What is the best antipsychotic medication for patients with prolonged QTc (QT interval corrected) interval or arrhythmia?

From the Guidelines

For patients with QTc prolongation or arrhythmia concerns, aripiprazole (Abilify) is the safest antipsychotic option, as it has not been associated with QTc prolongation or torsade de pointes (TdP) 1. When considering antipsychotic medications for patients with prolonged QTc interval or arrhythmia, it is crucial to prioritize those with the least risk of exacerbating these conditions.

• Aripiprazole stands out due to its lack of association with QTc prolongation or TdP, making it a preferable choice.
• Other antipsychotics like thioridazine, ziprasidone, quetiapine, and haloperidol have notable QTc-prolonging effects and should be avoided in patients with arrhythmia concerns.
• The safety of aripiprazole in this context is attributed to its pharmacological properties, which have minimal impact on cardiac ion channels, particularly the hERG potassium channels that affect cardiac repolarization and QT interval.
• Before initiating any antipsychotic therapy in patients with cardiac concerns, baseline ECG monitoring is recommended, along with follow-up ECGs after reaching steady-state concentrations, and correction of electrolyte abnormalities to minimize risks.
• A thorough medication review is also essential to identify and minimize other QT-prolonging drugs, ensuring the safest possible treatment regimen for patients with QTc prolongation or arrhythmia concerns.

From the FDA Drug Label

In clinical trials, quetiapine was not associated with a persistent increase in QT intervals. However, the QT effect was not systematically evaluated in a thorough QT study. 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) Paliperidone causes a modest increase in the corrected QT (QTc) interval. The use of paliperidone should be avoided in combination with other drugs that are known to prolong QTc including Class 1A (e.g., quinidine, procainamide) or Class III (e.g., amiodarone, sotalol) antiarrhythmic medications, antipsychotic medications (e.g., chlorpromazine, thioridazine), antibiotics (e.g., gatifloxacin, moxifloxacin), or any other class of medications known to prolong the QTc interval.

Best Antipsychotic Medication for Patients with Prolonged QTc Interval or Arrhythmia:

• There is no clear answer to this question based on the provided drug labels.
• Both quetiapine and paliperidone have warnings about QT prolongation, and their use should be avoided in combination with other drugs that are known to prolong QTc.
• No conclusion can be drawn about which antipsychotic medication is best for patients with prolonged QTc interval or arrhythmia based on the provided information 2 3.

From the Research

Antipsychotic Medications and QTc Prolongation

• Antipsychotic medications can prolong the QTc interval, increasing the risk of potentially fatal ventricular arrhythmias 4, 5, 6.
• The risk of QTc prolongation varies among antipsychotic medications, with some medications having a higher risk than others 4, 5, 7.

Medications with Lower Risk of QTc Prolongation

• Aripiprazole, brexpiprazole, and olanzapine are associated with a lower risk of QTc prolongation 5, 8, 7.
• Lurasidone is also associated with a lower risk of QTc prolongation, with one study suggesting it has the lowest risk among antipsychotic medications 7.

Medications with Higher Risk of QTc Prolongation

• Sertindole, ziprasidone, and amisulpride are associated with a higher risk of QTc prolongation 5, 7.
• Quetiapine and risperidone are also associated with an increased risk of QTc prolongation 5.

Monitoring and Management

• Regular ECG monitoring is recommended for patients at risk of QTc prolongation, particularly those with pre-existing cardiovascular disease or electrolyte abnormalities 4, 6.
• If substantial QTc prolongation is present, a change in pharmacologic treatment may be considered, although the risks and benefits of discontinuation should be carefully weighed 4.