Cardiac and QTc screening before ibogaine treatment

The published case reports of deaths associated with ibogaine cluster around pre-existing cardiac disease, concurrent QT-prolonging medication, electrolyte disturbance, and unsupervised or unmonitored administration. Those are all things a screening process can find. A programme that documents its screen has a defensible clinical record; a programme that relies on a conversation does not.

The purpose of the screen is not to produce a number. It is to reach a documented decision — proceed, proceed with added monitoring or specialist input, or do not treat — attributed to a named prescriber on a date, with the evidence behind it attached.

• A resting 12-lead ECG with the QT interval measured and rate-corrected, read by someone qualified to read it rather than by an automated printout alone.
• Rhythm and structural history: known arrhythmia, conduction abnormality, cardiomyopathy, heart failure, prior myocardial infarction, valvular disease.
• Symptom history that suggests undiagnosed disease: syncope or near-syncope, exertional chest pain, unexplained palpitations, unexplained seizures.
• Family history of sudden unexplained death, long QT syndrome, Brugada syndrome or cardiomyopathy, particularly before age 50.
• Serum potassium and magnesium, and their correction before treatment rather than during it.
• Liver and kidney function, since ibogaine is metabolised by CYP2D6 and impaired clearance raises and prolongs exposure.
• A full medication and supplement review for QT-prolonging agents, CYP2D6 inhibitors, and interacting substances.
• Baseline heart rate and blood pressure, noting that ibogaine characteristically causes bradycardia and hypotension.

Thresholds are a matter for each programme's medical director and its jurisdiction's guidance. The values below are the ones most commonly used as alerting points in practice, and they are what Ibogaine NZ ships as configurable defaults.

Two points matter more than the numbers. First, a QTc figure is only meaningful if the correction formula is recorded alongside it — Bazett overcorrects at high heart rates and undercorrects at low ones, and ibogaine slows the heart. Second, an alert has to reach a person. Threshold checks that live in a browser tab are missed; alerts raised in the record itself, with an acknowledgement trail, are not.

• QT-prolonging agents: several antipsychotics, methadone, some antiarrhythmics, some macrolide and fluoroquinolone antibiotics, some antiemetics and antifungals.
• CYP2D6 inhibitors, including a number of SSRIs, which slow ibogaine clearance and raise exposure.
• Agents and conditions causing hypokalaemia or hypomagnesaemia, including diuretics, prolonged vomiting and eating disorders.
• Stimulant use, which changes cardiac risk on the day and belongs in the pre-dose check rather than only in the intake interview.

Reviewing a medication list is not the same as changing one. Any decision to stop, reduce, substitute or taper a prescription medicine is made and managed by the patient's own prescribing clinician — a treatment programme's role is to identify the risk, put it in writing, and refer.

A screen that lives in a PDF or a shared document is hard to audit and easy to skip under time pressure. The version that holds up records each finding as a field, derives the readiness status from those fields, blocks the workflow until the required investigations exist, and stores the prescriber's decision — reviewed, more information required, specialist referral required, or not currently ready — with a timestamp and a name against it.

That is what the readiness module in Ibogaine NZ is: an eleven-stage clinical workflow from registration to post-treatment monitoring, with cardiac and laboratory findings entered by clinicians, interaction flags carrying their evidence source and level, and a one-click clinical report for referral or for the file.