Prolonged QT

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Jentiffr24

New Member
5+ Year Member
Joined
Sep 9, 2017
Messages
3
Reaction score
0
Hi,

What is the protocol for prolonged QT on antipsychotic medications?

I finally got a formerly severely paranoid delusional and violent male with Alzheimer's stabilized on Zyprexa 5 mg BID. However, the last EKG I ran showed Sinus Rhythym with a QTC of 504. I have put the Zyprexa on hold.

What is the protocol? Should I reduce the dose and run another EKG in a few days. Or, should I stop the Zyprexa completely and start something different? Other meds like Seroquel and Depakote have failed.

So, considering quality of life and risks vs benefits, my basic questions are,
1. At what QT interval do we reduce dose?
2. At what QT interval do we put the med on hold and for how many half lives?
3. At what QT interval do we switch to a different antipsychotic like Abilify?
4. How often should we repeat EKGs?

Thanks

Members don't see this ad.
 
I'll have to dig up some old papers I have on my hard drive about the 4 questions you asked. But as far as your current situation?

Severely delusional, violent Alzheimer's patient, finally stabilized on Zyprexa 5 mg bid? QTc of 504 isn't even a big deal.

I would just document the clear benefit of having this patient's behavior/safety on this medication and justify why you're going to continue using it.

An attending of mine once said. QT prolongation as a reason to avoid using antipsychotics is a poor excuse we use to NOT treat our patients even when a clear benefit and rationale exists for its use.
 
  • Like
Reactions: 1 users
Benefit risk discussion with family for zyprexa overall. I doubt the QTc of 504 is contributing much to the risk. If truly stabilized, makes a lot of sense to use. What are the family's priorities in his care?
 
  • Like
Reactions: 1 users
Members don't see this ad :)
If the EKG algorithm showed QTc of 504 really that is an average of all the QTc's and usually using the Bazett's formula. My guess is that if you manually check it with one of the newer formulas (Bazett's may be around 100 years old now) that it is actually significantly lower than 500.

I'd still use Bazett's for normal heart rates (Framingham for tachy/afib). Yes, Bazett's overestimates, but it's also the formula used in most adverse effects reports. That said, I would not discontinue the olanzapine. Document the risk.

If I was being very risk-averse, I'd try an SSRI instead. Citalopram only increases the QTc by ~10 ms, but I'd still avoid it considering it's already high, and go with escitalopram.
 
  • Like
Reactions: 1 user
There's not even great evidence that QT prolongation is itself important. Does your patient have a history of heart disease or conduction abnormalities?


Yes he has CAD with left axis deviation, and a Nonspecific intraventricular coduction delay
 
Yes he has CAD with left axis deviation, and a Nonspecific intraventricular coduction delay
Still sounds like if he's that severely demented and violent, I'd continue the medication.
 
  • Like
Reactions: 1 user
If I was being very risk-averse, I'd try an SSRI instead. Citalopram only increases the QTc by ~10 ms, but I'd still avoid it considering it's already high, and go with escitalopram.

How would Citalopram or Escitalopram help a patient who is severely paranoid and delusional?
 
  • Like
Reactions: 1 user
Yes he has CAD with left axis deviation, and a Nonspecific intraventricular coduction delay

That's a bit concerning. If you have the option, consult with a cardiologist. If not, see if you can source older EKGs (and if possible, echo) to determine if the NICD is a normal baseline or 2/2 a large old MI or 2/2 medications. If it's the former, you could document and ignore it. If it's either of the latter, you're looking at about a 2x increase in risk of sudden death. Of course, make sure there's no hypokalemia or mild av block and/or brady as those are usually seen with medication-induced qt prolongation.
 
How violent are we talking here too?
Is he or she redirectable or able to be de-escalated (even with considerable effort?)

And what is the setting? Are they in a SNF with minimal medical care? Med psych facility on telemetry? Etc
 
How violent are we talking here too?
Is he or she redirectable or able to be de-escalated (even with considerable effort?)

And what is the setting? Are they in a SNF with minimal medical care? Med psych facility on telemetry? Etc


This is a SNF with minimal medical care. I have to justify my actions for the state CMS guidelines. The patient was trying to beat up other residents, and staff. Advanced Dementia but not a candidate for Hospice. Will decreasing the dose of Zyprexa be any safer? I already have him on 20 mg of Paxil for sexual aggression. Should I consider Abilify over Zyprexa?
 
There is no algorithm for this. QTc itself is not a specific indicator of anything but may be a proxy for Torsades, which is the real concern. The electrophysiology is NOT "the QtC becomes so long that you get polymorphic vtach"- it probably has more to do with the individual ion channels etc; hence why some antipsychotics are definitely associated with QTc prolongation but NOT Torsades (Geodon). This is the best paper on the subject and though now dated should still be required reading http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.158.11.1774

In your person it's a risk/benefit situation. I agree with @slappy about getting cards input since he has significant CV disease with electrophysiologic changes. Also agree with celexa/lexapro. You also have to consider that antipsychotics increase all cause mortality in dementia patients with glaring NNHs, with Haldol being the primary offender (see table 3). Again this doesn't mean you can't keep the Zyprexa but you need to have informed discussions with family and get cardiology input etc This is the biggest paper about this Psychotropics and Risk of Death in Dementia
 
  • Like
Reactions: 4 users
This is a SNF with minimal medical care. I have to justify my actions for the state CMS guidelines. The patient was trying to beat up other residents, and staff. Advanced Dementia but not a candidate for Hospice. Will decreasing the dose of Zyprexa be any safer? I already have him on 20 mg of Paxil for sexual aggression. Should I consider Abilify over Zyprexa?

Would ideally try to maximize one med rather than use SSRI and antipsychotic combo. Theoretically if you're concerned about QT prolongation I think most psychotropics do that as well (incl SSRI). Zyprexa should ideally make Paxil unnecessary if dosed enough to treat agitation.

Wouldn't consider abilify over zyprexa. For some it can make them even more restless (akathisia is pretty common with abilify).

If you're concerned about the dose of zyprexa, you could try something like zyprexa 5 mg po qhs and 2.5 mg daily prn. And try to taper off from there until you find the lowest dose possible that controls symptoms without having to resort to prn.
 
  • Like
Reactions: 1 user
Top