The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the Editor

Editor, – Thank you to Michael McDonough for his comprehensive article on the safe prescribing of opioids (Aust Prescr 2012;35:20-4 ). In particular, Table 1 provides useful recommendations for the monitoring and management of possible emerging adverse effects.

The inclusion of oxycodone as a medication which prolongs QTc was surprising. This precaution does not appear in other sources of information discussing oxycodone, such as the reference cited for Table 11 , the approved product information for oxycodone, the Australian Medicines Handbook,2 Therapeutic Guidelines3 or the database which records medications that prolong QTc ( However, there has been research published which supports the occurrence of prolonged QTc by oxycodone in a dose-dependent manner.4 Is there any other literature that the author can refer us to which supports the prolongation of QTc by oxycodone?

The suggested strategy to manage this potential adverse effect in his article is to recommend an ECG. Given that the prescribing of oxycodone and oxycodone-related deaths have increased in Australia since 2002,5 does the author, as a practical consideration, advise that in all cases an ECG be performed before the initiation of all formulations of oxycodone?

Margaret Jordan
NPS facilitator
Illawarra Shoalhaven Medicare Local

Tania Colarco
Clinical pharmacist and NPS facilitator
Drug and Therapeutics Information Service (DATIS)
Repatriation General Hospital, Adelaide

Kirsty Lembke
Program officer
NPS, Sydney

Author's comments

Michael McDonough, author of the article, comments:

Thank you for raising two further questions from my article. As you have noted, I was also referring to the article about dose-dependent QTc prolongation by oxycodone.6

The concern is that drugs like oxycodone and others yet to be associated with QT prolongation appear to be identified later rather than sooner. We remain uncertain about the precise mechanism of fatal toxicity in both methadone- and more recently the rising number of oxycodone-related deaths in Victoria7 and the USA.8 However, the possibility, even if somewhat small, that QT prolongation may be a predisposing factor together with other arrhythmogenic risk factors – such as hypokalaemia, hypomagnesaemia, other drug interactions and heart disease – should be considered.

I believe baseline ECG recording is not appropriate as a screening recommendation because there is no evidence to guide the implementation of such a strategy. Also, this might give rise to concerns about degrees of variation in the QTc interval in various patients and potentially lead to excessive investigation and possibly over-intervention. Consensus recommendations about QTc monitoring in patients on methadone also draw attention to the controversies surrounding the management of degrees of QTc prolongation and the complexities involved in ‘risk versus benefit’ analyses in this scenario.9

I believe an annual ECG recording in the context of long-term and especially high-dose oxycodone treatment would constitute reasonable care and is preferable to not doing so. Furthermore, undertaking an ECG in any patient on oxycodone and with additional risk factors (mentioned above) would no doubt be a more compelling recommendation.


  1. Kalso E, Edwards JE, Moore RA, McQuay HJ. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 2004;112:372-80.
  2. Australian Medicines Handbook. Adelaide: AMH; 2012.
  3. eTG complete [internet]. Melbourne: Therapeutic Guidelines Limited; 2012.
  4. Fanoe S, Boje JensenG, Sjøgren P, Korsgaard MP, Grunnet M. Oxycodone is associated with dose-dependent QTc prolongation in patients and low-affinity inhibiting of hERG activity in vitro. Br J Clin Pharmacol 2009;67:172-9.
  5. Roxburgh A, Bruno R, Burns L. Prescription of opioid analgesics and related harms in Australia. Med J Aust 2011;195:280-4.
  6. Fanoe S, Boje Jensen G, Sjøgren P, Korsgaard MP, Grunnet M. Oxycodone is associated with dose-dependent QTc prolongation in patients and low-affinity inhibiting of hERG activity in vitro. Br J Clin Pharmacol 2009;67:172-9.
  7. Rintoul AC, Dobbin MD, Drummer OH, Ozanne-Smith J. Increasing deaths involving oxycodone, Victoria, Australia, 2000-09. Inj Prev 2011;17:254-9.
  8. Hall WD, Farrell MP. Minimising the misuse of oxycodone and other pharmaceutical opioids in Australia [editorial]. Med J Aust 2011;195:248-9.
  9. Krantz MJ, Martin J, Stimmel B, Mehta D, Haigney MC. QTc Interval Screening in methadone treatment. Ann Intern Med 2009;150:387-95.