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Salmon SJ, Coleman AE, Lynn CR, Sanders JE, Messenger KM. Single- and multiple-dose pharmacokinetics of sotalol hydrochloride in healthy cats. J Vet Cardiol 2023; 51:86-96. [PMID: 38118234 DOI: 10.1016/j.jvc.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/22/2023]
Abstract
INTRODUCTION/OBJECTIVES The objective of this study was to describe the single- and multiple-dose pharmacokinetics and urinary elimination of sotalol in healthy cats. ANIMALS Six adult purpose-bred cats MATERIALS AND METHODS: Cats were administered 2 mg sotalol/kg body weight as a single intravenous bolus and as a single oral dose in a randomized crossover study with a 2-week washout period. The same cats then received 3 mg sotalol/kg orally every 12 h for 2 weeks. Blood samples were collected at predetermined time points for 48 h postdose for quantification of sotalol using ultra-high-pressure liquid chromatography with mass spectrometry. Non-compartmental analysis was used to obtain pharmacokinetic parameters. Data are presented as median (min-max). RESULTS Following intravenous administration, plasma clearance and volume of distribution were 9.22 mL/min/kg (5.69-10.89) and 2175.56 (1961-2341.57) mL/kg, respectively. Bioavailability was 88.41% (62.75-130.29) following a single oral dose. Peak plasma concentration (Cmax) and time to Cmax were 0.94 μg/mL (0.45-1.17) and 1.5 h (0.5-4) after a single oral dose (2 mg/kg), and 2.29 μg/mL (1.91-2.48) and 1.0 h (0.5-1.5) with chronic oral dosing (3 mg/kg), respectively. Elimination half-life was 2.75 h (2.52-4.10) and 4.29 h (3.33-5.53) for single and chronic oral dosing, respectively. Accumulation index was 1.17 (1.09-1.29) after chronic dosing. Urinary sotalol recovery was 81-108% of the intravenous dose. CONCLUSIONS Oral sotalol administration resulted in plasma concentrations reportedly efficacious in other species, with good to excellent oral bioavailability. Urinary excretion appears to be a major route of elimination. Following repeated oral dosing, minimal drug accumulation was estimated. Additional studies in cats are recommended due to the possibility of nonlinear kinetics.
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Affiliation(s)
- S J Salmon
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, 2200 College Station Road, Athens, GA, 30605, USA
| | - A E Coleman
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, 2200 College Station Road, Athens, GA, 30605, USA.
| | - C R Lynn
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, 2200 College Station Road, Athens, GA, 30605, USA
| | - J E Sanders
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, 2200 College Station Road, Athens, GA, 30605, USA
| | - K M Messenger
- Department of Molecular Biomedical Sciences, North Carolina State University College of Veterinary Medicine, 1060 William Moore Drive, Raleigh, NC, 27607, USA
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Bouchard J, Shepherd G, Hoffman RS, Gosselin S, Roberts DM, Li Y, Nolin TD, Lavergne V, Ghannoum M. Extracorporeal treatment for poisoning to beta-adrenergic antagonists: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2021; 25:201. [PMID: 34112223 PMCID: PMC8194226 DOI: 10.1186/s13054-021-03585-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/26/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND β-adrenergic antagonists (BAAs) are used to treat cardiovascular disease such as ischemic heart disease, congestive heart failure, dysrhythmias, and hypertension. Poisoning from BAAs can lead to severe morbidity and mortality. We aimed to determine the utility of extracorporeal treatments (ECTRs) in BAAs poisoning. METHODS We conducted systematic reviews of the literature, screened studies, extracted data, and summarized findings following published EXTRIP methods. RESULTS A total of 76 studies (4 in vitro and 2 animal experiments, 1 pharmacokinetic simulation study, 37 pharmacokinetic studies on patients with end-stage kidney disease, and 32 case reports or case series) met inclusion criteria. Toxicokinetic or pharmacokinetic data were available on 334 patients (including 73 for atenolol, 54 for propranolol, and 17 for sotalol). For intermittent hemodialysis, atenolol, nadolol, practolol, and sotalol were assessed as dialyzable; acebutolol, bisoprolol, and metipranolol were assessed as moderately dialyzable; metoprolol and talinolol were considered slightly dialyzable; and betaxolol, carvedilol, labetalol, mepindolol, propranolol, and timolol were considered not dialyzable. Data were available for clinical analysis on 37 BAA poisoned patients (including 9 patients for atenolol, 9 for propranolol, and 9 for sotalol), and no reliable comparison between the ECTR cohort and historical controls treated with standard care alone could be performed. The EXTRIP workgroup recommends against using ECTR for patients severely poisoned with propranolol (strong recommendation, very low quality evidence). The workgroup offered no recommendation for ECTR in patients severely poisoned with atenolol or sotalol because of apparent balance of risks and benefits, except for impaired kidney function in which ECTR is suggested (weak recommendation, very low quality of evidence). Indications for ECTR in patients with impaired kidney function include refractory bradycardia and hypotension for atenolol or sotalol poisoning, and recurrent torsade de pointes for sotalol. Although other BAAs were considered dialyzable, clinical data were too limited to develop recommendations. CONCLUSIONS BAAs have different properties affecting their removal by ECTR. The EXTRIP workgroup assessed propranolol as non-dialyzable. Atenolol and sotalol were assessed as dialyzable in patients with kidney impairment, and the workgroup suggests ECTR in patients severely poisoned with these drugs when aforementioned indications are present.
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Affiliation(s)
- Josée Bouchard
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC, Canada
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Centre Antipoison du Québec, Quebec, QC, Canada
| | - Darren M Roberts
- Departments of Renal Medicine and Transplantation and Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, PA, USA
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-L'île-de-Montréal, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, QC, Canada.
- Verdun Hospital, 4000 Lasalle Boulevard, Verdun, Montreal, QC, H4G 2A3, Canada.
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Ting C, Malloy R, Knowles D. Assessment of Sotalol and Dofetilide Dosing at a Large Academic Medical Center. J Cardiovasc Pharmacol Ther 2020; 25:438-443. [PMID: 32347108 DOI: 10.1177/1074248420921740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients initiated on sotalol and dofetilide require inpatient monitoring and dose adjustments due to risks of corrected QT (QTc) prolongation and Torsades de pointes (TdP). Patients may receive higher initial doses than recommended due to close monitoring by specialized practitioners. The objective of this study was to describe prescribing practices of sotalol and dofetilide and to compare safety outcomes between standard and nonstandard dosing strategies. METHODS This was a single-center retrospective analysis of adult inpatients who underwent sotalol or dofetilide initiation between June 1, 2015, and August 1, 2018. The end points of this study included the percentage of patients who received standard and nonstandard dosing, incidence of QTc prolongation (≥500 milliseconds or ≥15% from baseline), incidence of TdP, and dose reduction or medication discontinuation. RESULTS A total of 379 patients (195 sotalol and 184 dofetilide) were included in this analysis. There were 110 (56.4%) patients in the sotalol group and 111 (58.4%) patients in the dofetilide group that received nonstandard initial dosing. Nonstandard dosing was associated with a greater incidence of QTc prolongation compared to standard dosing (57.5% vs 43.0%, P = .005). Only one patient in the nonstandard dosing group experienced TdP. Patients initiated on nonstandard dosing required dose reduction or therapy discontinuation (37.6% vs 23.4%, P = .003) more frequently. CONCLUSION Higher than recommended initial doses of sotalol or dofetilide were associated with higher incidence of QTc prolongation and more frequent therapy modification.
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Affiliation(s)
- Clara Ting
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Rhynn Malloy
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Danielle Knowles
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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Malá Z, Gebauer P. Capillary isotachophoresis with electrospray-ionization mass-spectrometric detection: Cationic electrolyte systems in the medium-alkaline range for selective analysis of medium strong bases. J Chromatogr A 2020; 1618:460907. [PMID: 31987524 DOI: 10.1016/j.chroma.2020.460907] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 01/13/2023]
Abstract
This work extends the present working range of isotachophoresis (ITP) with electrospray-ionization mass-spectrometric (ESI-MS) detection and describes for the first time a functional cationic electrolyte system for analyses at medium-alkaline pH. So far no ITP-MS application was published on the analysis of medium strong bases although there is a broad spectrum of potential analytes like biogenic amines, alkaloids or drugs, where this technique promises interesting gains in both sensitivity and specificity. The presented results include a selection of suitable sufficiently volatile ESI-compatible system components, discussion of factors affecting system properties, and recommendations for functional ITP electrolyte systems. Theoretical conclusions based on calculations and computer simulations are confirmed by experiments with a model mixture of beta-blockers. Practical applicability of the method is demonstrated on the example of analysis of sotalol in dried blood spots where direct injection of aqueous extract, ITP stacking and MS detection provide a fast, simple and sensitive technique with limits of quantitation on the sub-nM level.
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Affiliation(s)
- Zdena Malá
- Institute of Analytical Chemistry of the Czech Academy of Sciences, v.v.i., Veveří 97, CZ-602 00 Brno, Czech Republic
| | - Petr Gebauer
- Institute of Analytical Chemistry of the Czech Academy of Sciences, v.v.i., Veveří 97, CZ-602 00 Brno, Czech Republic.
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Biswas M, Levy A, Weber R, Tarakji K, Chung M, Noseworthy PA, Newton-Cheh C, Rosenberg MA. Multicenter Analysis of Dosing Protocols for Sotalol Initiation. J Cardiovasc Pharmacol Ther 2019; 25:212-218. [PMID: 31707834 DOI: 10.1177/1074248419887710] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Sotalol, a Vaughan-Williams Class III antiarrhythmic medication, is used to manage atrial arrhythmias. Due to its QT-prolonging effect and subsequent increased risk of torsade de pointes, many centers admit patients during the initial dosing period. Despite its widespread use, little information is available regarding dosing protocols during this period. In this multicenter investigation, dosing protocols in patients initiating sotalol therapy were examined to identify predictors of successful sotalol initiation. Over a 4-year period, patients admitted to 5 hospitals in the United States for inpatient telemetry monitoring during initiation for nonresearch purposes were enrolled. A 3-day course of 5 of 6 doses of sotalol was considered successful completion of the loading protocol. Of the 213 enrolled patients, over 90% were successfully discharged on sotalol. Significant bradycardia, ineffectiveness, and excessive QT prolongation were reasons for failed completion. Absence of a dose adjustment was a strong predictor of successful initiation (odds ratio: 6.6, 95% confidence interval: 1.3-32.7, P = .02). Hypertension, use of a calcium channel blocker, use of a separate β-blocker, and presence of a pacemaker were predictors of dose adjustments. Marginal structural models (ie, inverse probability weighting based on probability of a dose adjustment) verified that these factors also predicted successful initiation via preventing any dose adjustment and suggests that considering these factors may result in a higher likelihood of successful initiation in future investigations. In conclusion, we found that the majority of patients admitted for sotalol initiation are successfully discharged on the medication. The study findings suggest that factors predicting need for dose adjustment can be used to identify patients who could undergo outpatient initiation. Prospective studies are needed to verify this approach.
