Increased cardiac risk in concomitant methadone and diazepam treatment: pharmacodynamic interactions in cardiac ion channels

J Cardiovasc Pharmacol. 2010 Oct;56(4):420-30. doi: 10.1097/FJC.0b013e3181f1d21b.

Abstract

Methadone, a synthetic opioid for treatment of chronic pain and withdrawal from opioid dependence, has been linked to QT prolongation, potentially fatal torsades de pointes, and sudden cardiac death. Concomitant use of diazepam or other benzodiazepines in methadone maintenance treatment can increase the risk of sudden death. Therefore, we determined the effects of methadone and diazepam singly and in combination on cardiac action potentials (APs) and on the major ion channels responsible for cardiac repolarization. Using patch clamp recording in human stem cell-derived cardiomyocytes and stably transfected mammalian cells, we found that methadone produced concentration-dependent AP prolongation and ion channel block at low micromolar concentrations: hERG (IC50 = 1.7 μM), hNav1.5 (11.2 μM tonic block; 5.5 μM phasic block), and hCav1.2 (26.7 μM tonic block; 7.7 μM phasic block). Methadone was less potent in hKv4.3/hKChIP2.2 (IC50 = 39.0 μM) and hKvLQT1/hminK (53.3 μM). In contrast, diazepam blocked channels only at much higher concentrations and had no effect on AP duration at 1 μM. However, coadministration of 1-μM diazepam with methadone caused a statistically significant increase in AP duration and a 4-fold attenuation of hNav1.5 block (IC50 values were 44.2 μM and 26.6 μM, respectively, for tonic and phasic block), with no significant effect on methadone-induced block of hERG, hCav1.2, hKv4.3/hKChIP2.2, and hKvLQT1/hminK channels. Thus, although diazepam alone does not prolong the QT interval, the relief of methadone-induced Na channel block may leave hERG K channel block uncompensated, thereby increasing cardiac risk.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Action Potentials / drug effects
  • Calcium Channels, L-Type / physiology
  • Cells, Cultured
  • Diazepam / adverse effects*
  • Diazepam / pharmacology
  • Dose-Response Relationship, Drug
  • Drug Interactions
  • ERG1 Potassium Channel
  • Ether-A-Go-Go Potassium Channels / antagonists & inhibitors
  • Humans
  • Hypnotics and Sedatives / adverse effects*
  • Hypnotics and Sedatives / pharmacology
  • Ion Channels / antagonists & inhibitors
  • Ion Channels / physiology*
  • KCNQ1 Potassium Channel / antagonists & inhibitors
  • Kv Channel-Interacting Proteins / antagonists & inhibitors
  • Methadone / adverse effects*
  • Methadone / pharmacology
  • Muscle Proteins / antagonists & inhibitors
  • Myocytes, Cardiac / drug effects
  • Myocytes, Cardiac / physiology
  • NAV1.5 Voltage-Gated Sodium Channel
  • Narcotics / adverse effects*
  • Narcotics / pharmacology
  • Patch-Clamp Techniques
  • Potassium Channels, Inwardly Rectifying / antagonists & inhibitors
  • Sodium Channels

Substances

  • Calcium Channels, L-Type
  • ERG1 Potassium Channel
  • Ether-A-Go-Go Potassium Channels
  • Hypnotics and Sedatives
  • Ion Channels
  • KCNH2 protein, human
  • KCNIP2 protein, human
  • KCNJ2 protein, human
  • KCNQ1 Potassium Channel
  • Kv Channel-Interacting Proteins
  • L-type calcium channel alpha(1C)
  • Muscle Proteins
  • NAV1.5 Voltage-Gated Sodium Channel
  • Narcotics
  • Potassium Channels, Inwardly Rectifying
  • SCN5A protein, human
  • Sodium Channels
  • Diazepam
  • Methadone