A case study on escitalopram induced QTc prolongation and adverse drug reaction

Mohammed Abdul Salaam*1, Kameswari K2, Magesh3, Arunachalam P3 1Department of Psychiatry, Konaseema Institute of Medical Sciences Research Foundation, Amalapuram, Andhra Pradesh, India 2Department of Obstetrics and Gynaecology, Konaseema Institute of Medical Sciences Research Foundation, Amalapuram, Andhra Pradesh, India 3Department of Cardiology, Meenakshi Academy of Higher Education and Research, Chennai, Tamil Nadu, India


INTRODUCTION
Unfavorable medication response (ADR) can be characterized as any poisonous change which is suspected to be because of a medication, happens at dosages ordinarily utilized in man, requires treatment or decline in portion or demonstrates alert later on the utilization of a similar medication.
A QT intermission or QTC is an electrocardiographic amount of ventricular repolarization and depolarization. (Singh and Maldonado-Duran, 2014) The usual value of QT intermission is below 450ms in men and 460ms in women. (Schwartz et al., 2009) Antiarrhythmics, antibiotics, antipsychotics, antide-pressants are some of the medications/drugs can lead to prolonged QT interval. (Bazett, 1920) There are some hazard issues for QT continuation are feminine sex, age superior than 65year, electrolyte con licts (hypokalemia, hypomagnesemia) attendant QT-prolonging medicines. (Bhuiyan et al., 2013) The United States Food and Drug Administration (FDA) ICH E14 leadership for scienti ic assessment of QT/QTc intermission continuation and proarrhythmic possible for non-arrhythmic drugs recognized the threshold is in Counter 1 In Table 1. Interpretation <10 ms Low concern 10-20ms, QTc outliers +-clinical AES Increasing concern >20ms, +QTc outliers +-clinical AEs De inite concern QTc outliers: individual-level QTc > 500ms or change in QTc>60ms. Clinical AEs (Adverse Events): TdP, unexpected death, ventricular tachycardia, ventricular ibrillation or lutter, syncopation, appropriation. AE: TdP, torsades de pointes; US FDA; US Food and Drug Administration (Kanjanauthai et al., 2008). The study conducted in the Unites States from 2011 -2014 reported that the prevalence of QTc prolongation in adults on antidepressant therapy is 1% above in 60years or more of age.
Escitalopram is a drug which originates below the group of discriminating serotonin reuptake inhibitors (SSRIs) (antidepressants). It is the Senantiomer of the racemic copied of citalopram, that selectively constrains the reuptake of serotonin by little to no result on norepinephrine or dopamine reuptake. Escitalopram is metabolized by hepatic metabolism via CYP2C19 and CYP3A4 to S-desmethyl citalopram (S-DCT). S-DCT is absorbed to S-di-desmethyl citalopram (S-DDCT) via CYP2D6 (Funk and Bostwick, 2013).
There are some monitoring parameters to check if a patient is on escitalopram, including QTc changes, electrolyte, liver and renal function tests. Prolonged QT interval on ECG is reported in several studies as an adverse drug reaction. (Chat ield, 2015)

Situation Account
A 68-year-old feminine patient is acknowledged for the diagnosis of osteoporotic fracture with cord compression in Figure 1. She was a known case of hypertension and on medication T.Amlong 10mg for the past 3 years (Camm et al., 2012). She was admitted under the department of neurosurgery in a quaternary care hospital. She was treated with calcium and phosphorus with vitamin D chewable tablets once daily, Teriparatide 20mg once daily, Inj.paracetamol 1gm thrice daily after the ixation surgery (Beach et al., 2014). The patient showed signs of depression and was advised to take Tab. Escitalopram 10mg from the second day of admission. Electrolyte disturbances were seen, a mainly hypokalemic pattern was shown in the ECG (Chapel et al., 2011).

Figure 1: ECG report before escitalopram treatment
The ECG report shows a QTc interval of 454ms on the irst day. After the escitalopram treatment was initiated, the patient showed a QTc interval of 505ms in Figure 2. The potassium level was found to be 2.8mg/dl on the irst day (hypokalemia), along with QTc prolongation, which was treated with syrup potassium chloride 15ml thrice daily and serum potassium level increased to 3.4mg/dl. (Noord et al., 2009)

DISCUSSION
Unhappiness is presently one of the wildest increasing diagnosis completed by the physicians throughout the previous 5 years, and hence this is an increasing trend in the operation of escitalopram. Three cases of QTc prolongation with escitalopram was reported. (Dietle, 2015;Harrigan et al., 2004) The drug-prompted QT prolongation is believed to be brought about by the restraint of deferred potassium recti ier current IKr (fast) by explicit medications. IKr is an outward current constrained by the potassium divert that is dependable partially for the repolarization of ventricular myocytes. At the point when a medication meddles with this current, it along these lines upsets repolarization, and thus the QT stretch is delayed. (Hasnain et al., 2014;Potkin et al., 2013) CONCLUSIONS Practically all the antidepressants and antipsychotics have been connected to QT prolongation. The basic meds that are considered to have high danger are Selective serotonin reuptake inhibitors primarily escitalopram. New examinations on this point are relied upon to develop inferable from the FDA's prerequisite to explore the heart pro iles of the medication.