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 commonly used as review points in practice. Treatment Companion App provides fixed built-in review thresholds, and every prompt they produce must be reviewed by a clinician.

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. When a clinician-entered value crosses a built-in threshold, the platform records a prompt with an acknowledgement trail for clinician review. It does not detect a patient condition or obtain the measurement itself.

• 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 Treatment Companion App 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.