk KA, Bostwick JR. A comparison of the risk of QT prolongation among SSRIs. Ann Pharmacother. 2013;47(10):1330-41. DOI: 10.1177/1060028013501994. PubMed PMID: 24259697.
  17. Jasiak NM, Bostwick JR. Risk of QT/QTc prolongation among newer non-SSRI antidepressants. Ann Pharmacother. 2014;48(12):1620-8. DOI: 10.1177/1060028014550645. PubMed PMID: 25204465.
  18. Kurisu K, Yoshiuchi K. Comparison of Antipsychotics for the Treatment of Patients With Delirium and QTc Interval Prolongation: A Clinical Decision Analysis, Front Psychiatry. 2021;12:609678. [PubMed]
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