key: cord-0695256-b1v2luhh authors: Eveleens Maarse, Boukje C.; Graff, Claus; Kanters, Jørgen K.; van Esdonk, Michiel J.; Kemme, Michiel J. B.; in 't Veld, Aliede E.; Jansen, Manon A. A.; Moerland, Matthijs; Gal, Pim title: Effect of hydroxychloroquine on the cardiac ventricular repolarization: A randomized clinical trial date: 2021-08-24 journal: Br J Clin Pharmacol DOI: 10.1111/bcp.15013 sha: adf56389417411dd8ef76533332daa1ea26ef8a9 doc_id: 695256 cord_uid: b1v2luhh AIMS: Hydroxychloroquine has been suggested as possible treatment for severe acute respiratory syndrome‐coronavirus‐2. Studies reported an increased risk of QTcF‐prolongation after treatment with hydroxychloroquine. The aim of this study was to analyse the concentration‐dependent effects of hydroxychloroquine on the ventricular repolarization, including QTcF‐duration and T‐wave morphology. METHODS: Twenty young (≤30 y) and 20 elderly (65–75 y) healthy male subjects were included. Subjects were randomized to receive either a total dose of 2400 mg hydroxychloroquine over 5 days, or placebo (ratio 1:1). Follow‐up duration was 28 days. Electrocardiograms (ECGs) were recorded as triplicate at baseline and 4 postdose single recordings, followed by hydroxychloroquine concentration measurements. ECG intervals (RR, QRS, PR, QTcF, J‐Tpc, Tp‐Te) and T‐wave morphology, measured with the morphology combination score, were analysed with a prespecified linear mixed effects concentration–effect model. RESULTS: There were no significant associations between hydroxychloroquine concentrations and ECG characteristics, including RR‐, QRS‐ and QTcF‐interval (P = .09, .34, .25). Mean ΔΔQTcF‐interval prolongation did not exceed 5 ms and the upper limit of the 90% confidence interval did not exceed 10 ms at the highest measured concentrations (200 ng/mL). There were no associations between hydroxychloroquine concentration and the T‐wave morphology (P = .34 for morphology combination score). There was no significant effect of age group on ECG characteristics. CONCLUSION: In this study, hydroxychloroquine did not affect ventricular repolarization, including the QTcF‐interval and T‐wave morphology, at plasma concentrations up to 200 ng/mL. Based on this analysis, hydroxychloroquine does not appear to increase the risk of QTcF‐induced arrhythmias. Since January 2020, a pandemic of the severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has been expanding. Worldwide, over 4 million deaths associated with SARS-CoV-2 infection have been documented. 1 Being a new viral infection, no treatment was available initially, but hydroxychloroquine was suggested to potentially have a therapeutic or prophylactic effect on SARS-CoV-2 infection after promising results showing inhibition of virus replication in in vitro studies. 2, 3 Therefore, many SARS-CoV-2 infected patients were treated with hydroxychloroquine without proven clinical benefit of this drug, particularly during the first months of the pandemic. 4 After inconclusive results of initial clinical studies on the therapeutic and prophylactic efficacy of hydroxychloroquine for SARS-CoV-2, the World Health Organization eventually advised against its use for this infection as large randomized controlled trials showed that there was no clinical benefit of hydroxychloroquine for SARS-CoV-2 patients. [5] [6] [7] [8] [9] [10] Hydroxychloroquine was originally developed as antimalarial drug during World War II and has been used both as antimalarial drug and in the treatment of connective tissue diseases for decades, with only very few reports of cardiac death after use of hydroxychloroquine. [11] [12] [13] [14] Nonetheless, reports of QT-prolongation, torsade de pointes (TdP) and even cardiac death after use of hydroxychloroquine against SARS-CoV-2 infection have raised concerns about its proarrhythmic effects. 5, [15] [16] [17] [18] [19] More specifically, in a meta-analysis including 28 observational studies on the effect of hydroxychloroquine in SARS-CoV-2 patients, the frequency of TdP was 0.06% and the frequency of arrhythmogenic death was 0.69%, although it should be considered that hydroxychloroquine was combined with other QT-prolonging drugs in the majority of the studies (20 out of 28). 20 Recent observations on the cardiac side effects of hydroxychloroquine are in contrast to other studies that reported an association between use of hydroxychloroquine and a reduced cardiovascular risk. 21, 22 However, these studies, reporting a reduced cardiovascular risk associated with hydroxychloroquine use, were executed in patients with rheumatic diseases, who use hydroxychloroquine chronically, 21 analysis is not only of importance regarding the SARS-CoV-2 pandemic, as hydroxychloroquine is used in the standard treatment of a broad range of diseases. At time of development of hydroxychloroquine, proarrhythmic properties of new drugs were not as extensively studied as nowadays. 