Antidepressants/antipsychotics/ketoconazole interaction
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Sinoatrial node dysfunction: case report A 53-year-old woman experienced two episodes of symptomatic sinoatrial node dysfunction following treatment with lithium, carbamazepine and quetiapine in the first instance and lithium, quetiapine, escitalopram and ketoconazole in the second. The woman had a history of bipolar affective disorder and received lithium 250mg twice daily, carbamazepine 200mg once daily and quetiapine 200mg once daily [routes not stated]. She presented with severe fatigue, tremor and bradycardia [time to reaction onset not clearly stated]. ECG revealed sinus bradycardia, junctional escape rhythm and Mobitz II type second degree sinoatrial block. An external pacemaker was initiated due to sinus arrest. Carbamazepine was discontinued. Within 2 days, the woman had regained normal sinus rhythm. The pacemaker was switched off on day 3 and she was discharged after 9 days. Normal sinus rhythm was observed on follow-up 3 months later. The woman was readmitted after 5 months with a 1-day history of palpitations and fatigue. Medications included lithium 500mg twice daily, escitalopram 10mg [frequency not stated] and quetiapine 200mg once daily alongside ketoconazole 200mg once daily [routes not stated]. Ketoconazole had been initiated 10 days prior for intertrigo. ECG revealed intermittent sinus bradycardia with episodes of sinus arrest alongside atrial fibrillation and atrial tachycardia. Ketoconazole was discontinued. Her sinus rhythm returned after 1 day and she was discharged 4 days later. A permanent pacemaker was implanted 1 month later. Author comment: "Concomitant administration with ketoconazole, a potent CYP3A4 inhibitor, may lead to a significant reduction in the first-pass metabolism and hepatic clearance of quetiapine and thus potentially increase adverse effects". "[D]iscontinuation of carbamazepine after the first episode might also have increased quetiapine serum levels". Simko J, et al. Sinus node dysfunction due to psychotropic agents’s combination. Acta Neuropsychiatrica 24: 247-250, No. 4, Aug 2012. Available from: URL: 803077320 http://dx.doi.org/10.1111/j.1601-5215.2012.00639.x - Hungary
0114-9954/10/1421-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 29 Sep 2012 No. 1421
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