Chinese Journal of Antituberculosis ›› 2024, Vol. 46 ›› Issue (1): 8-17.doi: 10.19982/j.issn.1000-6621.20230271
• Guideline·Standard·Consensus • Previous Articles Next Articles
Chinese Antituberculosis Association, Editorial Board of Chinese Journal of Antituberculosis, Beijing Chest Hospital, Capital Medical University
Received:
2023-08-07
Online:
2024-01-10
Published:
2024-01-04
Contact:
Chu Naihui, Email: Supported by:
CLC Number:
Chinese Antituberculosis Association, Editorial Board of Chinese Journal of Antituberculosis, Beijing Chest Hospital, Capital Medical University. Expert consensus on clinical monitoring and management of QTc interval prolongation caused by anti-tuberculous drugs[J]. Chinese Journal of Antituberculosis, 2024, 46(1): 8-17. doi: 10.19982/j.issn.1000-6621.20230271
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URL: http://www.zgflzz.cn/EN/10.19982/j.issn.1000-6621.20230271
分类 | 危险因素 |
---|---|
先天性危险因素 | 女性 |
高龄(60岁以后风险增加) | |
遗传倾向 | |
先天性长QT间期综合征 | |
猝死家族史 | |
药物诱导QTc间期延长的既往史 | |
结构性心脏病/左心室功能障碍 | |
肝功能或肾功能损伤 | |
获得性危险因素 | 电解质紊乱 |
低钾血症 | |
严重低镁血症 | |
低钙血症 | |
甲状腺功能减退 | |
结构性和功能性心脏问题 | |
近期心房纤颤复律 | |
缺血性和充血性心脏病 | |
缺血性心肌病 | |
扩张或肥厚充血性心脏病 | |
充血性心力衰竭 | |
药物相互作用 | |
超过1种引起QTc间期延长的药物 | |
抑制其他可引起QTc间期延长药物代谢的药物 | |
结核病患者的常见情况 | |
HIV感染(潜在的附加临床风险因素,特别是疾病晚期和使用多种药物) | |
低体质量指数:营养不良、饥饿、消瘦综合征 | |
严重呕吐、腹泻导致低钾血症 | |
肝功能损伤 | |
肾功能损伤 | |
由于超剂量用药或静脉注射速度过快导致药物浓度增高 |
类别 | 代表药物 | 对QTc间期的影响 |
---|---|---|
抗结核药 | ||
氟喹诺酮类 | 莫西沙星 | 被认为是氟喹诺酮类药物中导致QTc间期延长最常见的药物,估计QTc间期延长10~20ms |
左氧氟沙星 | 有导致QTc间期延长的风险,认为比莫西沙星更安全 | |
加替沙星 | 有导致QTc间期延长的风险,认为比莫西沙星更安全 | |
吩嗪类 | 氯法齐明 | 研究较少,估计QTc间期延长10~20ms |
二芳基喹啉类 | 贝达喹啉 | QTc间期延长峰值发生在贝达喹啉开始治疗8周后,估计QTc间期延长10~15ms |
硝基二氢咪唑并噁唑类衍生物 | 德拉马尼 | QTc间期延长峰值发生在德拉马尼开始治疗8周后,估计QTc间期延长5~15ms |
氨基糖苷类 | 卷曲霉素 | 由于低钾血症或肾功能损伤导致QTc间期延长 |
阿米卡星、卡那霉素 | 由于肾功能损伤导致QTc间期延长 | |
抗心律失常药 | ||
抗心律失常药 | 索他洛尔、胺碘酮、洋地黄和其他药物 | 能够延长QTc间期并诱发尖端扭转型室性心动过速的最常见药物,需检查患者使用的所有可引起QTc间期延长的抗心律失常药物 |
