Safest Antidepressant for QT Prolongation?

[Blitz2006]

So if a patient (<50) is on a QT prolonging agent (potentially), would you:

1. Prescribe an anti-depressant?
2. And if you would, which one?
3. Should I do monthly EKG monitoring? Or is this overkill?

I did literature review today, and it seems like the safest 3 are : Paxil, Mirtazapine and Wellbutrin. But again, this is not 'No risk", just low. So is it still safe?

Also, I'm reading maybe Effexor is safe too. Safer than Paxil?


But this article says Effexor is "medium" -> QT Prolongation and Antidepressants

A comparison of the risk of QT prolongation among SSRIs - PubMed

For clinicians who choose not to use citalopram due to recent Food and Drug Administration (FDA) recommendations, other antidepressants within this class may be considered. When citalopram is not utilized based on risk factors for TdP, use of escitalopram is not likely the safest alternative...

pubmed.ncbi.nlm.nih.gov

"and paroxetine appears to have the lowest risk. "


Or is Mirtazapine the safest?

Mirtazapine's effect on the QT interval in medically hospitalized patients - PMC

Mirtazapine is generally well tolerated in medically ill patients with and without formal psychiatric comorbidity to target sleep, appetite, nausea, and pain. However, there is little data regarding mirtazapine's potential to prolong the corrected ...

www.ncbi.nlm.nih.gov

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[Sushirolls]

1) Prescribe
2) I've prescribed celexa to post OP day 1 patients after a myriad of cardiac procedures
3) overkill

 

[Stagg737]

APA's recommendations for QTc prolongation regarding most psych meds:

Resource Documents

View APA's official resource documents at psychiatry.org

www.psychiatry.org

Summary of different antidepressant classes according to them:

SSRIs: Zoloft has the most data as "safe". Paxil, Prozac, and Luvox don't significantly prolong QTc. Avoid Celexa and possibly Lexapro?
SNRIs: Avoid Venlafaxine b/c it's the worst, Desvenlafaxine is probably safe, Duloxetine doesn't have enough data but may shorten QTc, Milnacipran caused minor QTc prolongation but likely d/t changes in heart rate.
Bupropion: Decent evidence that it's safe, no arrhythmias seen in studies they quoted
Mirtazapine: Some studies showed significant risk for the elderly, some studies showed no difference in non-elderly compared to SSRIs, "use cautiously"
Trazodone: Some risk with overdose or patients with other QTc prolonging meds, otherwise generally safe
Viibryd and Trintellix: Not enough data, early data shows likely safe
TCAs: Avoid


You're going to find a lot of conflicting data depending on where you look, and other than a couple meds to avoid I don't think there's a real consensus. Imho, concerns for QTc prolongation are probably overstated and recommendations are likely far more conservative than necessary. The biggest thing I ask myself in regards to QTc are about how many risk factors the patient has. Minimal risk factors with QTc<500 and I generally don't care. A lot of risk factors or severe factors (80 yo guy who is psychotropically naive with extensive h/o arrhythmias on a bunch of other QTc prolonging meds) and I do start to pay closer attention and try to minimize risk. For antidepressants I've typically been taught Zoloft or Bupropion are probably the safest options for actual treatment of depression.

I think that in general, if you consider the risk factors and don't do anything too stupid, (for example giving the 80 yo guy above 10mg of IV Haldol with more scheduled) 99.99% of the time you'll be fine.


TL;DR: I agree with Sushirolls and would start an SSRI.

 

[wolfvgang22]

I usually start with sertraline. In this situation and most cardiac situations.

 

[michaelrack]

I use zoloft in cardiac patients, including those with prolonged Qtc. There is extensive safety data in the cardiac population and lack of drug interactions ( a problem with paxil/prozac and some cardiac meds such as plavix)

 

[hamstergang]

3. Should I do monthly EKG monitoring? Or is this overkill?

A cardiologist has recommended to me to obtain a baseline EKG and then once at steady state with a medication (and again if increasing the dose later). Continuing to check EKGs periodically doesn't seem needed.

 

[Merovinge]

If you are going to hold SSRI's for any patient taking any QT prolonging agent, much of the adult population and certainly most people being treated for acute bacterial infections, are not going to be able to take SSRIs. This whole outcry feels largely generated by EMRs that give us 100 different alerts every time a prescription is prescribed. This was a really obvious but unintended consequence of the EMR alerts with severe alert fatigue as well as making less informed clinicians make incorrect treatment choices.

The other thing that really gets me is how much worse the QT prolongation is for many non-psychotropic medications but the degree to which some psychiatrists worry about this compared to say, a surgeon.

 

[clausewitz2]

If you are going to hold SSRI's for any patient taking any QT prolonging agent, much of the adult population and certainly most people being treated for acute bacterial infections, are not going to be able to take SSRIs. This whole outcry feels largely generated by EMRs that give us 100 different alerts every time a prescription is prescribed. This was a really obvious but unintended consequence of the EMR alerts with severe alert fatigue as well as making less informed clinicians make incorrect treatment choices.

Just like how pharmacies call me because they are gravely concerned that prescribing lexapro 20 daily and doxepin 10 qHS puts someone at risk for serotonin syndrome. Just, no.

 

[calvnandhobbs68]

If you are going to hold SSRI's for any patient taking any QT prolonging agent, much of the adult population and certainly most people being treated for acute bacterial infections, are not going to be able to take SSRIs. This whole outcry feels largely generated by EMRs that give us 100 different alerts every time a prescription is prescribed. This was a really obvious but unintended consequence of the EMR alerts with severe alert fatigue as well as making less informed clinicians make incorrect treatment choices.

The other thing that really gets me is how much worse the QT prolongation is for many non-psychotropic medications but the degree to which some psychiatrists worry about this compared to say, a surgeon.

Yup. Way more relevant when talking about additional meds in a post op 75yo with a cardiac history getting pounded with IV compazine, zofran and toradol around the clock.

 

[Merovinge]

Just like how pharmacies call me because they are gravely concerned that prescribing lexapro 20 daily and doxepin 10 qHS puts someone at risk for serotonin syndrome. Just, no.

Yup, I had the trazodone 50, Zoloft 50 that the pharmacy was refusing to fill, good times...

 

[Mass Effect]

Yup, I had the trazodone 50, Zoloft 50 that the pharmacy was refusing to fill, good times...

Exact same combo and pharmacy called, not refusing to fill, but to ask "I just wanted to make sure you're aware there's a risk of serotonin syndrome?"

OP, I go with Zoloft. 100%