Risk Management of Hospitalized Psychiatric Patients Taking Multiple QTc-Prolonging Drugs.

PURPOSE/BACKGROUND: Drug-related QTc prolongation has been linked with Torsade de Pointes and sudden cardiac death. The objective of this study was to investigate the impact of starting an additional QTc-prolonging drug on the QTc interval of psychiatric inpatients. METHODS: An observational study was performed between May 2011 and December 2014 in 6 Belgian psychiatric hospitals. Inpatients who were already taking 1 QTc-prolonging drug or more could be included in the study when an additional QTc-prolonging drug was started. Electrocardiograms were performed at baseline and follow-up. Demographic, medical, medication, and laboratory data were collected. A risk score was used to estimate the risk of QTc prolongation based on patient-specific risk factors. A cutoff value of 8 points was set as high risk for QTc prolongation. RESULTS: One hundred fifty-two patients (44.7% women; mean age, 44 [SD, 17] years) were included who received a prescription for an additional QTc-prolonging drug. There was a small but significant difference (P = 0.032) in mean QTc interval between baseline (409.1 [SD, 21.8] milliseconds) and follow-up (411.8 [SD, 21.7] milliseconds). Three patients developed a prolonged QTc interval in the follow-up electrocardiogram (QTc, ≥450 [men]/470 [women] milliseconds); 8 patients had a delta QTc of 30 milliseconds or longer. No cases of torsade de pointes or sudden cardiac death were identified. Fifty-eight patients (38.2%) had a risk score of 8 or higher; these patients had a significantly longer QTc interval at follow-up than did patients with a risk score of lower than 8 (P < 0.001). IMPLICATIONS/CONCLUSIONS: Only a limited number of patients developed a prolonged QTc interval after the start of an additional QTc-prolonging drug. Nevertheless, it is still important to screen for high-risk patients at baseline. A risk score can help to select high-risk patients and to stimulate an appropriate and feasible risk management of QTc prolongation in psychiatry.

Frequency of use of QT-interval prolonging drugs in psychiatry in Belgium.

INTRODUCTION: Drug-induced QT-prolongation is an established risk factor for Torsade de pointes and sudden cardiac death. The list of QT-prolonging drugs is extensive and includes many drugs commonly used in psychiatry. AIM: In this study we performed a cross-sectional analysis of medication profiles to assess the prevalence of drug interactions potentially leading to QT-prolongation. SETTING: 6 psychiatric hospitals in Flanders, Belgium. METHODS: For each patient, the full medication list was screened for the presence of interactions, with special attention to those with an increased risk for QT-prolongation. Current practice on QT monitoring and prevention of drug-induced arrhythmia was assessed. MAIN OUTCOME MEASURE: Number of drug interactions with risk of QT-prolongation. RESULTS: 592 patients (46 % female; mean age 55.7 ± 17.1 years) were included in the analysis. 113 QT-prolonging interactions were identified in 43 patients (7.3 %). QT-prolonging interactions occurred most frequently with antidepressants (n = 102) and antipsychotics (n = 100). The precautions and follow-up provided by the different institutions when combining QT-prolonging drugs were very diverse. CONCLUSION: Drug combinations that are associated with QT-prolongation are frequently used in the chronic psychiatric setting. Persistent efforts should be undertaken to provide caregivers with clear guidelines on how to use these drugs in a responsible and safe way.

Osteoporosis after combined use of a neuroleptic and antidepressants.

UNLABELLED: Bone mineral density may be negatively influenced by hyperprolactinemia, which can be caused by atypic neuroleptics and antidepressants. CASE DESCRIPTION: The present paper reports about a spontaneous rib fracture in a female patient (age 52) taking neuroleptics (mainly risperidone), antidepressants (mainly sertraline), and anxiolytics (mainly lorazepam). At the time of the fracture a severe osteoporosis and a strongly enhanced plasma prolactin level (117 ng/ml; normal values: 3-24 ng/ml) were detected. The latter one normalized 2 months after abandoning sertraline and risperidone. After this normalization, the patient did not report further accidents up to now. DISCUSSION: Enhancement of plasma prolactin levels is linked to the mechanism of action of risperidone. Mammoplasia and increased plasma prolactin can occur during SSRI (Selective Serotonin Reuptake Inhibitors) or trazodone administration. The role of anxiolytics is less clear. The causal relationship between osteoporosis and long-term use of neuroleptics and antidepressants was assessed using probability scores, more particularly the Naranjo probability scale and the Bradford-Hill criteria of causality. A score of 6/13 (probable) was obtained with the Naranjo scale, whereas all 9 Bradford-Hill criteria were fulfilled. CONCLUSION: Although this case could not be fully explored, attention should be paid to bone mineral density loss in depressed patients taking a combined therapy of atypic antipsychotics and antidepressants.

Desire for information about drugs: a survey of the need for information in psychiatric in-patients.

BACKGROUND: Promoting therapy adherence requires understanding various psychosocial parameters, including patients' need for information. Drug information adapted to patients' needs may empower them and increase their confidence in drug therapy. OBJECTIVES: To explore psychiatric in-patients' information preferences and to test the reliability of a Dutch version of the Intrinsic Desire for Information (IDI) scale in psychiatric institutions in Flanders. METHODS: Standardised interviews were conducted with psychiatric patients in 11 hospitals. The interview consisted of the IDI-scale and five open questions. Patient demographics collected were sex, age, number of medicines taken, diagnosis, number of admissions during the past year, marital status, education level and occupation. RESULTS: 279 patient interviews were completed. A factor analysis on the original 12-item scale yielded 3 factors. An abbreviated scale was derived from the first factor (F1). This 6-item scale measured 'extent of information desired:' (EID) and consisted of six items (Cronbach's alpha = 0.73). A second factor (F2) measured 'information provider preference' (IPP) (alpha = 0.56) and a third factor (F3) measured 'inhibited information desire' (IID) (alpha = 0.69). EID was associated with number of medicines taken, duration of hospitalisation and marital status. CONCLUSION: The internal reliability of the EID-factor appears to be reproducible in the specific setting of psychiatric hospitals. It may be useful to help healthcare professionals develop pharmaceutical care towards psychiatric patients. Validation of the scale remains to be completed. Information need in psychiatric in-patients measured by the EID-score was comparable to the need measured in general hospitals during earlier research in England. Targeted information services seem to be desirable to enhance therapy adherence and quality of life in psychiatric patients.