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QT prolongation and myoclonus: case report A 51-year-old man developed QT prolongation during treatment with methadone and myoclonus during treatment with morphine for opioid use disorder (OUD) [not all routes stated; durations of treatment to reactions onset not stated]. The man, who had a history of OUD, was admitted to hospital for the management of hyponatraemia and alcohol intoxication. On admission, his anamnesis revealed that he was receiving maintenance therapy with methadone 100mg daily and had been in sustained OUD remission from 2015. He was receiving various concomitant medications. He was found to have hyponatraemia, cardiomegaly and mild interstitial pulmonary oedema [aetiologies unknown]. Electrocardiogram showed a significantly prolonged QTc, which was similar to the findings attained in the same year previously. The man’s dose of methadone was reduced from 100mg to 60mg administered in 3 doses throughout the day (20mg each) due to risk for Torsades de Pointes. He also received hydromorphone as required. However, he reported that the reduced dose of methadone was inadequate to manage his cravings. Thereafter, the therapy was switched to a trial slowrelease oral morphine 240mg daily for treatment of OUD. After the initiation of morphine, he developed myoclonus in the background setting of chronic kidney disease. Morphine was withdrawn. He started receiving hydromorphone as he was not a suitable candidate for injectable opioid agonist therapy. Thereafter, his myoclonus resolved and the dose of hydromorphone was titrated over the next 15 days. He had denied any ongoing opioid withdrawal or cravings. His QTc interval had also decreased. He was discharged with 24 hour hydromorphone formulation for ongoing management of both chronic pain and OUD. Later, he was lost to follow-up. Author comment: "We present a case of a patient with OUD [opioid use disorder] who was successfully switched and managed on oral hydromorphone after development of a prolonged QTc interval on methadone." "An initial dose of 240 mg [morphine] was prescribed daily, but, likely due to the patient’s chronic kidney disease, this resulted in the development of myoclonus and subsequent cessation of therapy." Braithwaite V, et al. Sustained-release Oral Hydromorphone for the Treatment of Opioid Use Disorder. Journal of Addiction Medicine 2019: 25 Oct 2019. Available 803433361 from: URL: http://doi.org/10.1097/ADM.0000000000000585 - Canada

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Reactions 16 Nov 2019 No. 1779