27 Although proarrhythmic properties of drugs are evaluated by measuring its QT-prolonging characteristics, the QT-interval is not an ideal marker for proarrhythmic risks as the extent of QT-prolongation is poorly correlated with TdP risk, and drugs that have a comparable rate of QT-prolongation can have different TdP incidences. 28, 29 Recently, a novel algorithm was developed to evaluate hERG effects on the ECG. 29 hERG channel block, associated with an increased TdP risk, has been shown to induce notches, asymmetry and flatness of Twaves. 29 These abnormalities can be summarized in the morphology What is already known about this subject • Hydroxychloroquine has been used as anti-malarial and anti-rheumatic drug for decades, with only very few reports of cardiac death after use of this drug. The current severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has raised renewed attention on hydroxychloroquine. • Concerns were raised on the proarrhythmic effects of hydroxychloroquine, that are presumably caused by blockage of the cardiac hERG channel. • This study analysed the effect of hydroxychloroquine, dosed in a regular regimen for SARS-CoV-2 patients, on the ventricular repolarization in a concentration-effect analysis. • This outcome can be explained by the maximal plasma concentration of this dosing regimen, that is not high enough to exert hERG channel inhibition. • We hypothesize that the observed QTcF-interval prolongation in SARS-Cov-2 patients using hydroxychloroquine is attributable to their general health status and comedication. combination score (MCS), resulting in a measure of TdP risk independent of heart rate ( Figure S1 ). [28] [29] [30] [31] [32] The present analysis aimed to investigate the concentrationeffect association between hydroxychloroquine and ventricular repolarization, including QTcF-interval and T-wave morphology, and other electrocardiographic parameters, using a standardized linear mixed effects modelling approach. We conducted a single-blind, randomized, placebo-controlled All subjects underwent medical screening, including medical history, physical examination, vital signs measurements, 12-lead ECG, urine analysis, drug screen and safety chemistry, coagulation and haematology blood sampling. Key inclusion criteria were: no clinically significant abnormalities during the investigations performed during screening and body mass index between 18 and 32 kg/m 2 , key exclusion criteria were: a known hypersensitivity reaction to chloroquine, hydroxychloroquine or 4-aminoquinolines, abnormalities in the resting ECG (including QTcF-interval >450 ms), evidence of any active or chronic disease or condition and a positive SARS-CoV-2 test. Use of concomitant medication was not permitted during the study, or 14 days (or 5 half-lives) prior to the study drug administration, with exception of paracetamol. Subjects were randomized to receive either orally dosed hydroxychloroquine sulphate (plaquenil) or placebo, with a 1:1 ratio, in a single-blind fashion. Randomization codes were generated by a studyindependent statistician and were placed in sealed emergency decoding envelopes. Tablets were dispensed by the pharmacy, according to the randomization list, in identical packaging. Study staff involved in dosing was not involved in performing PD-assays or analysis of the data. Subjects received doses of 400 mg hydroxychloroquine or placebo at t = 0, 12, 24, 48, 72 and 96 hours, for a total dose of 2400 mg. This dose was the standard dosing regimen for moderate to severe SARS-CoV-2 patients in the Netherlands when the study was conceived (regular dosing regimens consisted of a total dose between 2000 and 3800 mg). 33 ECG recordings were performed at baseline (triplicate ECG), 3 and 27 hours and 5 and 10 days after the first hydroxychloroquine administration (total of 7 ECGs). Corresponding plasma hydroxychloroquine concentrations were measured resulting in a total of 4 PK measurements with matching ECGs postdose. All subjects had eaten a meal before having taken hydroxychloroquine, to minimize gastrointestinal adverse effects, which have been reported after hydroxychloroquine use. 34 of T-wave morphology. 