Some reported causes and potentiators of the long QT syndrome

Congenital
Jervell and Lange-Nielsen syndrome (including "channelopathies") Romano-Ward syndrome Idiopathic
Acquired
Metabolic disorders Hypokalemia Hypomagnesemia Hypocalcemia Starvation Anorexia nervosa Liquid protein diets Hypothyroidism Bradyarrhythmias Sinus node dysfunction AV block: second or third degree	Other factors Myocardial ischemia or infarction, especially with prominent T-wave inversions Intracranial disease HIV infection Hypothermia Toxic exposure: organophosphate insecticides	Androgen deprivation therapy GnRH agonist/antagonist therapy Bilateral surgical orchiectomy Diuretic therapy via electrolyte disorders, particularly hypokalemia and hypomagnesemia Herbs Cinchona (contains quinine), iboga (ibogaine), licorice extract in overuse via electrolyte disturbances
Medications^*
High risk^¶
Adagrasib Ajmaline^Δ Amiodarone^◊ Arsenic trioxide Astemizole^§ Bedaquline Bepridil^§ Chlorpromazine Cisaparide (restricted availability)	Delamanid^Δ Disopyramide^◊ Dofetilide Dronedarone Haloperidol (IV) Ibutilide Ivosidenib Lenvatinib Levoketoconazole	Methadone Mobocertinib Papavirine (intracoronary) Procainamide Quetiapine Quinidine Quinine Revumenib Selpercatinib	Sertindole^Δ Sotalol Terfenadine^§ Vandetanib Vernakalant^Δ Ziprasidone
Moderate risk^¥
Amisulpride^Δ (oral)^‡ Azithromycin Capecitabine Carbetocin^Δ Certinib Chloroquine Citalopram Clarithromycin Clofazimine Clomipramine^† Clozapine Crizotinib Dabrafenib Dasatinib Deslurane Domperidone^Δ Doxepin^† Doxifluridine^Δ Droperidol	Encorafenib Entrectinib Erythromycin Escitalopram Etelcalcetide Fexinidazole Flecainide Floxuridine Fluconazole Fluorouracil (systemic) Flupentixol^Δ Gabobenate dimeglumine Gemifloxacin^Δ Gepirone Gilteritinib Halofantrine Haloperidol (oral) Imipramine^† Inotuzumab ozogamacin	Isoflurane Levetiracetam Levofloxacin (systemic) Lofexidine Lonafarnib Meglumine antimoniate Midostaurin Moxifloxacin Nilotinib Olanzapine Ondansetron (IV) Osimertinib Oxytocin Pazopanib Pentamidine Pilsicainide^§ Pimozide Piperaquine Probucol^§	Propafenone Propofol Quizartinib Ribociclib Risperidone Saquinavir Sevoflurane Sparfloxacin^Δ Sunitinib Tegafur^Δ Terbutaline Thioridazine Toremifene Vemurafenib Voriconazole
Low risk^**
Albuterol Alfuzosin Amisulpride (IV)^‡ Amitriptyline^† Anagrelide Apomorphine Arformoterol Artemether-lumefantrine Asenapine Atomoxetine Benperidol Bilastine^Δ Bosutinib Bromperidol Buprenorphine^¶¶ Buserelin Chlorpheniramine Ciprofloxacin (systemic) Clemastine Cocaine (topical) Degarelix Desipramine^† Desloratadine Deutetrabenazine Dexmedetomidine^ΔΔ Diphenhydramine Dolasetron Donepezil Efavirenz Eliglustat Eribulin Etrasimod	Fingolimod Fluoxetine Fluphenazine Fluvoxamine Formoterol Foscarnet Fostemsavir Galantamine Gepotidacin Givinostat Glasdegib Goserelin Granisetron Hydroxychloroquine (rare reports) Hydroxyzine Iloperidone Indacaterol Itraconazole Ketoconazole (systemic) Lacidipine Lapatinib Lefamulin Leuprolide Leuprolide-norethindrone Levalbuterol Levomepromazine (methotrimeprazine) Levomethadone Lithium Loperamide^◊◊ in overdose Lopinavir Loratadine Macimorelin	Maprotiline Mavorixafor Meclizine Mefloquine Mequitazine^Δ Metoclopramide (rare reports) Metronidazole (systemic) Mifepristone Mirtazapine Mizolastine Nelfinavir Norfloxacin Nortriptyline^† Ofloxacin (systemic) Olodaterol Ondansetron (oral) Osilodrostat Oxaliplatin Ozanimod^§§ Pacritinib Paliperidone Panobinostat Paroxetine Pasireotide Pefloxacin Periciazine^Δ Pimavanserin Pipamperone Pitolisant Ponesimod Posaconazole Primaquine	Promazine^Δ Radotinib Ranolazine (due to bradycardia) Relugolix Rilpivirine Rivastigmine Romidepsin Roxithromycin Salmeterol Sertraline Siponimod Solifenacin Sorafenib Sulpiride Tacrolimus (systemic) Tamoxifen Telavancin Teneligliptin Tetrabenazine Tiapride^Δ Trazodone Triclabendazole Trimeprazine (alimemazine)^Δ Triptorelin Tropisetron^Δ Vardenafil Vilanterol Vinflunine Voclosporin Vorinostat Zuclopenthixol

