Is quetiapine (quetiapine) safe for use in an elderly patient with a pacemaker (permanent artificial cardiac pacemaker)?

Quetiapine Safety in Elderly Patients with Pacemakers

Quetiapine should be used with extreme caution in elderly patients with pacemakers, and alternative treatments should be strongly considered, as the drug carries significant cardiovascular risks in this population including increased major adverse cardiovascular events, falls, and mortality. 1, 2, 3

Primary Safety Concerns

Cardiovascular Risks

• Low-dose quetiapine (even at doses used for sedation/anxiety) significantly increases the risk of major adverse cardiovascular events (adjusted hazard ratio 1.52), cardiovascular death (aHR 1.90), and non-fatal ischemic stroke (aHR 1.37) in continuous users 3
• The cardiovascular risk is particularly elevated in patients aged ≥65 years (aHR 1.24 for major adverse cardiovascular events) 3
• Common cardiovascular adverse events include postural hypotension (6-18% incidence) and tachycardia, which can be problematic in patients with underlying cardiac conduction issues 4, 2

Falls and Injury Risk

• Somnolence occurs in 25-39% of elderly patients, dizziness in 15-27%, and postural hypotension in 6-18% 2
• Quetiapine results in significantly higher rates of falls and injury compared to placebo in elderly patients 2
• These fall risks are compounded by the sedating effects and orthostatic changes that are particularly dangerous in the elderly 4, 5

AGS Beers Criteria Guidance

The 2019 American Geriatrics Society Beers Criteria provides clear direction:

• All antipsychotics, including quetiapine, carry a "Strong" recommendation to avoid in older adults due to increased risk of cerebrovascular accidents (stroke), cognitive decline, and mortality 1
• The only exceptions where quetiapine may be considered are: schizophrenia, bipolar disorder, or short-term use as an antiemetic during chemotherapy 1
• Off-label use for insomnia, anxiety, or agitation is explicitly discouraged given the substantial harm profile 1

Pacemaker-Specific Considerations

ECG and Conduction Effects

• While quetiapine does not typically cause clinically significant QTc prolongation at therapeutic doses (unlike some other antipsychotics), cardiovascular monitoring remains essential 6
• The presence of a pacemaker indicates underlying cardiac conduction disease, which increases vulnerability to quetiapine's cardiovascular effects 1
• Patients with pacemakers often have comorbid cardiovascular disease, further elevating the baseline risk for adverse cardiovascular events 1

Drug Interactions and Polypharmacy

• Elderly patients with pacemakers typically receive multiple cardiovascular medications (beta-blockers, antiarrhythmics, anticoagulants) 1
• Quetiapine is metabolized by CYP3A4, creating potential for drug interactions with common cardiac medications 6
• The European Society of Cardiology emphasizes that polypharmacy in elderly cardiovascular patients requires careful consideration of time-to-benefit versus time-to-harm, with quality of life as a priority 1

Dosing Considerations If Use Is Unavoidable

If quetiapine must be used despite these risks:

• Start at 25 mg/day in elderly patients (not the standard 50 mg/day used in younger adults) 6
• Increase by only 25-50 mg/day increments to reach effective dose 6
• Elderly patients demonstrate 20-30% higher plasma concentrations and up to 50% lower clearance compared to younger patients 6
• The effective dose in elderly patients is typically lower than in younger adults 6

Mortality Data

• Quetiapine use in elderly patients with dementia increases mortality risk, though the magnitude varies by comparison group 2
• Compared to risperidone and olanzapine, quetiapine showed lower mortality risk, but this does not negate the overall increased mortality compared to non-antipsychotic alternatives 2
• Cardiovascular death specifically is increased with continuous low-dose quetiapine use (aHR 1.90) 3

Recommended Clinical Approach

The safest approach is to avoid quetiapine entirely in elderly patients with pacemakers unless treating approved indications (schizophrenia, bipolar disorder). 1, 3

For off-label uses (insomnia, anxiety, agitation):

• Consider non-pharmacological interventions first 1
• If medication is necessary, use alternatives such as trazodone for insomnia or SSRIs for anxiety, which have more favorable safety profiles in elderly cardiac patients 3
• Z-drugs (zolpidem, zopiclone) carry lower cardiovascular risk than quetiapine for sleep disturbances 3

Monitoring Requirements If Prescribed

If quetiapine is deemed absolutely necessary:

• Obtain baseline ECG to assess QTc interval 6
• Monitor blood pressure (sitting and standing) to detect orthostatic hypotension 4, 2
• Assess fall risk and implement fall prevention strategies 2
• Monitor for cognitive impairment, which is significantly increased with quetiapine versus placebo 2
• Consider more frequent cardiology follow-up given the increased cardiovascular event risk 3

Key Pitfalls to Avoid

• Do not assume low doses are safe: The cardiovascular risk is present even at low doses (25-100 mg) used for sedation 3
• Do not overlook the "off-label" risk: Most quetiapine use in elderly patients (75%) is off-label, where the risk-benefit ratio is particularly unfavorable 2
• Do not ignore the cumulative risk: Women and those ≥65 years have compounded cardiovascular risk with quetiapine 3
• Do not prescribe without considering life expectancy and goals of care: In elderly patients with limited life expectancy, medications that increase near-term harm (falls, cardiovascular events) while providing minimal benefit should be avoided 1