Navigating the Minefield of QTc Interval‐Prolonging Therapy in Nursing Facility Residents

Abstract

BACKGROUND The exponential increase in the number of medications associated with clinically important prolongation of the heart rate‐corrected QT interval (QTc) places older adults at increased risk of arrhythmias including life‐threatening torsade de pointes (TdP) and sudden death. Risk factors, other than age older than 65 years and female sex, include multiple concurrent drugs that prolong QTc and a variety of underlying predisposing conditions. Although electronic medical records and pharmacy dispensing systems can alert clinicians to the risk of QTc‐prolonging therapy, more than 95% of safety alerts are overridden, and many systems have deactivated QTc drug interaction alerts. The clinical consequences, magnitude of the effect, mitigation strategies, and recommended monitoring are not well defined for nursing facility (NF) residents. DESIGN Narrative review. SETTING NFs in the United States. PARTICIPANTS NF residents. RESULTS Medications known to prolong QTc include selected anti‐infectives, antidepressants, urinary anticholinergics, antipsychotics, and cholinesterase inhibitors (eg, donepezil), used commonly in NFs. Drug‐drug interactions are a risk when adding a medication that exaggerates the effect or inhibits the metabolism of a QTc‐prolonging medication. The vast majority of patients in whom TdP is induced by noncardiac drugs have risk factors that are easily identifiable. CONCLUSIONS Recommendations are provided to improve standardization and use of drug interaction alerts, evaluate the risk of QTc‐prolonging drugs in older adults receiving generally lower doses, validate a QTc risk score addressing complex multimorbidity, garner evidence to guide clinical decision making, avail NFs of access to electrocardiograms and interpretive recommendations, and develop standards of practice for hosting risk discussions with residents and their families. J Am Geriatr Soc, 1–8, 2019.

Use of Electrocardiogram Monitoring in Adult Patients Taking High-Risk QT Interval Prolonging Medicines in Clinical Practice: Systematic Review and Meta-analysis

“…Simpler and more accessible methods to monitor QT, such as wearable digital devices, may offer a solution for the non-hospital settings. However, these remain immature and unvalidated in the context of drug-induced QT prolongation and further research is needed to confirm the feasibility of these [39,46,47]. Further development of remote monitoring for drug safety management is likely to be supported by improving awareness of drug safety benefits of both clinicians and consumers.…”

“…Although clinical decision support tools relating to QT interval prolonging medicines have been developed, these have been associated with limitations [46,[48][49][50]. Alternative information management systems such as data-driven drug-induced QT prolongation surveillance using adverse reaction signals derived from electrocardiogram data [51] are only just emerging and may hold important solutions to improve drug safety management at the point of care.…”