JAMA Study Reveals Risks in Prescription of QT-Prolonging Medications for Hemodialysis Patients

This cross-sectional study of 20 761 adults 60 years or older revealed that non-nephrology clinicians (and from nonacute settings) commonly prescribe QT-prolonging medications for patients with dialysis-dependent kidney failure. Prescriptions for potentially interacting medications often originated from different prescribers.

The study findings suggest the need for clinician- and health system–level strategies aimed at minimizing high-risk medication–prescribing practices in the population undergoing dialysis.

Hemodialysis, a life-sustaining treatment for individuals with end-stage renal disease, involves the removal of waste products and excess fluids from the blood. However, patients undergoing hemodialysis often experience electrolyte imbalances, particularly in potassium and magnesium levels, which can predispose them to cardiac arrhythmias, including QT prolongation.

QT prolongation, characterized by an abnormal QT interval prolongation on an electrocardiogram (ECG), increases the risk of potentially fatal ventricular arrhythmias, such as torsades de pointes. Certain medications, known as QT-prolonging drugs, can exacerbate this risk by further disrupting cardiac repolarization.

Against the above background, Virginia Wang, Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, and colleagues aimed to examine dispensation and prescription patterns of QT-prolonging medications with known torsades de pointe (TdP) risk and selected interacting medications prescribed to individuals receiving hemodialysis.

The study included patients enrolled in Medicare Parts A, B, and D receiving in-center hemodialysis from January 1 to December 31, 2019.

Exposures were new-user prescriptions for the seven most frequently filled QT-prolonging medications characterized by the timing of the new prescription relative to acute care encounters, the type of prescribing clinician and pharmacy that dispensed the medication, and concomitant selected medications used known to interact with the seven most frequently filled QT-prolonging medications with known TdP risk.

The main outcomes were the new-use episodes and frequencies of the most commonly filled QT-prolonging medications; prescribers and dispensing pharmacy characteristics for new use of medications; the timing of medication fills relative to acute care events; and the frequency and types of new-use episodes with concurrent use of potentially interacting medications.

Following were the study’s key findings:

• Of 20 761 individuals receiving hemodialysis in 2019 (mean age, 74 years; 51.1% male), 52.9% filled a study drug prescription.
• Approximately 80% (from 78.6% for odansetron to 93.9% for escitalopram) of study drug new-use prescriptions occurred outside of an acute care event.
• Between 36.8% and 61.0% of individual prescriptions originated from general medicine clinicians.
• Between 16.4% and 26.2% of these prescriptions occurred with the use of another QT-prolonging medication.
• Most potentially interacting drugs were prescribed by different clinicians (46.3%-65.5%).

As the prevalence of end-stage renal disease continues to rise globally, addressing the complexities of medication management in hemodialysis patients remains paramount in reducing the burden of cardiovascular morbidity and mortality in this vulnerable population.

Reference:

Wang V, Wang C, Assimon MM, Pun PH, Winkelmayer WC, Flythe JE. Prescription and Dispensation of QT-Prolonging Medications in Individuals Receiving Hemodialysis. JAMA Netw Open. 2024;7(4):e248732. doi:10.1001/jamanetworkopen.2024.8732