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van der Ree MH, van Dussen L, Rosenberg N, Stolwijk N, van den Berg S, van der Wel V, Jacobs BAW, Wilde AAM, Hollak CEM, Postema PG. Effectiveness and safety of mexiletine in patients at risk for (recurrent) ventricular arrhythmias: a systematic review. Europace 2022; 24:1809-1823. [PMID: 36036670 DOI: 10.1093/europace/euac087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
While mexiletine has been used for over 40 years for prevention of (recurrent) ventricular arrhythmias and for myotonia, patient access has recently been critically endangered. Here we aim to demonstrate the effectiveness and safety of mexiletine in the treatment of patients with (recurrent) ventricular arrhythmias, emphasizing the absolute necessity of its accessibility. Studies were included in this systematic review (PROSPERO, CRD42020213434) if the efficacy or safety of mexiletine in any dose was evaluated in patients at risk for (recurrent) ventricular arrhythmias with or without comparison with alternative treatments (e.g. placebo). A systematic search was performed in Ovid MEDLINE, Embase, and in the clinical trial registry databases ClinicalTrials.gov and ICTRP. Risk of bias were assessed and tailored to the different study designs. Large heterogeneity in study designs and outcome measures prompted a narrative synthesis approach. In total, 221 studies were included reporting on 8970 patients treated with mexiletine. Age ranged from 0 to 88 years. A decrease in ventricular arrhythmias of >50% was observed in 72% of the studies for pre-mature ventricular complexes, 64% for ventricular tachycardia, and 33% for ventricular fibrillation. Electrocardiographic effects of mexiletine were small; only in a subset of patients with primary arrhythmia syndromes, a relative (desired) QTc decrease was reproducibly observed. As for adverse events, gastrointestinal complaints were most frequently observed (33% of the patients). In this systematic review, we present all the currently available knowledge of mexiletine in patients at risk for (recurrent) ventricular arrhythmias and show that mexiletine is both effective and safe.
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Affiliation(s)
- Martijn H van der Ree
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Laura van Dussen
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Noa Rosenberg
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Nina Stolwijk
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Sibren van den Berg
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent van der Wel
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Bart A W Jacobs
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
- Department of Pharmacy, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
| | - Arthur A M Wilde
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
| | - Carla E M Hollak
- Department of Endocrinology and Metabolism, Amsterdam UMC-University of Amsterdam, Meibergdreef 15, 1105 AZ Amsterdam, The Netherlands
- Medicine for Society, Platform at Amsterdam UMC-University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter G Postema
- Department of Clinical Cardiology, Heart Center, Amsterdam UMC-University of Amsterdam, Cardiovascular Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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Rahm AK, Müller ME, Gramlich D, Lugenbiel P, Uludag E, Rivinius R, Ullrich ND, Schmack B, Ruhparwar A, Heimberger T, Weis T, Karck M, Katus HA, Thomas D. Inhibition of cardiac K v4.3 (I to) channel isoforms by class I antiarrhythmic drugs lidocaine and mexiletine. Eur J Pharmacol 2020; 880:173159. [PMID: 32360350 DOI: 10.1016/j.ejphar.2020.173159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 04/01/2020] [Accepted: 04/23/2020] [Indexed: 12/29/2022]
Abstract
Transient outward K+ current, Ito, contributes to cardiac action potential generation and is primarily carried by Kv4.3 (KCND3) channels. Two Kv4.3 isoforms are expressed in human ventricle and show differential remodeling in heart failure (HF). Lidocaine and mexiletine may be applied in selected patients to suppress ventricular arrhythmias, without effects on sudden cardiac death or mortality. Isoform-dependent effects of antiarrhythmic drugs on Kv4.3 channels and potential implications for remodeling-based antiarrhythmic management have not been assessed to date. We sought to test the hypotheses that Kv4.3 channels are targeted by lidocaine and mexiletine, and that drug sensitivity is determined in isoform-specific manner. Expression of KCND3 isoforms was quantified using qRT-PCR in left ventricular samples of patients with HF due to either ischemic or dilated cardiomyopathies (ICM or DCM). Long (Kv4.3-L) and short (Kv4.3-S) isoforms were heterologously expressed in Xenopus laevis oocytes to study drug sensitivity and effects on biophysical characteristics activation, deactivation, inactivation, and recovery from inactivation. In the present HF patient cohort KCND3 isoform expression did not differ between ICM and DCM. In vitro, lidocaine (IC50-Kv4.3-L: 0.8 mM; IC50-Kv4.3-S: 1.2 mM) and mexiletine (IC50-Kv4.3-L: 146 μM; IC50-Kv4.3-S: 160 μM) inhibited Kv4.3 with different sensitivity. Biophysical analyses identified accelerated and enhanced inactivation combined with delayed recovery from inactivation as primary biophysical mechanisms underlying Kv4.3 current reduction. In conclusion, differential effects on Kv4.3 isoforms extend the electropharmacological profile of lidocaine and mexiletine. Patient-specific remodeling of Kv4.3 isoforms may determine individual drug responses and requires consideration during clinical application of compounds targeting Kv4.3.
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Affiliation(s)
- Ann-Kathrin Rahm
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Mara Elena Müller
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Dominik Gramlich
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Patrick Lugenbiel
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Ecem Uludag
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Rasmus Rivinius
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Nina D Ullrich
- DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; Institute of Physiology and Pathophysiology, Division of Cardiovascular Physiology, University of Heidelberg, Im Neuenheimer Feld 307, 69120, Heidelberg, Germany
| | - Bastian Schmack
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Tanja Heimberger
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Tanja Weis
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Hugo A Katus
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Dierk Thomas
- Department of Cardiology, Medical University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; HCR (Heidelberg Center for Heart Rhythm Disorders), University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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