From the Guidelines
Domperidone is not considered safe for patients with heart failure due to its potential to prolong the QT interval and increase the risk of serious cardiac arrhythmias. The medication, a dopamine antagonist used primarily for nausea, vomiting, and gastric motility disorders, can increase the risk of sudden cardiac death, especially at higher doses (typically above 30mg daily) or in patients with cardiac risk factors 1. Heart failure patients often have electrolyte abnormalities, are on multiple medications that may interact with domperidone, and have structural heart changes that increase their vulnerability to arrhythmias. According to the acc/aha/esc 2006 guidelines, domperidone is listed as a drug with QT-prolonging potential, and its use is not recommended in patients with congenital long QT syndrome or those taking other QT-prolonging medications 1.
Some key points to consider when evaluating the safety of domperidone in heart failure patients include:
- The risk of QT interval prolongation and torsades de pointes, a potentially life-threatening arrhythmia
- The presence of electrolyte abnormalities, such as hypokalemia or hypomagnesemia, which can increase the risk of arrhythmias
- The use of other medications that may interact with domperidone or increase the risk of arrhythmias
- The patient's age, with those over 60 years being at higher risk
- The presence of structural heart changes or other cardiac conditions that may increase the risk of arrhythmias
If domperidone must be used in a heart failure patient, it should be at the lowest effective dose (typically 10mg three times daily or less), for the shortest duration possible, with close cardiac monitoring including ECG assessment before and during treatment 1. Alternative antiemetics with better cardiac safety profiles should be considered whenever possible for heart failure patients. The 2016 esc guidelines for the diagnosis and treatment of acute and chronic heart failure do not specifically address the use of domperidone in heart failure patients, but emphasize the importance of careful monitoring and management of patients with heart failure, including the use of medications that may affect cardiac function 1.
From the Research
Safety of Domperidone in Heart Failure
- The safety of domperidone in patients with heart failure is a concern due to its potential to prolong the QT interval, which can increase the risk of life-threatening arrhythmias 2, 3.
- A study found that 69.7% of patients receiving domperidone were also prescribed QT-interacting drugs, which can further increase the risk of arrhythmias 2.
- Another study found that domperidone was associated with a increased risk of cardiac adverse events, including QT prolongation, syncope, sudden death, cardiac arrest, and ventricular arrhythmias 3.
- However, a study found that domperidone at commonly prescribed doses (30-80 mg daily) was associated with QTc prolongation in only 6% of patients, and none of the patients had a QTc interval > 500 ms 4.
- It is also important to note that patients with heart failure, including those with preserved ejection fraction (HFpEF), may be at increased risk of QT interval prolongation due to other factors, such as concomitant medication use and underlying cardiac conditions 5.
- In patients with acute decompensated heart failure, the use of medications that can prolong the QT interval, including domperidone, should be carefully considered and monitored 6.
Key Findings
- Domperidone can prolong the QT interval and increase the risk of life-threatening arrhythmias 2, 3.
- The risk of QT prolongation is increased in patients with heart failure, including those with HFpEF 5.
- Concomitant use of QT-interacting medications can further increase the risk of arrhythmias 2.
- Domperidone at commonly prescribed doses may be safe in terms of QTc prolongation, but careful monitoring is still necessary 4.