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QTc Prolongation in Poison Center Exposures to CredibleMeds List of Substances with “Known Risk of Torsades de Pointes”

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Abstract

Many drugs carry some risk of QT interval prolongation, which can lead to life-threatening dysrhythmias including Torsades de Pointes (TdP). CredibleMeds.org identifies medications categorized as “Known Risk of TdP” but does not stratify risk in acute supratherapeutic ingestions. We sought to determine the proportion of cases exhibiting QTc prolongation and life-threatening dysrhythmias including ventricular tachycardia (VT)/ventricular fibrillation (VF), TdP, and asystole in patients exposed to these substances. Retrospective chart review of cases reported to our Regional Poison Center from 2014 to 2019 of exposures to one or more of the “Known Risk” substances was performed. Demographics, therapies, clinical effects, and medical outcome for each case were analyzed. There were 1125 exposures, of which 760 had a documented QTc interval. QTc ≥ 500 ms was reported in 138 (18.2%) of the 760 cases. The most common “Known Risk” substances were citalopram, escitalopram and cocaine. Although not in the “Known Risk” category, mirtazapine, amitriptyline, diphenhydramine, and trazodone had a statistically significant association with QTc > 500 ms. Life-threatening dysrhythmias occurred in 13 cases, with VT/VF in 6 of the 760 (0.8%) cases, and one case of TdP. Flecainide (OR 11.1, 95% CI 2.2–55.8) and methadone (OR 7.1, 95% CI 2.1–23.4) were associated with increased risk of all life-threatening dysrhythmias. Exposures to medications on the Credible Meds list of “Known Risk of TdP” QTc prolongation is common, but life-threatening dysrhythmias are rare. Mirtazapine, amitriptyline, diphenhydramine, and trazodone were associated with prolonged QTc. Flecainide and methadone had the highest associated risk of life-threatening dysrhythmias.

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Change history

  • 06 September 2022

    Kaitlin Ryan author ORCID number has been updated to 0000-0003-1587-9815.

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Authors and Affiliations

  1. Pharmacy Department, Children’s Wisconsin, 8915 West Connell Court, Milwaukee, WI, 53226, USA

    Kaitlin Ryan

  2. Department of Emergency Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA

    Paul Benz, Amy Zosel, Andrew Farkas & Jillian Theobald

  3. Wisconsin Poison Center, Children’s Wisconsin, 999 N 92nd St, Suite 660, Milwaukee, WI, 5226, USA

    Amy Zosel, Andrew Farkas & Jillian Theobald

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  1. Kaitlin Ryan
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  2. Paul Benz
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  4. Andrew Farkas
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  5. Jillian Theobald
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Contributions

The authors confirm contribution to the paper as follows: All authors contributed to the study conception and design. KR and PB completed the data collection. All authors analyzed the data, interpreted the results, and contributed to manuscript revisions. All authors reviewed the results and approved the final version of the manuscript.

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Correspondence to Kaitlin Ryan.

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Ryan, K., Benz, P., Zosel, A. et al. QTc Prolongation in Poison Center Exposures to CredibleMeds List of Substances with “Known Risk of Torsades de Pointes”. Cardiovasc Toxicol 22, 866–877 (2022). https://doi.org/10.1007/s12012-022-09764-4

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  • DOI: https://doi.org/10.1007/s12012-022-09764-4

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