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Affiliation(s)
- Minakshi Biswas
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew Levy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rachel Weber
- Division of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Khaldoun Tarakji
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mina Chung
- Center for Atrial Fibrillation, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | - Christopher Newton-Cheh
- Cardiovascular Research Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael A Rosenberg
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Aonuma K, Shiga T, Atarashi H, Doki K, Echizen H, Hagiwara N, Hasegawa J, Hayashi H, Hirao K, Ichida F, Ikeda T, Maeda Y, Matsumoto N, Sakaeda T, Shimizu W, Sugawara M, Totsuka K, Tsuchishita Y, Ueno K, Watanabe E, Hashiguchi M, Hirata S, Kasai H, Matsumoto Y, Nogami A, Sekiguchi Y, Shinohara T, Sugiyama A, Sumitomo N, Suzuki A, Takahashi N, Yukawa E, Homma M, Horie M, Inoue H, Ito H, Miura T, Ohe T, Shinozaki K, Tanaka K. Guidelines for Therapeutic Drug Monitoring of Cardiovascular Drugs Clinical Use of Blood Drug Concentration Monitoring (JCS 2015) ― Digest Version ―. Circ J 2017; 81:581-612. [DOI: 10.1253/circj.cj-66-0138] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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7
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Pharmacokinetics of intravenously and orally administered sotalol hydrochloride in horses and effects on surface electrocardiogram and left ventricular systolic function. Vet J 2016; 208:60-4. [DOI: 10.1016/j.tvjl.2015.09.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 09/22/2015] [Accepted: 09/24/2015] [Indexed: 11/22/2022]
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Himmel HM, Bussek A, Hoffmann M, Beckmann R, Lohmann H, Schmidt M, Wettwer E. Field and action potential recordings in heart slices: correlation with established in vitro and in vivo models. Br J Pharmacol 2012; 166:276-96. [PMID: 22074238 PMCID: PMC3415654 DOI: 10.1111/j.1476-5381.2011.01775.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 09/23/2011] [Accepted: 09/29/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Action potential (AP) recordings in ex vivo heart preparations constitute an important component of the preclinical cardiac safety assessment according to the ICH S7B guideline. Most AP measurement models are sensitive, predictive and informative but suffer from a low throughput. Here, effects of selected anti-arrhythmics (flecainide, quinidine, atenolol, sotalol, dofetilide, nifedipine, verapamil) on field/action potentials (FP/AP) of guinea pig and rabbit ventricular slices are presented and compared with data from established in vitro and in vivo models. EXPERIMENTAL APPROACH Data from measurements of membrane currents (hERG, I(Na) ), AP/FP (guinea pig and rabbit ventricular slices), AP (rabbit Purkinje fibre), haemodynamic/ECG parameters (conscious, telemetered dog) were collected, compared and correlated to complementary published data (focused literature search). KEY RESULTS The selected anti-arrhythmics, flecainide, quinidine, atenolol, sotalol, dofetilide, nifedipine and verapamil, influenced the shape of AP/FP of guinea pig and rabbit ventricular slices in a manner similar to that observed for rabbit PF. The findings obtained from slice preparations are in line with measurements of membrane currents in vitro, papillary muscle AP in vitro and haemodynamic/ECG parameters from conscious dogs in vivo, and were also corroborated by published data. CONCLUSION AND IMPLICATIONS FP and AP recordings from heart slices correlated well with established in vitro and in vivo models in terms of pharmacology and predictability. Heart slice preparations yield similar results as papillary muscle but offer enhanced throughput for mechanistic investigations and may substantially reduce the use of laboratory animals.
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Ayad RF, Assar MD, Simpson L, Garner JB, Schussler JM. Causes and management of drug-induced long QT syndrome. Proc (Bayl Univ Med Cent) 2011; 23:250-5. [PMID: 20671821 DOI: 10.1080/08998280.2010.11928628] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Long QT syndrome (LQTS) is characterized by inherited or acquired prolonged QT interval on the surface electrocardiogram. This can lead to torsade de pointes ventricular tachycardia (TdP VT) and ventricular fibrillation. In the acquired form of the disease, medications from several classes can cause TdP VT or potentiate the electrocardiographic findings. These include class IA and III antiarrhythmics, antibiotics (macrolides and quinolones), antidepressants (tricyclics and selective serotonin reuptake inhibitors), antipsychotics (haloperidol and phenothiazines), and antiemetics (ondansetron and prochlorperazine). We present four cases of drug-induced LQTS resulting in life-threatening cardiac arrhythmias. Antiarrhythmic medications were the cause in two cases, and the other two cases involved noncardiac medications. All four patients had at least one risk factor for LQTS in addition to the offending drug, including female gender, hypokalemia, hypomagnesemia, and bradycardia. In one patient, amiodarone was administered for treatment of VT, although the correct diagnosis was actually TdP VT. In patients with polymorphic VT or ventricular fibrillation without a significant history of cardiovascular disease, drug-induced LQTS should be high in the differential diagnosis. Prompt diagnosis is key, as amiodarone, while often used to suppress VT, is potentially harmful in the setting of LQTS and TdP VT.
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Affiliation(s)
- Ramy F Ayad
- Division of Cardiology, Department of Internal Medicine, Baylor Jack and Jane hamilton Heart and Vascular Hospital and Baylor University Medical Center at Dallas
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Prior H, McMahon N, Schofield J, Valentin JP. Non-invasive telemetric electrocardiogram assessment in conscious beagle dogs. J Pharmacol Toxicol Methods 2009; 60:167-73. [PMID: 19539041 DOI: 10.1016/j.vascn.2009.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 06/09/2009] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The primary objective of this investigation was to evaluate the sensitivity of a non-invasive telemetry system for the detection of drug-induced electrocardiogram (ECG) changes in conscious, freely moving dogs. A secondary objective was to compare, in the same set of dogs, ECG data acquired by a non-invasive system with data acquired from a surgically implanted telemetry device (invasive system). METHODS Continuous beat-to-beat Lead II ECG data were simultaneously acquired from 6 male dogs using a non-invasive and an invasive telemetry system for 1h pre-dose and 6h following a sham control dose or single oral doses of (+/-) sotalol (4, 8 or 16 mg/kg). ECG parameters of heart rate, RR, PQ, QRS, QT and QT corrected for heart rate according to Van de Water (QTcV) and by an individual linear regression formula (QTcR), were determined. RESULTS AND DISCUSSION Statistically significant dose-dependent reduction of heart rate, and increases in PQ, QT and QTc (V and R) were detected at all dose levels of (+/-) sotalol, with partial recovery during the 6-hour monitoring period. Statistically significant correlations for heart rate, RR, PQ, QT and QTc (V and R) were found between the two systems. QRS duration did not correlate. However, the difference between the two systems was consistent over the range studied. Based on these findings, the non-invasive system is quantitatively comparable to invasive telemetry, and can be used successfully to acquire continuous ECG data on a beat-to-beat basis from conscious freely moving dogs for at least 6h post-dose.
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Affiliation(s)
- Helen Prior
- Safety Assessment UK, AstraZeneca UK Ltd, Mereside, Alderley Park, Macclesfield, Cheshire, SK10 4TG, England, United Kingdom.
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Srivastava A, Khan MA, Watkiss J. Post induction arrhythmia in a renal patient: an unexpected risk factor. Anaesthesia 2009; 64:439-43. [PMID: 19317712 DOI: 10.1111/j.1365-2044.2008.05783.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 44 year-old woman was anaesthetised for a transplant nephrectomy. About 10 min after induction of anaesthesia she had several runs of ventricular tachycardia followed by ventricular fibrillation requiring 30 s of cardiopulmonary resuscitation, after which she reverted to sinus rhythm. Review of her chest X-ray, suggested that the haemodialysis catheter (Permcath) position may have precipitated this event. However, subsequent investigation found that she had toxic serum levels of sotalol, with a prolonged corrected QT interval on the electrocardiogram. She was started on sotalol while her renal graft was functioning well but it was not reviewed when the graft started to fail and she had to commence haemodialysis. This led to the accumulation of sotalol and explains her serum sotalol value of 7.1 mg x l(-1) on the day of the event. Concentrations greater than 2.5 mg x l(-1) are generally considered toxic.
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SALERNO DAVIDM. Part IV: Class II, Class III, and Class IV Antiarrhythmic Drugs, Comparative Efficacy of Drugs, and Effect of Drugs on Mortality - A Review of Their Pharmaco kinetics, Efficacy, and Toxicity*. J Cardiovasc Electrophysiol 2008. [DOI: 10.1111/j.1540-8167.1991.tb01714.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lynch JJ, Wilson AW, Hernandez LE, Nelson RA, Marsh KC, Cox BF, Mittelstadt SW. Dose-response effects of sotalol on cardiovascular function in conscious, freely moving cynomolgus monkeys. Br J Pharmacol 2008; 154:1439-45. [PMID: 18516073 DOI: 10.1038/bjp.2008.206] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND AND PURPOSE The non-selective beta-adrenoceptor antagonist, D,L-sotalol (sotalol) is commonly employed as a positive control during preclinical cardiovascular safety pharmacology testing, mainly because of its ability to prolong QT interval duration. However, no information appears in the literature, except in abstract form, regarding the dose-response effects of sotalol in unanesthetized monkeys. The current study was conducted to determine the dose- and plasma-response effects of orally administered sotalol on cardiovascular function in conscious non-human primates. EXPERIMENTAL APPROACH Male cynomolgus monkeys were implanted with telemetry devices and the effects of sotalol hydrochloride (5, 10 and 30 mg kg(-1) of body weight, p.o.) on arterial blood pressure, heart rate, body temperature and electrocardiogram waveform were continuously monitored for 6 h after dosing. Blood was sampled for the measurement of plasma concentrations of sotalol. KEY RESULTS Sotalol dose dependently decreased heart rate and prolonged RR, PR, QT and corrected QT intervals, while having little or no effects on the QRS complex, arterial pressure or body temperature, over the dose range tested. When the data were related to plasma concentrations of sotalol, it was clear that the cardiovascular effects occurred in a similar pattern and to a comparable degree as those reported in human studies. CONCLUSIONS AND IMPLICATIONS The current study helps demonstrate the validity of utilizing telemetry-instrumented non-human primates for the cardiovascular safety pharmacology assessment of drugs prior to first-in-human testing, and its findings may serve as a reference source for the dose- and plasma-response effects of orally administered sotalol in conscious monkeys.
