Rare but relevant: Ibogaine and cardiovascular complications—prolonged QT interval and ventricular arrhythmias

Revived interest in psychedelic-assisted therapies has also renewed focus on ibogaine, a psychoactive alkaloid, for its notable anti-addictive potential. Evidence from observational, open-label, and limited randomized placebo-controlled trials indicates that ibogaine and its metabolite noribogaine reduce craving and withdrawal symptoms in opioid and cocaine-dependent individuals, primarily through multiple pharmacological mechanisms; however, ibogaine presents a rare yet clinically significant cardiotoxic risk: QTc prolongation and potentially fatal ventricular arrhythmias such as Torsades des Pointes. Case reports demonstrate that these events occur with therapeutic doses of ibogaine and in individuals without pre-existing cardiac conditions. A large interindividual variability in CYP2D6 metabolism of ibogaine was shown and might contribute to higher cardiovascular risk in certain individuals. Recent efforts to improve safety of ibogaine include different dosing strategies, cardiovascular monitoring and the development of ibogaine analogues, which retain anti-addictive efficacy while lacking cardiotoxicity in preclinical models. Future ibogaine-assisted treatment should be conducted exclusively under controlled medical supervision, with CYP2D6 genotyping and rigorous monitoring of cardiovascular functioning. Future clinical trials should prioritize evaluation of safer analogues and personalized dosing strategies to optimize the benefit-risk profile of this emerging therapy.