36 The QT interval was corrected for heart rate using the Fridericia method (QTcF ¼ QT= ffiffiffiffiffiffi RR 3 p ). The J-Tp interval was corrected for heart rate using the formula JTpc ¼ JÀTpeak RR 0:58 . Blood sampling occurred after ECG sampling and the actual timepoint of the drawn blood sample was recorded for the pharmacokinetic analysis. Hydroxychloroquine plasma concentrations were measured by Ardena Bioanalytical Laboratory (Assen, the Netherlands) using a validated liquid chromatography-tandem mass spectrometry method. The lower limit of quantification of the analysis was 5 ng/mL. Hydroxychloroquine plasma concentrations were above the lower limit of quantification as shown in Figure 1 for all measurements. No apparent difference in systemic hydroxychloroquine exposure between age groups was identified. ΔPD ijk ¼ θ 0 þ θ 1 TRT þ θ 2 PD i,0 À PD 0 À Á þ θ 3 NTIM j þ θ 4 C ijk à 1 þ θ 5 à Age group ð Þ where ΔPD ijk The exploratory analysis of all baseline-corrected ECG parameters showed a linear trend (Figures 2 and S2) obtained for all parameters in which the median and prediction interval of the model correctly described the distribution of the data. No structural misspecifications were identified in any of the models ( Figure S3 ). slope estimate ΔΔQTcF = 0.017, 95%CI À0.033 to 0.068, P = .25). As can be observed in both Table 2 and Figure 3 , there were no significant associations between hydroxychloroquine concentration and RR-interval, QTcF-interval and the MCS (slope estimate ΔΔRR = À0.341, 95%CI À0.841 to 0.160, P = .091; slope estimate ΔΔMCS = 6.30  10 À5 , 95%CI À2  10 À4 to 4  10 À4 , P = .34). For the other investigated parameters, reference is made to Figure S4 . Notably, in the concentration range up to 200 ng/mL that was investigated, the mean QTcF interval prolongation did not exceed 5 ms and the upper limit of the 90% CI did not exceed 10 ms. There was also no association between hydroxychloroquine concentration and T-wave morphology indices. In the present analysis, we studied the concentration-dependent effects of hydroxychloroquine on QTcF-interval and other ECG characteristics in healthy volunteers. We found no effect of hydroxychloroquine on any of the investigated indices of ventricular repolarization, with a mean ΔΔQTcF at the highest hydroxychloroquine concentration that was investigated below the threshold of concern of 5 ms. 23 Additionally, there was no effect of hydroxychloroquine on the MCS (slope estimate ΔΔMCS = 6.30  10 À5 , P = .34). As a reference, in a large primary care population (over 200 000 subjects), an increased MCS of 0.10 was associated with an increased mortality (adjusted hazard ratio for men: 1.61). 45 In our study, healthy subjects QTcF: Fridericia-corrected QT interval; MCS: morphology combination score the lowest IC50 into account, this IC50 is equivalent to a plasma concentration of around 840 ng/mL, >4 times higher than the maximum plasma concentration in our study. 46 As we used a standard dosing regimen for SARS-CoV-2 patients, it is considered unlikely that in hospitalized patients with comparable regimens, concentrations would be substantially higher as compared to the population in this analysis. Some regimens used higher doses of hydroxychloroquine for treatment of SARS-CoV-2 patients, but even in case of a double plasma concentration compared to the studied regimen, clinically relevant hERG channel inhibition will not be achieved as described above. Note that hydroxychloroquine has a long half-life (between 32 and 50 days), which means that impaired excretion is not expected to result in substantially greater accumulation of hydroxychloroquine in patients as compared to healthy volunteers. 47 Although this study enabled us to analyse the effect of hydroxychloroquine on ECG characteristics profoundly, the study also had its limitations. First, no supratherapeutic dose levels were investigated. We do not expect higher plasma levels in patients as compared to healthy subjects due to the pharmacokinetic properties of this drug (i.e. high bioavailability and slow elimination). 54 could have increased the level of uncertainty in the estimates, the size of the 90% CIs of the ECG parameters were still below the threshold of concern. Lastly, there was no positive control in this study. However, again the small variability in measured QT-times shows the low uncertainty and consistency in results, alleviating the need of a positive control. This concentration-effect analysis in healthy subjects provides insight in the effects of hydroxychloroquine on ventricular repolarization, without confounding factors due to illness or hospitalization. The results of this concentration-effect ECG analysis showed that hydroxychloroquine did not affect the ventricular repolarization, including QTcF-interval and T-wave morphology, at concentrations similar to concentrations achieved in SARS-CoV-2 patients. Therefore, we hypothesize that the observed QT-prolongation in SARS-CoV-2 patients is caused by other factors than their hydroxychloroquine use, although hydroxychloroquine involvement cannot be fully excluded. These results suggest that hydroxychloroquine does not increase the risk of QT-mediated ventricular arrhythmias in the studied dosing regimen and population. 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