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Affiliation(s)
- J J Lynch
- Department of Integrative Pharmacology, Global Pharmaceutical Research and Development, Abbott Laboratories, Abbott Park, IL 60064-6119, USA.
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Hirst C, Cook S, Dai W, Perez-Gutthann S, Andrews E. A call for international harmonization in therapeutic risk management. Pharmacoepidemiol Drug Saf 2006; 15:839-49; discussion 850-1. [PMID: 16981215 DOI: 10.1002/pds.1319] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Therapeutic risk management is required to ensure that the benefits of a particular drug outweigh the risks in general practice. Current risk management strategies and handling of risk management and pharmacovigilance issues differ across borders. Differences in key regulatory decisions on the same product around the world, including the handling of safety issues with cisapride, dofetilide, and isotretinoin, bring into question the robustness of these decisions and the procedures currently in place to manage the risks to the public of products with potentially unfavorable risk-benefit balances. These differences may be partly due to differences in health care systems, regulatory requirements and procedures, and cultures. Greater international harmonization in approaches to risk management potentially would improve safety of medicines around the world by developing a greater uniformity in acquiring and interpreting risk-benefit evidence. The appropriateness and effectiveness of risk management interventions in different regions should be examined, and international strategies should be 'fine-tuned' for each regional health care setting. Recently issued international guidance on risk management and pharmacovigilance may help to improve consistency of decision-making around the world and promote better international communication and collaboration.
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Läer S, Elshoff JP, Meibohm B, Weil J, Mir TS, Zhang W, Hulpke-Wette M. Development of a safe and effective pediatric dosing regimen for sotalol based on population pharmacokinetics and pharmacodynamics in children with supraventricular tachycardia. J Am Coll Cardiol 2005; 46:1322-30. [PMID: 16198851 DOI: 10.1016/j.jacc.2005.06.061] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Revised: 06/04/2005] [Accepted: 06/13/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The objective of this study was to develop age-specific dosage guidelines for sotalol in children with supraventricular tachycardia (SVT) based on a population pharmacokinetic covariate analysis, clinical trial simulations, and pharmacodynamics. BACKGROUND A rapid onset of an effective and safe antiarrhythmic sotalol therapy, especially for infants and neonates, is frequently delayed because of age-dependent interpatient variability in pharmacokinetics and pharmacodynamics. METHODS Pediatric patients with SVT (mean age 3.51 years [range 0.03 to 17 years]) were analyzed after oral sotalol doses of 1.0 to 9.9 mg/kg/day using population pharmacokinetic analysis and clinical trial simulation (n = 76), pharmacokinetic/pharmacodynamic modeling for QT interval prolongation (n = 32), and for the concentration-antiarrhythmic-response relationship (n = 15). RESULTS Inter-individual differences in oral clearance and volume of distribution could largely be attributed to size and weight differences, with an additional age effect on clearance in children younger than one year. Neonates showed a higher sensitivity toward QTc interval prolongation compared with older patients. In a subgroup of 15 patients, one-half of the patients converted into sinus rhythm at sotalol trough levels of 0.4 mug/ml and more than 95% at 1.0 mug/ml. Dosing recommendations derived for different age groups based on these findings were starting dose and target dose of 2 and 4 mg/kg/day for neonates, 3 and 6 mg/kg/day for infants and children <6 years, and 2 and 4 mg/kg/day for children >6 years. CONCLUSIONS This study provides an example for rational drug dosage in children that copes with interpatient variability and can be easily switched to an individually guided therapy based on effective sotalol trough levels.
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Affiliation(s)
- Stephanie Läer
- Department of Clinical Pharmacy and Therapeutics, University Düsseldorf, Düsseldorf, Germany.
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16
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Sasaki H, Shimizu N, Suganami H, Yamamoto K. QT PRODACT: Inter-facility Variability in Electrocardiographic and Hemodynamic Parameters in Conscious Dogs and Monkeys. J Pharmacol Sci 2005; 99:513-22. [PMID: 16493191 DOI: 10.1254/jphs.qt-b6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
In safety pharmacology studies, the effect of a test compound on the electrocardiogram is routinely examined by using conscious dogs. However, the results may be widely variable. The monkey, on the other hand, has scarcely been used for such studies; and as yet, there have not been reported studies on monkeys conducted at several facilities with a standard protocol. In the present study, we examined inter-facility variabilities in electrocardiographic and hemodynamic parameters as described below. We analyzed the data from 8 facilities (9 test groups) on dogs and 5 facilities (7 test groups) on monkeys. This data was obtained from the studies employing the following standard protocol: dl-Sotalol or a vehicle (0.5 w/v% methylcellulose solution) was given to animals; and the PR interval, QRS duration, QT interval, heart rate, and mean blood pressure were determined time-sequentially before and after administration of the vehicle or dl-sotalol in each test group. dl-Sotalol produced a prolongation of the maximum mean QTcF interval in conscious dogs and QTcB interval in conscious monkeys by more than 10% in every test group. No difference in the corrected QT interval among the test groups was observed in dogs, but a difference was observed in monkeys.
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Affiliation(s)
- Hiroyuki Sasaki
- Japan Pharmaceutical Manufacturers Association (JPMA)/QT PRODACT, Tokyo, Japan.
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17
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LaPointe NMA, Pamer CA, Kramer JM. New antiarrhythmic agents for atrial fibrillation and atrial flutter: United States drug market response as an indicator of acceptance. Pharmacotherapy 2004; 23:1316-21. [PMID: 14594348 DOI: 10.1592/phco.23.12.1316.32703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine how well dofetilide and Betapace AF (sotalol, approved solely for atrial fibrillation and atrial flutter), with their detailed dosing and monitoring guidelines for safety, were accepted into clinical practice during the 2 calendar years after their introduction. METHODS AND RESULTS We reviewed the number of new, refill, and total prescriptions of all antiarrhythmic agents in the United States from April 2000-December 2001 to assess use of dofetilide and Betapace AF in the drug market. Both were prescribed very infrequently throughout the study period. In addition, the infrequent reported use of these drugs for patients with atrial fibrillation and flutter indicated poor acceptance of these agents by prescribing physicians. We speculated that the restricted distribution and required educational program for dofetilide, as well as the availability of generic sotalol products, may have discouraged physicians from prescribing both dofetilide and Betapace AE CONCLUSION: A common goal for both the dofetilide risk-management program and the creation of a sotalol product indicated solely for atrial fibrillation and atrial flutter was to provide safer treatment for patients with these arrhythmias. Unfortunately, limited penetration of dofetilide and Betapace AF into the U.S. market suggests that drugs without a risk-management program or detailed dosing guidelines were more likely than dofetilide or Betapace AF to be selected for treatment of atrial fibrillation and atrial flutter.
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Affiliation(s)
- Nancy M Allen LaPointe
- Duke Center for Education and Research on Therapeutics, Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715, USA.
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18
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Allen LaPointe NM, Chen A, Hammill B, DeLong E, Kramer JM, Califf RM. Evaluation of the dofetilide risk-management program. Am Heart J 2004; 146:894-901. [PMID: 14597941 DOI: 10.1016/s0002-8703(03)00409-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dose-dependent torsades de pointes has been shown to occur with dofetilide (Tikosyn) and sotalol HCl (Betapace AF); thus, detailed dosing and monitoring recommendations to minimize this risk are included in the product labeling for both drugs. Only dofetilide, however, has a mandated risk-management program that restricts distribution of the drug and requires prescriber education on the drug. We investigated whether this program improved adherence to dosing and monitoring recommendations for dofetilide as compared with sotalol. METHODS Charts for 47 patients taking dofetilide and 117 patients taking sotalol were reviewed. RESULTS The recommended starting dose was prescribed more frequently in the dofetilide group than in the sotalol group (79% vs 35%, P <.001). A higher number of patients in the dofetilide group compared with the sotalol group received the recommended baseline tests for potassium (100% vs 82%, P <.001), magnesium (89% vs 38%, P <.001), serum creatinine (100% vs 82%, P <.001), and electrocardiography (94% vs 67%, P <.001). A significantly greater proportion of patients in the dofetilide group received recommended electrocardiograms obtained after the first dose (94% for dofetilide vs 43% for sotalol, P <.001) and subsequent doses (80% for dofetilide vs 3.5% for sotalol, P <.001). CONCLUSION Better adherence to several dosing and monitoring recommendations in the dofetilide group may be caused by the presence of the risk-management program. However, low usage of dofetilide during the study period may signify an unintended, negative consequence of the risk-management program.
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Affiliation(s)
- Nancy M Allen LaPointe
- Duke Center for Education and Research on Therapeutics and the Division of Cardiology, Duke Clinical Research Institute, Durham, NC 27715, USA.
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19
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Abstract
Drug-induced QT interval prolongation is now a major concern in safety pharmacology. Regulatory authorities such as the US FDA and the European Medicines Agency require in vitro testing of all drug candidates against the potential risk for QT interval prolongation prior to clinical trials. Common in vitro methods include organ models (Langendorff heart), conventional electrophysiology on cardiac myocytes, and heterologous expression systems of human ether-a-go-go-related gene (hERG) channels. A novel approach is to study electrophysiological properties of cultured cardiac myocytes by micro-electrode arrays (MEA). This technology utilises multi channel recording from an array of embedded substrate-integrated extracellular electrodes using cardiac tissue from the ventricles of embryonic chickens. The detected field potentials allow a partial reconstruction of the shape and time course of the underlying action potential. In particular, the duration of action potentials of ventricular myocytes is closely related to the QT interval on an ECG. This novel technique was used to study reference substances with a reported QT interval prolonging effect. These substances were E4031, amiodarone, quinidine and sotalol. These substances show a significant prolongation of the field potential. However, verapamil, a typical 'false positive' when using the hERG assay does not cause any field potential prolongation using the MEA assay. Whereas the heterologous hERG assay limits cardiac repolarisation to just one channel, the MEA assay reflects the full range of mechanisms involved in cardiac action potential regulation. In summary, screening compounds in cardiac myocytes with the MEA technology against QT interval prolongation can overcome the problem of a single cell assay to potentially report 'false positives'.
