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In reply

We thank Drs Krantz and Mehler for their comments and for highlighting this important problem. Indeed, we are aware of the arrhythmogenic effects of opioid antagonists, and might also highlight that although the authors' own article¹ showing that "very high-dose" methadone can cause torsade de points ventricular tachycardia, the actual dosages reported actually range from 65 to 1000 mg/d. Thus, clinicians should be aware that a range of doses of potentially proarrhythmic drugs may be dangerous in patients predisposed to this complication.

For the interested reader, a constantly updated Web site for QT interval–prolonging drugs may be found at http://www.torsades.org.

Nora Goldschlager, MD; Andrew E. Epstein, MD
for the Practice Guidelines Subcommittee, North American Society of Pacing and Electrophysiology
San Francisco, Calif

1. Krantz MJ, Lewkowiez L, Hays H, Woodroffe M, Robertson AD, Mehler PS. Torsade de pointes associated with very-high dose methadone. Ann Intern Med. 2002;137:501-504. FREE FULL TEXT

Arch Intern Med. 2003;163:1615.

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