抗精神病药 | ||
吩噻嗪类 | 氯丙嗪 | 有发生尖端扭转型室性心动过速的报道,考虑替换为其他抗精神病药物 |
丁酰苯类 | 氟哌啶醇 | 在气管插管后或精神病需使用较高剂量氟哌啶醇时,通常发生QTc间期延长,但在较低剂量时也可能发生 |
硫利达嗪 | 秘鲁用于广泛耐药结核病患者的抗精神病药物,相关数据很少,不良反应相对少见,但也可产生心脏毒性,使QTc间期延长,可考虑替代其他精神安定药 | |
抗抑郁药 | ||
三环类抗抑郁药 | 阿米替林、麦普替林 | 仅在高剂量使用时观察到QTc间期延长,在低剂量或无其他引起QTc间期延长的风险因素下未观察到 |
选择性5-羟色胺再摄取抑制剂 | 西酞普兰、艾司西酞普兰 | 被认为是抗抑郁药中QTc间期延长风险较高的药物,建议使用替代药物治疗 |
消化系统药 | ||
促胃肠动力药物 | 多潘立酮 | QTc间期延长的风险高,不建议使用 |
止吐药 | 昂丹司琼 | 高剂量使用或静脉使用时观察到QTc间期延长 |
甲氧氯普胺 | 导致QTc间期延长的不同机制,当存在相关危险因素时会发生 | |
抗感染药 | ||
大环内酯类 | 克拉霉素、阿奇霉素 | 长期使用常有发生尖端扭转型室性心动过速的报道 |
氨基糖苷类 | 阿米卡星、卡那霉素 | 可能因肾功能损伤导致QTc间期延长 |
唑类 | 氟康唑、伏立康唑、伊曲康唑、酮康唑 | 存在其他伴随的危险因素时,使用的唑类有潜在的QTc间期延长风险 |
磺胺类 | 甲氧苄氨嘧啶、磺胺甲恶唑、乙胺嘧啶 | 可导致QTc间期延长,甚至诱发尖端扭转型室性心动过速 |
抗疟药 | 卤泛群、氯喹、奎宁 | 特别是静脉使用药物时QTc间期延长更明显 |
喷他脒 | 用于治疗或预防肺孢子菌感染,仅在静脉给药时发生QTc间期延长 | |
利尿剂 | ||
泮利尿剂 | 呋塞米、托拉塞米 | 因血钾丢失导致QTc间期延长 |
噻嗪类利尿剂 | 氢氯噻嗪、甲氯噻嗪 | 因血钾丢失导致QTc间期延长 |
抗逆转录病毒药物 | ||
非核苷类抗逆转录酶抑制剂 | 依法韦仑 | 在其他危险因素存在的情况下,可发生QTc间期延长 |
核苷类抗逆转录酶抑制剂 | 替诺福韦 | 由于Fanconi综合征引起的肾毒性,导致低钾血症 |
蛋白酶抑制剂 | 沙奎那韦 | PR间期和QTc间期延长,呈剂量依赖性 |
蛋白酶抑制剂 | 阿扎那韦 | 在其他危险因素存在的情况下,可发生QTc间期延长 |
蛋白酶抑制剂 | 利托那韦 | 可能通过抑制CYP3A4酶,减慢通过CYP3A4酶介导的药物代谢,增加这些药物浓度,从而发生QTc间期延长,如多潘立酮 |
镇痛药 | ||
阿片受体激动剂 | 美沙酮 | 降低危害的阿片类替代品,长期使用可导致QTc间期延长 |
QTc间期水平 | 指标定义 | 管理措施a |
---|---|---|
正常 | QTc间期≤450ms(男性)、≤470ms(女性) | 继续原方案治疗,每月监测ECG |
轻度延长 | 男性患者≤470ms或较基线增幅<30ms | 继续原方案治疗,每月监测ECG |
中度延长 | 470~499ms或30ms<较基线增幅<60ms | 若无心脏临床症状(胸痛、心悸、眩晕、晕厥),则继续采用原方案治疗,1周后重复监测ECG;若出现上述临床症状,则中止潜在可引起QTc间期延长的药物治疗,1周内重复监测ECG;同时排除其他延长QTc间期的影响因素(药物、电解质紊乱、甲状腺功能降低),并给予适当的处理措施 |
重度延长 | QTc间期≥500ms或较基线增幅≥60ms | 30min后重复ECG检查,如果持续延长,则中止贝达喹啉、左氧氟沙星(莫西沙星)、氯法齐明治疗。排除其他延长QTc间期的影响因素(药物、电解质紊乱、甲状腺功能降低),并给予适当的处理措施,咨询心内科专家。48h后重复监测ECG,若QTc间期下降,则改为每周监测ECG;当QTc间期>470ms,如使用莫西沙星,则停用,采用左氧氟沙星替代莫西沙星(如果药物敏感性试验结果提示对左氧氟沙星敏感)治疗,依次重启左氧氟沙星、氯法齐明,永久停用贝达喹啉治疗,期间监测ECG;若2周内QTc间期依然>470ms,则应再次咨询心内科专家,并请专家组评估患者获益及风险,酌情调整抗结核治疗方案 |
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