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Affiliation(s)
- Thomas Meyer
- Multi Channel Systems MCS GmbH, Reutlingen, Germany.
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20
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Abstract
Most antiarrhythmic drugs fulfil the formal requirements for rational use of therapeutic drug monitoring, as they show highly variable plasma concentration profiles at a given dose and a direct concentration-effect relationship. Therapeutic ranges for antiarrhythmic drugs are, however, often very poorly defined. Effective drug concentrations are based on small studies or studies not designed to establish a therapeutic range, with varying dosage regimens and unstandardised sampling procedures. There are large numbers of nonresponders and considerable overlap between therapeutic and toxic concentrations. Furthermore, no study has ever shown that therapeutic drug monitoring makes a significant difference in clinical outcome. Therapeutic concentration ranges for antiarrhythmic drugs as they exist today can give an overall impression about the drug concentrations required in the majority of patients. They may also be helpful for dosage adjustment in patients with renal or hepatic failure or in patients with possible toxicological or compliance problems. Their use in optimising individual antiarrhythmic therapy, however, is very limited.
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Affiliation(s)
- Gesche Jürgens
- Department of Clinical Pharmacology, Copenhagen University Hospital, Copenhagen, Denmark.
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21
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Meurs KM, Spier AW, Wright NA, Atkins CE, DeFrancesco TC, Gordon SG, Hamlin RL, Keene BW, Miller MW, Moise NS. Comparison of the effects of four antiarrhythmic treatments for familial ventricular arrhythmias in Boxers. J Am Vet Med Assoc 2002; 221:522-7. [PMID: 12184702 DOI: 10.2460/javma.2002.221.522] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effect of 4 antiarrhythmic treatment protocols on number of ventricular premature complexes (VPC), severity of arrhythmia, heart rate (HR), and number of syncopal episodes in Boxers with ventricular tachyarrhythmias. DESIGN Randomized controlled clinical trial. ANIMALS 49 Boxers. PROCEDURE Dogs with > 500 VPC/24 h via 24-hour ambulatory ECG (AECG) were treated with atenolol (n = 11), procainamide (11), sotalol (16), or mexiletine and atenolol (11) for 21 to 28 days. Results of pre- and posttreatment AECG were compared with regard to number of VPC/24 h; maximum, mean, and minimum HR; severity of arrhythmia; and occurrence of syncope. RESULTS Significant differences between pre- and posttreatment number of VPC, severity of arrhythmia, HR variables, or occurrence of syncope were not observed in dogs treated with atenolol or procainamide. Significant reductions in number of VPC, severity of arrythmia, and maximum and mean HR were observed in dogs treated with mexiletine-atenolol or sotalol; occurrence of syncope was not significantly different between these 2 treatment groups. CONCLUSIONS AND CLINICAL RELEVANCE Treatment with sotalol or mexiletine-atenolol was well tolerated and efficacious. Treatment with procainamide or atenolol was not effective.
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Affiliation(s)
- Kathryn M Meurs
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus 43210, USA
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22
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Abstract
Atrial fibrillation (AF) is the commonest arrhythmia. It presents in distinct patterns of paroxysmal, persistent and chronic AF, and patient management aims differ according to the pattern. In paroxysmal AF, drug treatment with beta-blockers, class Ic and class III agents reduce the frequency and duration of episodes. In persistent AF (recent onset, non-paroxysmal), early cardioversion with either pharmacological agents or by direct current (DC) cardioversion should be actively considered, in those patients who are suitable. Patients most likely to cardiovert and remain in sinus rhythm include those with duration of AF of <1 year, an acute reversible cause, left atrial diameter <50 mm and good left ventricular function on echocardiography. Recent data show that maintenance of sinus rhythm after successful cardioversion is enhanced by the use of class III drugs including amiodarone and dofetilide. In chronic or permanent AF, management is aimed at controlling the ventricular rate response with combinations of digoxin, beta-blockers and calcium antagonists with atrio-ventricular nodal activity (diltiazem and verapamil). There is some debate about the prognostic significance of AF. Certainly AF is associated with an excess mortality but this is largely accounted for by its association with serious intrinsic heart disease and the thrombo-embolic complications of the arrhythmia. Atrial fibrillation is a common default arrhythmia for the sick heart.
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Affiliation(s)
- K S Channer
- Royal Hallamshire Hospital, Sheffield, England
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23
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Gintant GA, Limberis JT, McDermott JS, Wegner CD, Cox BF. The canine Purkinje fiber: an in vitro model system for acquired long QT syndrome and drug-induced arrhythmogenesis. J Cardiovasc Pharmacol 2001; 37:607-18. [PMID: 11336111 DOI: 10.1097/00005344-200105000-00012] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Torsade de pointes is a rare but potentially fatal ventricular arrhythmia associated with drug-induced delayed repolarization and prolongation of the QT interval. To determine if the arrhythmogenic potential of noncardiac drugs can be assessed in vitro, we evaluated the effects of 12 drugs on the action potential duration (APD) of cardiac Purkinje fibers and compared results with clinical observations. APD changes in canine and porcine fibers were evaluated under physiologic conditions (37 degrees C, [K+]0 = 4 mM) using standard microelectrode techniques. Six of seven drugs associated with QT prolongation or torsade de pointes in man (cisapride, erythromycin, grepafloxacin, moxifloxacin, sertindole, and sotalol) affected concentration-dependent prolongation of the APD in canine fibers during slow stimulation (2-s basic cycle length), attaining greater than 15% prolongation at high concentrations (> or = 10-fold clinically encountered plasma levels). Each of five drugs not linked clinically to QT prolongation and torsade de pointes (azithromycin, enalaprilat, fluoxetine, indomethacin, and pinacidil) failed to attain 15% prolongation, with fluoxetine, indomethacin, and pinacidil abbreviating the APD. Drugs eliciting the greatest prolongation also demonstrated prominent reverse rate-dependent effects. The antihistamine terfenadine (linked to dose-dependent QT prolongation and torsade de pointes clinically) only minimally prolonged the APD in canine and porcine fibers (and exerted no effect on midmyocardial fibers from left ventricular free wall) at supratherapeutic concentrations. On the basis of concentration-dependent APD prolongation and reverse rate-dependent effects, this Purkinje fiber model detects six of seven drugs linked clinically to acquired long QT syndrome and torsade de pointes, and clears each of five drugs not associated with repolarization abnormalities (overall 92% accuracy), validating the utility of this Purkinje fiber model in the preclinical evaluation of QT prolongation and proarrhythmic risk by noncardiac drugs.
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Affiliation(s)
- G A Gintant
- Department of Integrative Pharmacology, Abbott Laboratories, Abbott Park, Illinois 60064-6119, USA
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Santos SR, Papini O, Omosako CE, Pereira MD, Quintavalle TB, Riccio MF, Kurata A, Pereira VA, Di-Pietro G, Della-Paschoa OE, Danhof M, Da-Luz PL. A simple HPLC-fluorescence method for the measurement of R,S-sotalol in the plasma of patients with life-threatening cardiac arrhythmias. Braz J Med Biol Res 2000; 33:199-204. [PMID: 10657059 DOI: 10.1590/s0100-879x2000000200006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
R,S-sotalol, a ss-blocker drug with class III antiarrhythmic properties, is prescribed to patients with ventricular, atrial and supraventricular arrhythmias. A simple and sensitive method based on HPLC-fluorescence is described for the quantification of R,S-sotalol racemate in 500 microl of plasma. R,S-sotalol and its internal standard (atenolol) were eluted after 5.9 and 8.5 min, respectively, from a 4-micron C18 reverse-phase column using a mobile phase consisting of 80 mM KH2PO4, pH 4.6, and acetonitrile (95:5, v/v) at a flow rate of 0.5 ml/min with detection at lambdaex = 235 nm and lambdaem = 310 nm, respectively. This method, validated on the basis of R,S-sotalol measurements in spiked blank plasma, presented 20 ng/ml sensitivity, 20-10,000 ng/ml linearity, and 2.9 and 4.8% intra- and interassay precision, respectively. Plasma sotalol concentrations were determined by applying this method to investigate five high-risk patients with atrial fibrillation admitted to the Emergency Service of the Medical School Hospital, who received sotalol, 160 mg po, as loading dose. Blood samples were collected from a peripheral vein at zero, 0.5, 1.0, 1.5, 2.0, 3.0, 4. 0, 6.0, 8.0, 12.0 and 24.0 h after drug administration. A two-compartment open model was applied. Data obtained, expressed as mean, were: C MAX = 1230 ng/ml, T MAX = 1.8 h, AUC T = 10645 ng h-1 ml-1, Kab = 1.23 h-1, alpha = 0.95 h-1, ss = 0.09 h-1, t((1/2))ss = 7.8 h, ClT/F = 3.94 ml min-1 kg-1, and Vd/F = 2.53 l/kg. A good systemic availability and a fast absorption were obtained. Drug distribution was reduced to the same extent in terms of total body clearance when patients and healthy volunteers were compared, and consequently elimination half-life remained unchanged. Thus, the method described in the present study is useful for therapeutic drug monitoring purposes, pharmacokinetic investigation and pharmacokinetic-pharmacodynamic sotalol studies in patients with tachyarrhythmias.
