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False sense of safety by daily QTc interval monitoring during methadone IVPCA titration in a patient with chronic pain

Authors Miranda-Grajales H, Hao J, Cruciani RA

Received 8 January 2013

Accepted for publication 31 January 2013

Published 20 May 2013 Volume 2013:6 Pages 375—378

DOI https://doi.org/10.2147/JPR.S42487

Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 4

Hector Miranda-Grajales, Joy Hao, Ricardo A Cruciani

Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, USA

Abstract: It has been proposed that some deaths attributed to methadone are related to prolongation of the QTc interval; however, there are no clear recommendations on electrocardiogram (ECG) monitoring in patients undergoing intravenous methadone infusion. This is a report on a patient receiving methadone intravenous patient-controlled analgesia titration for the treatment of chronic pain. Initially, her daily ECGs showed QTc intervals within normal limits; however, she experienced a rapid increase in QTc interval from 317 ms to 784 ms within a 24-hour period after methadone had been discontinued for excessive sedation. QTc interval greater than 500 ms is considered to be high risk for the fatal arrhythmia Torsades de Pointes. Daily ECGs did not detect a gradual increase in the QTc interval that would have alerted the medical staff of the need to decrease or stop the methadone before reaching a prolonged QTc interval associated with cardiotoxicity. In selected cases where aggressive methadone titration is required, more intensive monitoring, such as telemetry or ECG determinations every 12 hours, might help detect changes in QTc interval duration that might otherwise be missed by daily ECG determinations.

Keywords: methadone, QTc prolongation, opioids, opioid side effects, IVPCA methadone

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