From the Guidelines
Aripiprazole (Abilify) would have less QT prolongation risk compared to quetiapine (Seroquel). According to the study published in Pediatrics 1, Aripiprazole has minimal impact on cardiac repolarization, with a mean QT prolongation of 0 ms. In contrast, quetiapine has a mean QT prolongation of 6 ms. Another study published in the European Heart Journal 2 also supports this finding, stating that Aripiprazole has not been associated with QTc prolongation or torsades de pointes.
The following antipsychotics have been ranked by their QT prolongation risk:
- Aripiprazole: 0 ms
- Olanzapine: 2 ms
- Risperidone: 0-5 ms
- Quetiapine: 6 ms
- Haloperidol: 7 ms
- Clozapine: 8-10 ms
- Pimozide: 13 ms
- Ziprasidone: 5-22 ms
- Thioridazine: 25-30 ms
When switching from quetiapine to a safer alternative like Aripiprazole, a gradual cross-titration is typically recommended, with careful monitoring during the transition period. For patients with existing cardiovascular risk factors, baseline and follow-up ECGs are advisable when initiating any antipsychotic therapy. The clinical significance of QT prolongation relates to the increased risk of developing torsades de pointes, a potentially fatal ventricular arrhythmia, which makes medication selection important in patients with risk factors such as heart disease, electrolyte abnormalities, or concomitant use of other QT-prolonging medications 2.
Key considerations for minimizing QT prolongation risk include:
- Avoiding concomitant use of other QT-prolonging medications
- Monitoring electrolyte levels and avoiding abnormalities
- Avoiding high doses of antipsychotics
- Using antipsychotics with lower QT prolongation risk, such as Aripiprazole
- Carefully monitoring patients with existing cardiovascular risk factors.
From the FDA Drug Label
In clinical trials, quetiapine was not associated with a persistent increase in QT intervals. The use of quetiapine should be avoided in combination with other drugs that are known to prolong QTc including Class 1A antiarrythmics (e.g., quinidine, procainamide) or Class III antiarrythmics (e.g., amiodarone, sotalol), antipsychotic medications (e.g., ziprasidone, chlorpromazine, thioridazine), antibiotics (e.g., gatifloxacin, moxifloxacin), or any other class of medications known to prolong the QTc interval (e.g., pentamidine, levomethadyl acetate, methadone)
WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS Ziprasidone is not approved for the treatment of patients with dementia-related psychosis ( 5. 1)
QT Interval Prolongation: Ziprasidone use should be avoided in patients with bradycardia, hypokalemia or hypomagnesemia, congenital prolongation of the QT interval, or in combination with other drugs that have demonstrated QT prolongation.
Comparison of QT Prolongation Risk
- Quetiapine: not associated with a persistent increase in QT intervals, but should be avoided in combination with other drugs that are known to prolong QTc.
- Ziprasidone: use should be avoided in patients with bradycardia, hypokalemia or hypomagnesemia, congenital prolongation of the QT interval, or in combination with other drugs that have demonstrated QT prolongation.
Based on the information provided, quetiapine may have a lower risk of QT prolongation compared to ziprasidone, as quetiapine was not associated with a persistent increase in QT intervals in clinical trials 3. However, it is essential to consider the individual patient's risk factors and medical history when selecting an antipsychotic medication.
From the Research
Antipsychotics with Lower QT Prolongation Risk
- Lurasidone is associated with the lowest risk of QT prolongation, as suggested by a pharmacovigilance study 4.
- Aripiprazole, brexpiprazole, and olanzapine do not increase QT interval, according to a meta-analysis of randomized controlled trials 5.
- Lurasidone has a good weight and metabolic profile and no cardiovascular adverse effects, such as orthostatic hypotension or prolongation of the QTc interval 6.
Comparison with Seroquel (Quetiapine)
- Quetiapine is associated with QT prolongation and greater odds of torsades de pointes ventricular tachycardia, especially in cases of drug overdose 5.
- In contrast, lurasidone, aripiprazole, brexpiprazole, and olanzapine are considered to have a lower risk of QT prolongation compared to quetiapine 4, 5, 6, 7.