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Affiliation(s)
- S R Santos
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina and Faculdade de Ciências Farmacêuticas, Universidade de São Paulo, São Paulo, SP, Brasil
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25
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Lip G. How Would I Manage a 60–year-old Woman Presenting with Atrial Fibrillation? J R Coll Physicians Edinb 1999. [DOI: 10.1177/147827159902900407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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26
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Ammer R, Lehmann G, Plewan A, Puetter K, Alt E. Marked reduction in atrial defibrillation thresholds with repeated internal cardioversion. J Am Coll Cardiol 1999; 34:1569-76. [PMID: 10551708 DOI: 10.1016/s0735-1097(99)00377-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study was performed to assess the atrial defibrillation threshold in patients with recurrent atrial fibrillation (AF) using repeated internal cardioversion. BACKGROUND Previous studies in patients with chronic AF undergoing internal cardioversion have shown this method to be effective and safe. However, current energy requirements might preclude patients with longer-lasting AF from being eligible for an implantable atrial defibrillator. METHODS Internal shocks were delivered via defibrillation electrodes placed in the right atrium (cathode) and the coronary sinus (anode) or the right atrium (cathode) and the left pulmonary artery. After cardioversion, patients were orally treated with sotalol (mean 189 +/- 63 mg/day). Eighty consecutive patients with chronic AF (mean duration 291 +/- 237 days) underwent internal cardioversion, and sinus rhythm was restored in 74 patients. Eighteen patients underwent repeated internal cardioversion using the same electrode position and shock configuration after recurrence of AF (mean duration 34 +/- 25 days). RESULTS In these 18 patients, the overall mean defibrillation threshold was 6.67 +/- 3.09 J for the first cardioversion and 3.83 +/- 2.62 J for the second (p = 0.003). Mean lead impedance was 55.6 +/- 5.1 ohms and 57.1 +/- 3.7 ohms, respectively (not significant). For sedation, 6.7 +/- 2.9 mg and 3.9 +/- 2.2 mg midazolam were administered intravenously (p = 0.003), and the pain score (0 = not felt, 10 = intolerable) was 5.1 +/- 1.9 and 2.7 +/- 1.8 (p = 0.001). Uni- and multivariate analyses revealed only the duration of AF before cardioversion to be of relevance, lasting 175 +/- 113 days before the first and 34 +/- 25 days before the second cardioversion in these 18 patients (p = 0.002). CONCLUSIONS If the duration of AF is reduced, a significant reduction in defibrillation energy requirements for internal cardioversion ensues. This might extend the group of patients eligible for an implantable atrial defibrillator despite relatively high initial defibrillation thresholds.
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Affiliation(s)
- R Ammer
- Medizinische Klinik, Klinikum Rechts der Isar der Technischen Universität München, Munich, Germany
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27
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Abstract
Aggravation of arrhythmia with antiarrhythmic drugs is not an infrequent side effect associated with antiarrhythmic drugs. Defined as the provocation of a new arrhythmia or a significant increase in the frequency of a preexisting arrhythmia, it occurs with all antiarrhythmic agents, although the incidence varies from 6% to 23% with the different drugs. In general, arrhythmia aggravation is an early event, occurring within the first several days of initiating drugs therapy. It has been found, however, that this complication can also occur as a late event, particularly in patients who have evidence of ongoing ischemia that may be overt or silent. Although there is no good way to predict the patient who is likely to experience this complication, it has been observed that there several predictors of an increased risk for experiencing arrhythmia aggravation including significant underlying heart disease, congestive heart failure, evidence of active or potentially active ischemia, and electrolyte abnormalities, particularly hypokalemia.
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Affiliation(s)
- P J Podrid
- Section of Cardiology, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118-2393, USA
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28
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Steeds RP, Birchall AS, Smith M, Channer KS. An open label, randomised, crossover study comparing sotalol and atenolol in the treatment of symptomatic paroxysmal atrial fibrillation. Heart 1999; 82:170-5. [PMID: 10409530 PMCID: PMC1729147 DOI: 10.1136/hrt.82.2.170] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare sotalol and atenolol in the treatment of symptomatic paroxysmal atrial fibrillation. DESIGN Prospective, randomised, open label, crossover study. SETTING University hospital. PATIENTS 47 subjects aged over 50 years were recruited from the hospital outpatient department following ECG documentation of paroxysmal atrial fibrillation that coincided with symptoms. Six patients withdrew and 41 completed the trial. INTERVENTIONS Patients were randomised to one month's treatment with sotalol 80 mg twice daily or atenolol 50 mg once daily. Treatment arms were then crossed over. Patients underwent 72 hour Holter monitoring before randomisation and repeat studies were carried out at the end of both treatment periods. Symptom assessments were completed using linear analogue scales and the Nottingham health profile. MAIN OUTCOME MEASURE Frequency of paroxysmal atrial fibrillation; secondary outcome measures included average and total duration of paroxysmal atrial fibrillation, total ectopic count, and symptom assessments. RESULTS A reduction in the number and duration of episodes of paroxysmal atrial fibrillation was noted following treatment with sotalol and atenolol. There was no difference in frequency of paroxysmal atrial fibrillation during treatment with sotalol or atenolol (median difference 0; 95% confidence interval (CI) 0 to 1; p = 0.47). There was no difference in total duration of paroxysmal atrial fibrillation (median difference 0 min; 95% CI -1 to 2; p = 0. 51) or in average duration (median difference 0 min; 95% CI 0 to 1; p = 0.31). No difference was found in total ectopic count between sotalol and atenolol (median difference -123; 95% CI -362 to 135; p = 0.14). Treatments were equally tolerated with no difference in linear analogue scores for symptoms of paroxysmal atrial fibrillation (median difference -5; 95% CI -20 to 5; p = 0.26) or in all categories of the Nottingham health profile. CONCLUSIONS No difference was found in terms of ECG or symptomatic control of paroxysmal atrial fibrillation between prescribing sotalol 80 mg twice daily and atenolol 50 mg once daily. There was an improvement in paroxysmal atrial fibrillation from baseline following treatment with either sotalol or atenolol.
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Affiliation(s)
- R P Steeds
- Department of Cardiology, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK
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29
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Seidl K, Hauer B, Schwick NG, Zahn R, Senges J. Comparison of metoprolol and sotalol in preventing ventricular tachyarrhythmias after the implantation of a cardioverter/defibrillator. Am J Cardiol 1998; 82:744-8. [PMID: 9761084 DOI: 10.1016/s0002-9149(98)00478-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The purpose of this prospective study was to evaluate, on an intention-to-treat basis, the efficacy of d,l-sotalol and metoprolol with regards to the recurrence of arrhythmic events after implantable cardioverter defibrillator (ICD) implantation. After ICD implantation, 70 patients were randomly assigned to treatment with either metoprolol (mean dosage 104+/-37 mg/day in 35 patients) or d,l-sotalol (mean dosage 242+/-109 mg/day in 35 patients). During follow up ventricular tachycardia (VT), fast VT, and ventricular fibrillation (VF) episodes were calculated. Metoprolol treatment led to a marked reduction in the recurrence of arrhythmic events. Actuarial rates for absence of VT recurrence at 1 and 2 years were significantly higher in the metoprolol group compared with the d,l-sotalol group (83% and 80% vs 57% and 51%, respectively, p=0.016). The actuarial rates for absence of fast VT or VF were 80% in the metoprolol group compared with 46% in the d,l-sotalol group (p=0.002). During a follow up of 26+/-16 months, there were 3 deaths in the metoprolol group compared with 6 deaths in the d,l-sotalol group. Actuarial rates of overall survival were not significantly different in the 2 groups (91% vs 83%, p=0.287). In this prospective, randomized, controlled study the recurrence rate of ventricular tachyarrhythmias in patients treated with metoprolol was lower than in patients treated by d,l-sotolol.
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Affiliation(s)
- K Seidl
- Department of Cardiology, Herzzentrum Ludwigshafen, Germany
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30
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Abstract
Beta blockers have traditionally been considered relatively poor antiarrhythmic agents for patients with ventricular arrhythmias. This view is based on the observations that beta blockers are less effective in suppressing spontaneous ventricular ectopy or inducible ventricular arrhythmias than are the class I and class III agents. However, there are convincing data that beta blockers can have a clinically important antiarrhythmic effect and prevent arrhythmic and sudden death. Beta blockers have multiple potential effects that can contribute to a therapeutic antiarrhythmic action, including an antiadrenergic/vagomimetic effect, a decrease in ventricular fibrillation threshold, and prevention of a catecholamine reversal of concomitant class I/III antiarrhythmic drug effects. Postinfarction trials, recent congestive heart failure studies, and observations in patients who are at risk for sustained ventricular arrhythmias all suggest a potent antiarrhythmic effect of beta blockade.
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Affiliation(s)
- M J Reiter
- University of Colorado Health Sciences Center, Denver 80262, USA
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31
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Eckardt L, Haverkamp W, Göttker U, Madeja M, Johna R, Borggrefe M, Breithardt G. Divergent effect of acute ventricular dilatation on the electrophysiologic characteristics of d,l-sotalol and flecainide in the isolated rabbit heart. J Cardiovasc Electrophysiol 1998; 9:366-83. [PMID: 9581953 DOI: 10.1111/j.1540-8167.1998.tb00925.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The interaction between acute ventricular dilatation (AVD) as one aspect of ventricular dysfunction and Class I and III antiarrhythmic drugs is uncertain. We therefore investigated the effects of AVD on the electrophysiologic properties of d,l-sotalol and flecainide. METHODS AND RESULTS The isolated rabbit heart was used as a model of AVD. The ventricular size and, therefore, the diastolic pressure were modified by sudden volume changes of a fluid-filled balloon placed in the left ventricle. Pacing was performed alternately using epi- and endocardial monophasic action potential (MAP)-pacing catheters at cycle lengths from 1,000 to 300 msec. d,l-Sotalol (10 microM) resulted in a significant (P < 0.05) lengthening of refractoriness (+13.5% +/- 3.1%), MAP duration (+14.9% +/- 3.2%), and QT interval (+15.5% +/- 4.1%) (mean +/- SEM at 1,000 msec). These effects had a reverse rate-dependence. AVD to a diastolic pressure of 30 mmHg reduced refractoriness and left ventricular MAP duration. In comparison with the control group with the same extent of AVD, d,l-sotalol still led to a significant prolongation of repolarization for all cycle lengths except 300 msec, so that its effects were not absolutely but relatively preserved. In contrast, flecainide (2 microM) had no significant effects on refractoriness or MAP duration. It led to a significant, rate-dependent increase of pacing thresholds (+47.6% +/- 8.2%), prolongation of QRS (+48.8% +/- 5.6%), and conduction time (+78.6% +/- 8.6%) (mean +/- SEM at 300 msec). In the flecainide group, AVD significantly increased the normal rate-dependent prolongation of QRS (+16.7% +/- 5.5%) and conduction time (+17.1% +/- 4.3%). CONCLUSION Our data demonstrate that, during AVD, the Class III effect of d,l-sotalol is preserved, whereas flecainide's effect of slowing conduction is exaggerated. This may contribute to flecainide-related proarrhythmia in certain clinical situations.
