Pharmacokinetic-pharmacodynamic modelling of QT interval prolongation following citalopram overdoses.
OBJECTIVE
To develop a pharmacokinetic-pharmacodynamic model describing the time-course of QT interval prolongation after citalopram overdose and to evaluate the effect of charcoal on the relative risk of developing abnormal QT and heart-rate combinations.


METHODS
Plasma concentrations and electrocardiograph (ECG) data from 52 patients after 62 citalopram overdose events were analysed in WinBUGS using a Bayesian approach. The reported doses ranged from 20 to 1700 mg and on 17 of the events a single dose of activated charcoal was administered. The developed pharmacokinetic-pharmacodynamic model was used for predicting the probability of having abnormal combinations of QT-RR, which was assumed to be related to an increased risk for torsade de pointes (TdP).


RESULTS
The absolute QT interval was related to the observed heart rate with an estimated individual heart-rate correction factor [alpha = 0.36, between-subject coefficient of variation (CV) = 29%]. The heart-rate corrected QT interval was linearly dependent on the predicted citalopram concentration (slope = 40 ms l mg(-1), between-subject CV = 70%) in a hypothetical effect-compartment (half-life of effect-delay = 1.4 h). The heart-rate corrected QT was predicted to be higher in women than in men and to increase with age. Administration of activated charcoal resulted in a pronounced reduction of the QT prolongation and was shown to reduce the risk of having abnormal combinations of QT-RR by approximately 60% for citalopram doses above 600 mg.


CONCLUSIONS
Citalopram caused a delayed lengthening of the QT interval. Administration of activated charcoal was shown to reduce the risk that the QT interval exceeds a previously defined threshold and therefore is expected to reduce the risk of TdP.
Friberg
Lena E
LE
School of Pharmacy, University of Queensland, Brisbane, Australia. lena.friberg@farmbio.uu.se
Isbister
Geoffrey K
GK
Duffull
Stephen B
SB
D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D018687:Antidepressive Agents, Second-Generation / Q000097:blood / Q000506:poisoning*; D002606:Charcoal / Q000627:therapeutic use; D015283:Citalopram / Q000097:blood / Q000506:poisoning*; D062787:Drug Overdose / Q000097:blood / Q000150:complications* / Q000628:therapy; D004562:Electrocardiography / Q000187:drug effects; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D008133:Long QT Syndrome / Q000097:blood / Q000139:chemically induced* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D012737:Sex Factors; D016171:Torsades de Pointes / Q000139:chemically induced / Q000517:prevention & control
D018687:Antidepressive Agents, Second-Generation; D015283:Citalopram; D002606:Charcoal