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Torsades de pointes (first report for dextropropoxyphene) in an elderly patient: case report A 74-year-old woman developed torsades de pointes (TdP) during treatment with fluoxetine [Flutine] and dextropropoxyphene/paracetamol [routes not stated]. The woman was admitted for recurrent syncope that started 1 week following an elective orthopaedic surgery. Her medical history included depression, and her medications included fluoxetine 20mg daily, which she had been receiving for several years. One week before admission, she started receiving an analgesic containing dextropropoxyphene 40mg and paracetamol [acetaminophen] 500mg for postoperative pain; her dextropropoxyphene dose ranged from 120 to 160mg daily. She experienced several syncopal episodes on the day of admission. Shortly after admission, an ECG revealed QT prolongation with TdP; one episode deteriorated to ventricular fibrillation and was terminated by DC shock. She had mild hypokalaemia, and an echocardiogram revealed left ventricular hypertrophy. The woman received magnesium, potassium, and a temporary pacemaker implant due to recurrent TdP. She also received beta-blocker therapy and sedation. Her QTc interval progressively shortened to 450ms, and there was no recurrence of arrhythmic episodes. In addition to her chronic therapeutic regimen, she was discharged on bisoprolol and potassium. Her symptoms had not recurred during 6 months’ follow-up. A review of her past ECGs revealed a QTc of 450ms during fluoxetine therapy, but before treatment with dextropropoxyphene. The presence of the D85N/heterozygous polymorphism in KCNE1 was noted on genetic screening. Author comment: "We present the first documented case of torsades de pointes related to the use of propoxyphene. . . As almost invariably occurs during drug induced torsade from medications with no cardiac indications, our patient had several well-described risk factors for such a complication. These included . . . use of additional medications that could lead to further potassium channel blockade and QT prolongation (in this case, the antidepressant fluoxetine)." Adler A, et al. Propoxyphene-induced torsades de pointes. Heart Rhythm 8: 1952-1954, No. 12, Dec 2011. Available from: URL: http://dx.doi.org/10.1016/ 803066723 j.hrthm.2011.07.015 - Israel

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Editorial comment: A search of AdisBase, Medline, Embase and the WHO ADR database did not reveal any reports of torsade de pointes associated with dextropropoxyphene.

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Reactions 11 Feb 2012 No. 1388