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Affiliation(s)
- L Eckardt
- Hospital of the Westfälische Wilhelms-University, Department of Cardiology and Angiology and Institute for Arteriosclerosis Research, Münster, Germany.
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Abstract
Atrial fibrillation is an extremely common arrhythmia that is associated with significant sequelae. Certain aspects of therapy, such as anticoagulation, are studied in well-constructed randomized trials. Other therapy, such as the maintenance of sinus rhythm with antiarrhythmic agents, is supported by limited evidence. This article reviews the epidemiology and medical treatment of this arrhythmia, addressing anticoagulation, ventricular rate control, and restoration and maintenance of sinus rhythm. Randomized trials in progress that attempt to answer important questions in the management of atrial fibrillation are also discussed.
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Affiliation(s)
- F A Masoudi
- Department of Medicine, University of Colorado Health Sciences Center, Denver, USA
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Link MS, Foote CB, Sloan SB, Homoud MK, Wang PJ, Estes NA. Torsade de pointes and prolonged QT interval from surreptitious use of sotalol: use of drug levels in diagnosis. Chest 1997; 112:556-7. [PMID: 9266902 DOI: 10.1378/chest.112.2.556] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Torsade de pointes is a well-established toxic effect of sotalol hydrochloride. In a patient presenting with torsade de pointes and a long QTc interval of unknown cause, a serum sotalol level was used to secure an otherwise difficult diagnosis.
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Affiliation(s)
- M S Link
- Cardiac Arrhythmia Service, Tufts/New England Medical Center, Boston, MA 02111, USA
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Lehmann MH, Hardy S, Archibald D, quart B, MacNeil DJ. Sex difference in risk of torsade de pointes with d,l-sotalol. Circulation 1996; 94:2535-41. [PMID: 8921798 DOI: 10.1161/01.cir.94.10.2535] [Citation(s) in RCA: 336] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The present study was undertaken to test the hypothesis that women are more prone than men to develop torsade de pointes (TdP) in a defined cohort of patients exposed to the QT-prolonging antiarrhythmic drug d,l-sotalol. METHODS AND RESULTS In a database derived from 22 clinical trials involving 3135 adult patients who received oral d,l-sotalol (median follow-up, 164 days), TdP developed in 44 (1.9%) of 2336 men and in 33 (4.1%) of 799 women (P < .001). Logistic regression analysis identified female sex (P < .0001), presenting arrhythmia of sustained ventricular tachycardia or fibrillation (P < .0001), history of congestive heart failure (P < .001), and d,l-sotalol dose > 320 mg/d (P < .001) as factors most predictive of TdP; in addition to these, a serum creatinine > 1.4 mg/dL in women and > 1.6 mg/dL in men was weakly predictive (P < .05). After adjustment for these risk factors, women had threefold greater odds of developing TdP than men. The sex difference in TdP risk was age independent and could not be explained by differential dose-related bradycardic responses in women versus men. CONCLUSIONS Women are at increased risk of developing TdP during-administration of d,l-sotalol. This finding needs to be taken into account, together with other TdP risk factors, when patients are treated with this antiarrhythmic agent. Given the consistency between the present and other recent observations, greater caution in women regarding use of QT-prolonging drugs, in general, is advisable.
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Affiliation(s)
- M H Lehmann
- Department of Medicine/Division of Cardiology, Sinai Hospital, Detroit, Mich 48235, USA
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35
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Uemura H, Hara Y, Endou M, Mori K, Nakaya H. Interaction of class III antiarrhythmic drugs with muscarinic M2 and M3 receptors: radioligand binding and functional studies. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 1995; 353:73-9. [PMID: 8750919 DOI: 10.1007/bf00168918] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We have recently reported that class III antiarrhythmic drugs inhibit the muscarinic acetylcholine (ACh) receptor-operated K+ current (IK,ACh) in guinea-pig atrial cells by different molecular mechanisms. The data obtained from the patch-clamp study suggest that D,L-sotalol inhibits IK,ACh by blocking the muscarinic receptors, whereas MS-551 inhibits the K+ current by blocking the muscarinic receptors and depressing the function of the K+ channel itself and/or the guanine nucleotide-binding protein (G protein). This study was undertaken to determine whether the class III antiarrhythmic drugs D,L-sotalol and MS-551 interact with the muscarinic receptors of cardiac and peripheral tissues. Both drugs inhibited concentration dependently the specific [3H]N-methylscopolamine ([3H]-NMS) binding to membrane preparations obtained from guinea-pig atria and submandibular glands. The competition curves of these drugs for [3H]-NMS binding to glandular membranes were monophasic, suggesting competition with [3H]-NMS at a single site. Although the competition curve of D,L-sotalol for [3H]-NMS binding to atrial membranes was monophasic, that of MS-551 was biphasic and showed high- and low-affinity states of binding. D,L-Sotalol showed slightly, but significantly, higher affinity for cardiac-type muscarinic receptors (M2) than for glandular-type muscarinic receptors (M3). The inhibition constant (Ki) for MS-551 in glandular membranes was also slightly greater than the high-affinity Ki value for the drug in atrial membranes. In guinea-pig left atria and ilea, D,L-sotalol shifted the concentration-response curves for the negative inotropic effect and the contracting effect of carbachol in a parallel manner. The slopes of Schild plot were not significantly different from unity, suggesting competitive antagonism, and the pA2 for D,L-sotalol in left atria was slightly greater than that in ilea. MS-551 also shifted the concentration response curve for the negative inotropic effect of carbachol in atrial preparations to a greater extent than that for the contracting effect in ileal preparations, although MS-551 failed to show a pure competitive antagonism. These results suggest that both D,L-sotalol and MS-551 interact with cardiac M2 and peripheral M3 receptors, and that at high concentrations they exert anticholinergic activity in cardiac and peripheral tissues.
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Affiliation(s)
- H Uemura
- Department of Pharmacology, School of Medicine, Chiba University, Japan
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36
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Stafford PJ, Cooper J, de Bono DP, Vincent R, Garratt CJ. Effect of low dose sotalol on the signal averaged P wave in patients with paroxysmal atrial fibrillation. Heart 1995; 74:636-40. [PMID: 8541169 PMCID: PMC484120 DOI: 10.1136/hrt.74.6.636] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To investigate the effects of low dose sotalol on the signal averaged surface P wave in patients with paroxysmal atrial fibrillation. DESIGN A longitudinal within patient crossover study. SETTING Cardiac departments of a regional cardiothoracic centre and a district general hospital. PATIENTS Sixteen patients with documented paroxysmal atrial fibrillation. The median (range) age of the patients was 65.5 (36-70) years; 11 were men. MAIN OUTCOME MEASURES Analysis of the signal averaged P wave recorded from patients not receiving antiarrhythmic medication and after 4-6 weeks' treatment with sotalol. P wave limits were defined automatically by a computer algorithm. Filtered P wave duration and energies contained in frequency bands from 20, 30, 40, 60, and 80 to 150 Hz of the P wave spectrum expressed as absolute values (P20, P30, etc) and as ratios of high to low frequency energy (PR20, PR30, etc) were measured. RESULTS No difference in P wave duration was observed between the groups studied (mean (SEM) 149 (4) without medication and 152 (3) ms with sotalol). Significant decreases in high frequency P wave energy (for example P60: 4.3 (0.4) v 3.3 (0.3) microV2.s, P = 0.003) and energy ratio (PR60: 5.6 (0.5) v 4.7 (0.6), P = 0.03) were observed during sotalol treatment. These changes were independent of heart rate. CONCLUSIONS Treatment with low dose sotalol reduces high frequency P wave energy but does not change P wave duration. These results are consistent with the class III effect of the drug and suggest that signal averaging of the surface P wave may be a useful non-invasive measure of drug induced changes in atrial electrophysiology.
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Affiliation(s)
- P J Stafford
- Academic Department of Cardiology, Glenfield General Hospital, Leicester
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37
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Shimizu T, Hiraoka M, Nakanomyo H. Enantioselective determination of sotalol enantiomers in biological fluids using high-performance liquid chromatography. JOURNAL OF CHROMATOGRAPHY. B, BIOMEDICAL APPLICATIONS 1995; 674:77-83. [PMID: 8749254 DOI: 10.1016/0378-4347(95)00304-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A simple and sensitive high-performance liquid chromatographic (HPLC) method for the determination of (+)-(S)-sotalol and (-)-(R)-sotalol in biological fluids was established. Following extraction with isopropyl alcohol from biological samples on a Sep-Pak C18 cartridge, the eluent was derivatized with 2,3,4,6-tetra-O-acetyl-beta-D-glucopyranosyl isothiocyanate (GITC). The diastereoisomeric derivates were resolved by HPLC with UV detection at 225 nm. Calibration was linear from 0.022 to 4.41 micrograms/ml in human plasma and from 0.22 to 88.2 micrograms/ml in human urine for both (+)-(S)- and (-)-(R)-sotalol. The lower limit of determination was 0.022 microgram/ml for plasma and 0.22 microgram/ml for urine. The within-day and day-to-day coefficients of variation were less than 7.5% for each enantiomer at 0.09 and 1.8 microgram/ml in plasma and at 0.44 and 4.4 micrograms/ml in urine. The method is also applicable to other biological specimens such as rat, mouse and rabbit plasma.