This is not a complete list of all corrected QT interval (QTc)-prolonging drugs and does not include drugs with either a minor degree or isolated association(s) with QTc prolongation that appear to be safe in most patients but may need to be avoided in patients with congenital long QT syndrome, depending upon clinical circumstances. A more complete list of such drugs is available at the CredibleMeds website^[1]. For precautions related to medications and drug interactions, refer to the UpToDate topic review of acquired long QT syndrome discussion of medications and the drug interactions program.

AV: atrioventricular; ECG: electrocardiogram; FDA: US Food and Drug Administration; GnRH: gonadotropin-releasing hormone; HIV: human immunodeficiency virus; IV: intravenous; TdP: torsades de pointes.

* Classifications provided by UpToDate Lexidrug are consistent with FDA guidance^[2,3]. The use of other classification criteria may lead to some agents being classified differently by other sources.

¶ The "high risk" category includes drugs with evidence of likely or probable association with TdP or clinically significant QT prolongation typically defined as a mean QTc increase of >60 msec from baseline and/or a QTc increased to >500 msec in a significant proportion of patients.

Δ Not available in the United States.

◊ In contrast with other class III antiarrhythmic drugs, amiodarone is rarely associated with TdP; refer to accompanying text within UpToDate topic reviews of acquired long QT syndrome.

§ Withdrawn from market in most countries due to adverse CV effects.

¥ The "moderate risk" category includes drugs with evidence of a possible association with TdP or moderate QT prolongation typically defined as a mean QTc increase of 20 to 59 msec from baseline and/or an increase to a QTc of 460 to 499 msec in a significant proportion of patients.

‡ IV amisulpride antiemetic use is associated with less QTc prolongation than the higher doses administered orally as an antipsychotic.

† Some other cyclic antidepressants (ie, amoxapine, protriptyline, trimipramine) may also prolong the QT interval, but data are insufficient to identify level of risk with confidence; refer to UpToDate content on cyclic antidepressant pharmacology, administration, and side effects.

** The "low risk" category includes drugs with minimal or uncertain evidence of association with TdP or clinically significant QTc prolongation; many of these drugs have label warnings regarding possible QTc effects or recommendations to avoid use, or increase ECG monitoring, when combined with other QTc prolonging drugs.

¶¶ Rarely associated with significant QTc prolongation at usual doses for treatment of opioid use disorder, making buprenorphine a suitable alternative for patients with methadone-associated QTc prolongation. Refer to UpToDate clinical topic reviews.

ΔΔ The FDA labeling for the sublingual preparation of dexmedetomidine warns against use in patients at elevated risk for QTc prolongation. Both IV (ie, sedative) and sublingual formulations of dexmedetomidine have a low risk of QTc prolongation and have not been implicated in TdP.

◊◊ Over-the-counter; available without a prescription.

§§ Not associated with significant QTc prolongation in healthy persons. Refer to UpToDate clinical topic for potential adverse cardiovascular (CV) effects in patients with CV disease.

References:

CredibleMeds QT drugs list website, sponsored by the Science Foundation of the University of Arizona. Available at: http://crediblemeds.org/.
Clinical evaluation of QT/QTc interval prolongation and proarrhythmic potential for non-antiarrhythmic drugs – Questions and answers (revision 2). U.S. Department of Health and Human Services 2017. Available at: https://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM073161.pdf (Accessed on July 1, 2024).
QTc information in human prescription drug and biological product labeling: Draft guidance. U.S. Department of Health and Human Services 2023. Available at: https://www.fda.gov/media/170814/download (Accessed on July 1, 2024).

Drug classifications from UpToDate Lexidrug. More information available at https://online.lexi.com/.

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Some reported causes and potentiators of the long QT syndrome