Giudicessi JR, Noseworthy PA, Friedman PA, Ackerman MJ.
Mayo Clin Proc. 2020 Apr 7. pii: S0025-6196(20)30313-X. doi: 10.1016/j.mayocp.2020.03.024. [Epub ahead of print] PMID: 32359771 Free PMC Article
Select item 32259298
As the coronavirus disease 19 (COVID-19) global pandemic rages across the globe, the race to prevent and treat this deadly disease has led to the “off-label” repurposing of drugs such as hydroxychloroquine and lopinavir/ritonavir, which have the potential for unwanted QT-interval prolongation and a risk of drug-induced sudden cardiac death. With the possibility that a considerable proportion of the world’s population soon could receive COVID-19 pharmacotherapies with torsadogenic potential for therapy or postexposure prophylaxis, this document serves to help health care professionals mitigate the risk of drug-induced ventricular arrhythmias while minimizing risk of COVID-19 exposure to personnel and conserving the limited supply of personal protective equipment.
Figure 1 Approach to mitigating the risk of drug-induced torsades de pointes (TdP)/drug-induced sudden cardiac death in patients with coronavirus disease 19 (COVID-19) treated following a hypothetical treatment algorithm with “off-label” hydroxychloroquine alone or in combination with azithromycin. Both medications are known HERG blockers with both QTc- prolonging and torsadogenic potential. The estimated 99th percentile QTc values (derived from otherwise healthy individuals), which places a patient in the “green light” category, are less than 460 ms before puberty, less than 470 ms in men, and less than 480 ms in women. We estimate that the baseline QTc assessment will place 90% of patients in green light, 9% in yellow light, and 1% in red light status. ∗Severe COVID-19 cases are defined as a respiratory rate of greater than 30 breaths/min (adults) or 40 breaths/min (children), oxygen saturation of 93% or less, PaO2 to fraction of inspired oxygen ratio less than 300, or lung infiltrates involving more than 50% of the lung field after 24 to 48 hours. ¥Repurposed antiviral alternatives such as lopinavir/ritonavir also have QTc-prolonging effects. CHF = congestive heart failure; CKD = chronic kidney disease; COPD = chronic obstructive pulmonary disease; CV = cardiovascular; ECG = electrocardiography; ICU = intensive care unit; NIAID = National Institute of Allergy and Infectious Diseases.