After more than 300 defibrillation shocks, patient still alive 12 years later refractory torsade de pointes due to polypharmacy and persistent vomiting

Acquired torsade de pointes ventricular tachycardia [TdP] is a rare but serious lifethreatening arrhythmia caused by an array of cardiac and non-cardiac drugs. It is often refractory to pharmacological therapy and may result in death or require frequent defibrillations. In our case study a young female patient with no underlying heart disease developed very frequent sustained TdP requiring frequent defibrillations without which she would have certainly died. The ventricular arrhythmia in this patient was of multifactorial origin-cisapride, drug-drug interaction and persistent vomiting resulting in electrolyte disturbance and malnutrition. The patient survived after more than 300 defibrillation shocks over a period of 5 days and she is still alive 12 years later

Effect of cisapride on corrected QT interval in neonates.

OBJECTIVE: To evaluate the effect of cisapride on corrected QT (QTc) interval in neonates at the Queen Sirikit National Institute of Child Health. METHOD: A prospective study was performed to see the effects of cisapride on QTc interval in 20 neonates between 1st July 2001 and 31st January 2002. QTc interval was determined just before, 48 hours, 7 days and 15 days after the start of treatment with cisapride. QTc interval was calculated by averaging QT/square root(RR) values obtained from 5 consecutive beats in lead II of the EKG. Baseline electrolyte and calcium levels were drawn on all infants before treatment of cisapride. Drug dose ranged from 0.1-0.2 mg/kg every 6 to 8 hours. RESULTS: Twenty infants were enrolled in the survey but complete data was obtained on 18 infants only. QTc interval of > 0.45 seconds was not found in any neonate. There was no significant difference of QTc interval before and 48 hours, 7 days and 15 days after cisapride administration (p = 0.861). There were also no statistically significant effects of age at starting cisapride, weight, gestational age and dose on QTc interval (p = 0.581, 0.65, 0.8, and 0.497). There were no adverse effects such as diarrhea or jaundice during the study. CONCLUSION: Term and preterm infants using cisapride at the doses of 0.4-0.8 mg/kg/day did not develop QTc prolongation, arrhythmias or adverse effects. In the absence of risk factors, cisapride may be safe for use in neonates.

Actualidades sobre cisaprida / Current concepts on cisapride

La cisaprida es hasta hoy el procinético intestinal de mayor uso en el mundo para el tratamiento de los trastornos de motilidad gastrointestinal, en México disponible de 1987 a la fecha, la farmacocinética y farmacodinámica han cobrado inusitada importancia al reportarse efectos adversos cardiacos potencialmente mortales (arritmias) principalmente con el uso combinado con medicamentos metabolizados por el citocromo P450 fracción 3 A4 en los que se incluye una larga lista de antibióticos, antimicóticos, antihistamínicos, antiarrítmicos etc, aún más el 24 de marzo de 2000 en Estados Unidos Janssen Pharmaceuticals y la FDA emitieron un comunicado para el uso restringido de la cisaprida. En nuestro país es posible que en un futuro cercano se haga lo mismo.

La cisaprida no altera el intervalo Q-T prolongado en pacientes con cirrosis hepática / Cisapride does not modify prolonged Q-T interval in patients with liver cirrhosis

Background: Abnormal small bowel motility, observed in liver cirrhosis, can be reversed with cisapride. Since both cisapride and liver disease are associated with prolonged QT interval, the possibility of adverse cardiovascular effects might be expected with cisapride treatment in these patients. Aim: To evaluate QT interval and other electrocardiographic changes during long term treatment with cisapride in cirrhotic patients. Patients and methods: Forty seven cirrhotic patients were studied. Electrocardiogram was recorded and the QT interval corrected according to Bazzett's formula was determined (normal value <0.44 s). Seventeen patients were treated with cisapride, 10 mg tid for seven months and electrocardiographic controls were performed at the end of the treatment. Results: The mean corrected QT interval was 0.46 ñ 0.03 s (range 0.4-0.53). 34 patients (64 percent) had QTc prolongation (0.47 ñ 0,02 s). Statistically significant higher values of QTc were observed in patients at Child Pugh stage B and C compared to stage A. No statistically significant difference according to the etiology of liver disease, were observed. No changes in mean QTc duration were observed during cisapride treatment. Conclusions: In spite that a prolonged QTc was a frequent finding in our serie of selected patients, no cardiovascular adverse effects were observed with long term cisapride treatment

Fármacos de uso pediátrico, QT prolongado y trastornos del ritmo cardíaco / Medications of pediatric use, long QT and cardiac rhythm disturbances

En los últimos años se ha observado un progresivo aumento de publicaciones que describen alteraciones del ritmo cardíaco graves, e incluso muerte súbita, en pacientes pediátricos que reciben fármacos habituales de la terapéutica pediátrica. Entre los fármacos mencionados destacan cisaprida y otros de uso gastroenterológico, antibióticos macrólidos, antifúngicos, antihistamínicos y psicotrópicos. Estas complicaciones son poco frecuentes, ocurren en relación a sobredosis, uso combinado de ellos o en determinadas condiciones de mayor susceptibilidad de los pacientes. Estos fármacos pueden prolongar anormalmente el intervalo QT del electrocardiograma, lo que predispone a arritmias ventriculares graves y a muerte súbita. Se revisan algunos de estos fármacos, se describen los mecanismos a través de los cuales producen estas arritmias y se dan recomendaciones para su uso seguro en pediatría, especialmente en pacientes con mayor susceptibilidad, y así prevenir esta seria complicación de la farmacoterapia pediátrica