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Affiliation(s)
- T Shimizu
- Kanagawa Laboratories, Bristol-Myers Squibb, Japan
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38
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Mori K, Hara Y, Saito T, Masuda Y, Nakaya H. Anticholinergic effects of class III antiarrhythmic drugs in guinea pig atrial cells. Different molecular mechanisms. Circulation 1995; 91:2834-43. [PMID: 7758191 DOI: 10.1161/01.cir.91.11.2834] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND It is well known that vagal stimulation increases the vulnerability to atrial fibrillation via muscarinic receptor-mediated shortening of refractory period. Recently it has been reported that some class III antiarrhythmic drugs effectively terminate or prevent atrial flutter and fibrillation by prolonging atrial effective refractory period. However, effects of class III antiarrhythmic drugs on the muscarinic acetylcholine receptor-operated K+ current (IK.ACh), which is important for the repolarization phase of the action potential in atrial cells, have not been thoroughly examined. METHODS AND RESULTS Effects of three class III antiarrhythmic drugs, d,l-sotalol, E-4031, and MS-551, on the carbachol (1 mumol/L)-induced action potential shortening and outward K+ current were examined in guinea pig atrial cells by conventional microelectrode and patch clamp techniques. In isolated left atria, d,l-sotalol (100 mumol/L), E-4031 (3 mumol/L), and MS-551 (30 mumol/L) partially reversed the carbachol-induced action potential shortening. In isolated single atrial cells, IK.ACh was activated by extracellular application of carbachol (1 mumol/L) or adenosine (10 mumol/L) or by intracellular loading of GTP gamma S (100 mumol/L). Sotalol (3 to 1000 mumol/L), E-4031 (1 to 100 mumol/L), and MS-551 (1 to 100 mumol/L) inhibited the carbachol-induced IK.ACh in a concentration-dependent manner, and their IC50 (half-maximal inhibition) values were 35.5, 7.8, and 11.4 mumol/L, respectively. However, the GTP gamma S-induced and adenosine-induced IK.ACh were inhibited by high concentrations of E-4031 and MS-551 but not by sotalol. CONCLUSIONS Sotalol may inhibit IK.ACh by the blockade of the atrial muscarinic receptors, whereas E-4031 and MS-551 may inhibit the current not only by blocking the muscarinic receptors but also by depressing the function of the K+ channel itself and/or G proteins. These drugs may potentially be useful for the prevention and termination of atrial flutter and fibrillation through their inhibitory action on IK.ACh.
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Affiliation(s)
- K Mori
- Department of Pharmacology, School of Medicine, Chiba University, Japan
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39
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Abstract
Sotalol is a water-soluble, nonselective, beta-adrenergic blocker that was recently approved in oral form in the United States for the treatment of ventricular arrhythmias that are judged to be life-threatening. As a beta-blocker, sotalol is unique in having additional class-III antiarrhythmic activity. It is still not resolved whether sotalol is more effective than other beta-blockers in managing arrhythmias, but there are suggestions that it might possess greater antiarrhythmic and life-protecting activities than other types of antiarrhythmic drugs. The drug is well tolerated, but, because of its electrophysiologic activity, there is a small risk of proarrhythmia, specifically the development of polymorphic ventricular tachycardia and torsade de pointes.
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Affiliation(s)
- E Cavusoglu
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
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40
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Claudel JP, Touboul P. Sotalol: from "just another beta blocker" to "the prototype of class III antidysrhythmic compound". Pacing Clin Electrophysiol 1995; 18:451-67. [PMID: 7770366 DOI: 10.1111/j.1540-8159.1995.tb02545.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Sotalol is a beta-blocking drug devoid of membrane stabilizing properties, as well as intrinsic sympathomimetic actions, or cardioselectivity. In addition, sotalol prolongs atrial and ventricular repolarization (Class III antiarrhythmic activity). It appears to have less myocardial depressant effect than other beta-blocking agents. Given orally, bioavailability of the drug reaches 100%. Sotalol's plasma half-life is 15 hours (range 7-18) and is dependent only on renal function. In clinical practice, it has been found effective in the suppression of nearly all supraventricular and ventricular dysrhythmias except those related to prolonged ventricular repolarization. Most common adverse effects are dyspnea, bradycardia, and fatigue, which results in drug termination in 16% of the cases. Torsades de pointes usually associated with bradycardia and drug induced QTc prolongation has been reported in 1.9%-3.5% of the patients receiving sotalol. This complication may be reduced by limiting the dose (< 640 mg/day) especially in patients with impaired renal function. In addition hypokalemia must be avoided. To sum up, the combination of Class II and Class III effects may carry additional benefits. However, further studies are required to test such hypotheses.
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Affiliation(s)
- J P Claudel
- Service de Soins Intensifs Cardiologiques (U-51), Hôpital Cardiovasculaire Louis Pradel, Lyon, France
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41
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Singh BN, Kehoe R, Woosley RL, Scheinman M, Quart B. Multicenter trial of sotalol compared with procainamide in the suppression of inducible ventricular tachycardia: a double-blind, randomized parallel evaluation. Sotalol Multicenter Study Group. Am Heart J 1995; 129:87-97. [PMID: 7817931 DOI: 10.1016/0002-8703(95)90048-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Sotalol is the prototype class III agent that combines beta-blocking properties with the propensity to prolong the effective refractory period by lengthening the action potential duration. Its precise effect on the prevention of ventricular tachycardia-ventricular fibrillation (VTVF) compared to class I agents has not been evaluated in a blinded study. In a double-blind parallel-design multicenter study, the electrophysiologic and antiarrhythmic effects of intravenous and oral sotalol (n = 55) and procainamide (n = 55) were therefore compared in patients with VTVF inducible by programmed electric stimulation. Sotalol produced a greater effect on lengthening the ventricular effective refractory period (VERP). It prevented the inducibility of VTVF in 30% versus 20% for procainamide, but this was not significantly different. In an alternate therapy group (n = 41) of similar patients previously refractory to or intolerant of procainamide, intravenous sotalol prevented inducibility in 32%. The pooled overall sotalol efficacy rate was 31%. There was a significant relation between the increase in the VERP and the prevention of inducibility of VTVF (n = 56; p < 0.02). VERP of > or = 300 msec was critical for the prevention of VTVF inducibility. Thirteen sotalol and 6 procainamide responders from the randomized group and 30 from the nonrandomized groups completed 1 year of oral sotalol therapy follow-up. Life-table analysis of these patient in each group showed a trend in favor of sotalol; however, statistical analysis was not possible because of the small numbers of patients. Both sotalol and procainamide were well tolerated. In the randomized group there was one case of sudden death during treatment with sotalol and two cases of nonfatal torsades de pointes in the procainamide group and two in the sotalol group; in the nonrandomized alternate therapy group, there were 6 cases of nonfatal torsades de pointes. The data support the emerging role of sotalol in the control of symptomatic ventricular tachycardia and fibrillation.
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Affiliation(s)
- B N Singh
- Department of Cardiology, Veterans Affairs Medical Center of West Los Angeles, CA 90073
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42
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Abstract
Sotalol is a novel antiarrhythmic agent combining beta-adrenergic-antagonist actions with the ability to increase cardiac repolarization and refractoriness. The drug's electrophysiologic and clinical profile is different from that of conventional beta-receptor antagonists. As compared with other antiarrhythmic agents, sotalol prevents recurrences of arrhythmia in a higher proportion of patients, particularly among those presenting with ventricular tachycardia and aborted sudden cardiac death. The net hemodynamic effect of sotalol is the result of a balance between the depressant effects due to beta-receptor blockade and an action that tends to increase contractility. Although initially marketed in the United States for treatment of life-threatening ventricular arrhythmias, sotalol also has demonstrated efficacy in many patients with supraventricular arrhythmias. As with all drugs that prolong the QT interval, the syndrome of torsade de pointes is a serious potential adverse effect.
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Affiliation(s)
- S H Hohnloser
- Department of Cardiology, University Hospital, Freiburg, Germany
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43
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Patrick GM, Pollock CA, Ibels LS, Caterson RJ. Sotalol and end-stage renal failure. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1994; 24:319-20. [PMID: 7980222 DOI: 10.1111/j.1445-5994.1994.tb02185.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- G M Patrick
- Department of Renal Medicine, Royal North Shore Hospital, Sydney, NSW
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44
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Böcker D, Breithardt G, Block M, Borggrefe M. Management of patients with ventricular tachyarrhythmias: does an optimal therapy exist? Pacing Clin Electrophysiol 1994; 17:559-70. [PMID: 7513887 DOI: 10.1111/j.1540-8159.1994.tb01426.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- D Böcker
- Hospital of the Westfälische Wilhelms-University of Münster, Germany
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45
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Labhasetwar V, Underwood T, Gallagher M, Murphy G, Langberg J, Levy RJ. Sotalol controlled-release systems for arrhythmias: in vitro characterization, in vivo drug disposition, and electrophysiologic effects. J Pharm Sci 1994; 83:156-64. [PMID: 8169781 DOI: 10.1002/jps.2600830209] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
An array of controlled-release formulations of sotalol were investigated for epicardial drug delivery in short-term and chronic long-term treatment models with dogs. A nondegradable matrix formulation of sotalol made with polyurethane was studied by use of short-term treatment model with dogs, and the electrophysiologic effects were compared with those resulting from an intravenous dose of 2 mg/kg of body weight. Epicardial sotalol-polyurethane matrices were also used in 7-day canine implant studies. A sotalol-silicone rubber matrix was used in 60-day epicardial canine implant studies. A biodegradable poly(dl-lactide-co-glycolide) (PLGA) microsphere formulation of sotalol was also studied as a pericardial injection in another series involving 30-day dog experiments. The short-term treatment electrophysiologic effects observed with the epicardial (left ventricular) implantation of a sotalol-polyurethane matrix formulation were comparable to those observed with intravenous sotalol. However, the total dose delivered by the matrix over a 2-h experimental period was 25 times smaller than the intravenous dose (0.077 versus 2 mg/kg). Furthermore, coronary venous sotalol levels after sotalol-polyurethane matrix implantation were in the therapeutic range (1812.4 +/- 415.1 ng/mL), whereas simultaneous peripheral venous levels were more than 1 order of magnitude lower (149.8 +/- 14.1 ng/mL). An intravenous bolus administration of sotalol (2 mg/kg) resulted in coronary venous levels (1537.1 +/- 44.6 ng/mL) that were very close to simultaneous peripheral venous levels (1428.6 +/- 63.9 ng/mL).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- V Labhasetwar
- Department of Pediatrics, University of Michigan, Ann Arbor 48109
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46
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Abstract
OBJECTIVE To review the pharmacology, pharmacokinetic, dosing, adverse effects, and therapeutic uses of sotalol. DATA IDENTIFICATION Articles were identified with an English-language literature computer search via Knowledge Finder, using the term sotalol, and with an extensive search of bibliographies of identified articles. STUDY SELECTION Relevant or representative animal studies, human trials, and case reports were selected for evaluation. DATA EXTRACTION The literature was assessed for quality, methodology, and outcome information. DATA SYNTHESIS Sotalol is a racemic compound with Class II (beta-blocking properties) and Class III (prolonged action potential) antiarrhythmic activity. It has been suggested that the plasma concentration associated with QTc prolongation (a measure of the Class III action) is much greater than that associated with beta-blockade. Therefore, sotalol is categorized as a Class III antiarrhythmic agent. The 1-isomer is responsible for the beta-blocking activity, whereas both isomers have Class III properties. After oral dosing in fasting patients with normal renal function, sotalol is > 90 percent absorbed, achieves peak serum concentrations in 2-4 h, is excreted unchanged 80-90 percent in the urine, has a volume of distribution of 1-2 L/kg, and has an elimination half-life of about 12 h. Sotalol is effective in patients with life-threatening ventricular arrhythmias that have been refractory to other conventional antiarrhythmic drugs. In general, sotalol appears to be well tolerated, with many of its adverse effects caused by beta-blocking activity. As with other antiarrhythmic agents, the possibility of proarrhythmia (frequently torsade de pointes) exists. CONCLUSIONS Racemic sotalol is an effective Class III antiarrhythmic agent approved by the Food and Drug Administration for the treatment of documented life-threatening ventricular arrhythmias. Investigations continue with racemic sotalol in the management of supraventricular arrhythmias. Trials with the d-isomer are also ongoing.
