hello
just wondering if people are aware of the research around this potential problem of QTc prolongation and high doses of methadone(100mg or more). If you are aware and are doing something about it could you perhaps let me know what you are doing.

I work at the cdt in rochdale and we are looking at setting up a protocol to deal with this situation. looks like we are going to be doing ecgs on people on 100mg or more and if the dose increases more ecgs. we are lucky enough that the local acute trust has an sla already for doing ecgs on clients from the mental health services in rochdale and they have said we can send clients for ecgs under that agreement. i'm just asking if anyone has any input about setting up a protocol about this. many thanks
sean

Hi there, this one has been rumbling under the surface for a while now, - will check out the current NTA 'line' on best practice and let you know. I think what you are planning to do is pretty close to, if not absolutely what we would recommend at the moment, and in particular, the links you are making with secondary care here demonstrate potential benefit of the idea of a holistic 'treatment system' in each locality, with all disciplines working together.
Suffice to say we are not sure yet how significant the problem of QTc intervals will prove to be, and some sort of trial is underway in one of the London teaching hospitals (Maudsley I think) to look into it further. Will post again tomorrow

Susi Harris (NTA Clinical Team GP)

This message has been edited. Last edited by: susi harris,

OK have now had a chance to speak to Emily Finch at the NTA. First thing to say is we can't give any definitve clinical guidance at this stage, there is still alot of uncertainty around this one.
2. A very good review has just come out in Sept issue of Addiction by Justy et al - it is generally supportive of the policy you are currently adopting.
3. The work at the Maudsley is part of a psychiatrist's MD degree there and is not likely to be published for at least a year.
4. When the Orange Guidelines are reviewed (process started this month, current expected release date Sept 07) there will be definitive guidance.

Hope this helps

Susi

I hope this isn't upsetting anyone but again please, certainly no critcism but i find this interesting but cannot quite grasp.
Maybe, he said in hope, there is some truth in the 'it's better to ask than remain ignorant' POV eh?
Just, if you can be bothered, someone break this down a little cheers.
Best
Tony B

basically there was some researchin the 70s (which was buried) and some recently, just been published in the lancet about heart rhythmns and methadone effecting this. if u look at a heart trace (e.g. the opening sequence of casualty has quite a nice example ) the peaks and troughs are labelled p, q, r, s, t. a heart trace measures how long this takes to occur. if the time taken between q and t is longer than 500ms (milliseconds i think) then this can cause problems with the ventricles of the heart, and in extremem cases cause ventricular tachycardia which can lead to death. however the research did suggest that those with qt prolongation didnt appear to be experienceing any problems, and i couldnt find any reports of any deaths caused by this.

hope this helps and is what u wanted to know tony if not apologies for rambling on

the research in the lancet also suggested switching to subutex if a person is getting problems with the heart while on methadone. it would appear to be only methadone which can cause this problem. you should also look at if the client is also taking stimulants, antipsychotics, tri cyclic antidepressant and other drugs which are know to affect the heart, also low potassium and magnesium can contribute to qt prolongation

This message has been edited. Last edited by: sean,

Thanks Sean. that's lovely and clear. This has been discussed by email around Birmingham, since the lancet article, but i don't think any concrete plans in action yet. i haven't done any ECGs on anyone yet. Your post might focus my mind.

The deaths I have come across over the years have all been people on lowish doses of methadone, in combination with other substances (alcohol, benzos, cocaine) . Does anyone have figures for the number of deaths nationally in people on high dose methadone? I haven't read the original Lancet article yet . maybe the info is in there? i think i am trying to get to our local drugs related deaths meeting, soonish, so I'll see if they've looked at this yet. Too many meetings.

the article in the lancet is more of a review of other research. neither does it publish any numbers regarding deaths.

Morning all,
We have just had a letter aboout one of our patients who is registered with the practice but not prescribed by us.
Reported by consultant physician as having QTc interval of 602ms 'And as such Mr******* should never recieve methadone in the future' The patient self-discharged from the hospital his reason for admission was due to pt reporting having a 'Fit'

Hi Simon,

This is just the sort of issue we have been dicussing here...we need to be very clear with the cardiologists...'You tell us what the risk of Torsade de Pointes (or more exactly the risk of sudden death) is and we'll balance the risks of giving or witholding methadone!'

Surely the guy just needs a clever pacemaker thingy...and the cardiologist should balance the risk of not doing it...

quote:

Originally posted by Nigel Modern at home:
Hi Simon,

This is just the sort of issue we have been dicussing here...we need to be very clear with the cardiologists...'You tell us what the risk of Torsade de Pointes (or more exactly the risk of sudden death) is and we'll balance the risks of giving or witholding methadone!'

Surely the guy just needs a clever pacemaker thingy...and the cardiologist should balance the risk of not doing it...

Nigel,
Problem here is that this patient does not engage very well and was not seen by a cardiologist before he discharged himself.
It could prove quite difficult if patients do not keep the Cardiology appointments and do not engage. I will be interested to see how this picture develops and hear other peoples experiences. I wonder will we all be soon doing ECG's in practice. How did those leads go was it
Ride
Your
Green
Bike?
Did it start with left wrist?

just linking this to the other thread where similar subjects being discussed.

http://smmgp.groupee.net/eve/forums/a/tpc/f/1064030241/m/4091066662