Hydroxychloroquine
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Sinus bradycardia and QTc prolongation following off-label use: case report An 84-year-old woman developed sinus bradycardia and QTc prolongation following off-label use of hydroxychloroquine for coronavirus disease 2019 (COVID-19). The woman was admitted on 04 February 2020 with fever. Based on real-time (RT)-PCR tests results, she was diagnosed with COVID-19. She had a complex medical history including hypertension, Alzheimer’s disease and stage 4 chronic kidney disease. In February 2020, she started receiving cobicistat/darunavir [darunavir/cobicistat] tablets 150mg/800mg once a day as off-label antiviral therapy, along with nifedipine and irbesartan for hypertension. She was also initiated with continuous renal replacement therapy (CRRT) daily on the second day due to severe oliguria. On hospital day 15, during CRRT, she exhibited asymptomatic hypotension, which resolved following administration of IV fluid supplementation and discontinuation of ultrafiltration. On day 25, chest CT scan showed an improvement in pneumonia, with mild increase in pleural effusion. As she continued to show positive result for COVID-19, she was switched from cobicistat/darunavir to off-label hydroxychloroquine 200mg twice daily in March 2020. For the next few days, she showed stable respiratory and circulatory conditions. On day 30, her heart rate decreased unexpectedly to 51 bpm. Subsequent ECG showed sinus bradycardia with prolonged QTc of 553ms. At that time, her potassium level was 4.2 mmol/L. The woman’s hydroxychloroquine was therefore discontinued and she was initiated with isoproterenol. As she exhibited decreased BP, epinephrine was added to the treatment. Her systolic BP was maintained over 110mm Hg. During next 24 hours, she developed ventricular fibrillation, while her heart rate remained between 40 bpm and 50 bpm. She was intubated and rescued by defibrillation. She underwent a temporary pacemaker implantation to keep heart rate above 60 bpm. The treatment with isoproterenol and epinephrine was gradually decreased to withdrawal, while pacing was set at 45 bpm in the following three days. During these 3 days, her heart rate gradually increased above 60 bpm and QTc shortened. After 2 days of isoproterenol and epinephrine withdrawal, she exhibited normal QTc interval (450ms), which was under control over the following days of hospitalisation. Kang Y, et al. Suspected Hydroxychloroquine-Induced Sinus Bradycardia and QTc Prolongation in a Patient with COVID-19. International Heart Journal : 12 Sep 2020. 803506249 Available from: URL: http://doi.org/10.1536/ihj.20-271
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Reactions 10 Oct 2020 No. 1825
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