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Affiliation(s)
- J M Nappi
- Department of Hospital Pharmacy Practice and Administration, College of Pharmacy, Medical University of South Carolina, Charleston 29425
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47
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Fitton A, Sorkin EM. Sotalol. An updated review of its pharmacological properties and therapeutic use in cardiac arrhythmias. Drugs 1993; 46:678-719. [PMID: 7506652 DOI: 10.2165/00003495-199346040-00007] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Sotalol is a nonselective beta-adrenoceptor antagonist which prolongs cardiac repolarisation independently of its antiadrenergic action (class III antiarrhythmic properties). The antiarrhythmic action of sotalol appears to arise predominantly from its class III properties, and the drug exhibits a broader antiarrhythmic profile than the conventional beta-blockers. Sotalol is effective in controlling paroxysmal supraventricular tachycardias and the ventricular response to atrial fibrillation/flutter in Wolff-Parkinson-White syndrome, in maintaining sinus rhythm after cardioversion of atrial fibrillation/flutter, and in preventing initiation of supraventricular tachyarrhythmias following coronary artery bypass surgery. Sotalol shows promise in the control of nonmalignant and life-threatening ventricular arrhythmias, particularly those associated with ischaemic heart disease. It is effective in suppressing complex forms of ventricular ectopy, displaying superior antiectopic activity to propranolol and metoprolol. The acute efficacy of sotalol in preventing reinduction of sustained ventricular tachyarrhythmias and suppressing spontaneous episodes of these arrhythmias on Holter monitoring is translated into long term prophylactic efficacy against arrhythmia recurrence in approximately 55 to 85% of patients with refractory life-threatening ventricular arrhythmias. In addition, sotalol offers the advantage over the class I agents of reducing cardiac and all-cause mortality in the high risk population with life-threatening ventricular arrhythmias. The adverse effects of sotalol are primarily related to its beta-blocking activity and its class III property of prolonging cardiac repolarisation. Sotalol is devoid of overt cardiodepressant activity in patients with mild or moderate left ventricular dysfunction. The overall arrhythmogenic potential is moderately low, but torsade de pointes may develop in conjunction with excessive prolongation of the QT interval due to bradycardia, hypokalaemia or high plasma concentrations of the drug. In summary, sotalol displays a broad spectrum of antiarrhythmic activity, is haemodynamically well tolerated, and confers a relatively low proarrhythmic risk. It is likely to prove particularly appropriate in the treatment and prophylaxis of life-threatening ventricular tachyarrhythmias.
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Affiliation(s)
- A Fitton
- Adis International Limited, Auckland, New Zealand
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48
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Abstract
Two trial designs have been used in evaluating sotalol in patients with sustained tachyarrhythmias: open-label dose escalation and randomized comparison with reference agents. At least 7 open-label studies (n = 16-65) have been reported from single centers in patients in whom trials of numerous other antiarrhythmic agents were unsuccessful. At the doses used, usually 320-640 mg/day, plasma concentrations were in the range associated with both beta blockade and class III antiarrhythmic activity (2-3 micrograms/mL). These concentrations produced electrophysiologic changes that were consistent across studies: 10-16% increase in right ventricular effective refractory period (ERP), 4-8% increase in corrected QT interval (QTc), and 17-30% increase in sinus cycle length (corresponding to a 15-23% decrease in heart rate). In these open-label trials, sotalol suppressed inducible ventricular tachyarrhythmias in 20-72% of patients; the higher degrees of efficacy were reported when induction protocols were confined to double extrastimuli. Side effects leading to discontinuation of sotalol in patients with sustained ventricular tachycardia or fibrillation include fatigue (4.0%), marked bradycardia (3.0%), torsades de pointes (3.0%), and heart failure or pulmonary edema (1.0%). A multicenter randomized trial compared intravenous sotalol with intravenous procainamide in a double-blind prospective fashion. Sotalol suppressed ventricular tachyarrhythmias inducible with triple extrastimuli in 15 (30%) of 50 patients, whereas procainamide was effective in 10 (20%) of 50. In this and other series, responsiveness to sotalol was prospectively identified by a particularly fast tachycardia at baseline (e.g., cycle length of < 270 msec), but not by the extent of changes in global indices of repolarization (QTc, ERP).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- D M Roden
- Department of Medicine and Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-6602
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49
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Abstract
Sotalol is an antiarrhythmic agent with combined class II and III properties. It is nearly completely absorbed after oral administration and undergoes essentially no first-pass hepatic metabolism. As a result, its absolute bioavailability is 90-100%. Peak plasma concentrations are reached 2-4 hours after an oral dose. Administering sotalol with food reduces its bioavailability by approximately 20%. A 2-compartment model adequately describes the decline of sotalol plasma concentrations after intravenous or oral administration. The drug has an apparent volume of distribution of 1.2-2.4 liters/kg. Results of animal studies indicate that sotalol distributes into a number of tissues, including those of the heart, liver, and kidney, but it is hydrophilic and thus penetrates the central nervous system poorly. Sotalol does not bind to plasma proteins. No significant biotransformation of sotalol takes place in humans. Sotalol is primarily eliminated by renal excretion, with approximately 80-90% of a dose being excreted unchanged in the urine; a small amount is excreted unchanged in the feces. In subjects with normal renal function, total body clearance of sotalol averages 150 mL/min and the terminal elimination half-life is 10-20 hours. Long-term administration of sotalol does not alter its kinetics, and plasma concentrations following single or multiple doses are proportional to the dose. Sotalol is a racemic mixture of the d- and l-stereoisomers. d,l-Sotalol is excreted in the urine equally as d- and l-sotalol, and there is no evidence of racemization. The clearance of sotalol is reduced and its elimination half-life is prolonged in patients with renal insufficiency; as a result, dosage adjustment is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J J Hanyok
- Cardiovascular Clinical Research, Bristol-Myers Squibb Pharmaceutical Research Institute, Princeton, New Jersey 08543
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50
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Dorian P, Newman D, Berman N, Hardy J, Mitchell J. Sotalol and type IA drugs in combination prevent recurrence of sustained ventricular tachycardia. J Am Coll Cardiol 1993; 22:106-13. [PMID: 8509529 DOI: 10.1016/0735-1097(93)90823-j] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study assessed the efficacy of the combination of sotalol and either quinidine or procainamide in preventing sustained ventricular tachycardia inducibility and recurrence and prospectively evaluated the ability of the drug combination to prevent ventricular tachycardia recurrence when the arrhythmia remained inducible but was modified. BACKGROUND Individual antiarrhythmic drugs are often ineffective in preventing the induction and recurrence of sustained ventricular tachycardia. Beta-adrenergic blockade and prolongation of refractoriness may be important components of successful antiarrhythmic therapy in patients with ventricular tachycardia. We reasoned that the combination of sotalol, which has beta-adrenergic blocking properties and prolonged ventricular refractoriness, and quinidine or procainamide, two agents that slow conduction and prolong refractory periods, would be effective therapy in such patients. METHODS We administered low dose sotalol (205 +/- 84 mg/day) plus quinidine sulfate (1,278 +/- 479 mg/day) or procainamide (2,393 +/- 1,423 mg/day) to 50 patients with spontaneous sustained ventricular tachycardia or fibrillation and inducible ventricular tachycardia. RESULTS In 21 (46%) of 46 patients, ventricular tachycardia was rendered noninducible at electrophysiologic study (group I), and in 17 patients (37%), inducible tachycardia was modified according to prospectively identified criteria (group II), for a combined 83% response rate. Ventricular refractory periods increased from 252 +/- 24 to 316 +/- 28 ms and from 265 +/- 33 to 316 +/- 24 ms in groups I and II, respectively (p < 0.001), but from 234 +/- 19 to only 286 +/- 13 ms in the group of patients with unmodified ventricular tachycardia inducibility (n = 8, group III, p < 0.001). Cycle length of induced ventricular tachycardia slowed from 324 +/- 62 to 432 +/- 70 ms in group II patients (p < 0.001), whereas it slowed less in group III patients (279 +/- 73 to 314 +/- 63 ms, p = NS). Forty-two of the 50 patients (including all patients in groups I and II) were discharged on treatment with the drug combination. After 25 +/- 19 months of follow-up, the actuarial recurrence rate of ventricular tachycardia was 6%, 6% and 11% at 1, 2 and 3 years, respectively. Among patients in whom this drug combination was unsuccessful at electrophysiologic study (group III) and in those who received alternative therapy after combination therapy was discontinued because of side effects, actuarial recurrence rates were 9%, 14% and 32% at 1, 2 and 3 years, respectively. CONCLUSIONS The combination of sotalol plus quinidine or procainamide markedly prolongs ventricular refractoriness and slows induced ventricular tachycardia in a high proportion of patients. Patients with modified or noninducible tachycardia have a low rate of arrhythmia recurrence in follow-up. This drug combination deserves further evaluation.
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Affiliation(s)
- P Dorian
- Department of Medicine, University of Toronto, Ontario, Canada
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