Long-term treatment of ventricular arrhythmias with oral mexiletine

Effectiveness and safety of mexiletine in patients at risk for (recurrent) ventricular arrhythmias: a systematic review

While mexiletine has been used for over 40 years for prevention of (recurrent) ventricular arrhythmias and for myotonia, patient access has recently been critically endangered. Here we aim to demonstrate the effectiveness and safety of mexiletine in the treatment of patients with (recurrent) ventricular arrhythmias, emphasizing the absolute necessity of its accessibility. Studies were included in this systematic review (PROSPERO, CRD42020213434) if the efficacy or safety of mexiletine in any dose was evaluated in patients at risk for (recurrent) ventricular arrhythmias with or without comparison with alternative treatments (e.g. placebo). A systematic search was performed in Ovid MEDLINE, Embase, and in the clinical trial registry databases ClinicalTrials.gov and ICTRP. Risk of bias were assessed and tailored to the different study designs. Large heterogeneity in study designs and outcome measures prompted a narrative synthesis approach. In total, 221 studies were included reporting on 8970 patients treated with mexiletine. Age ranged from 0 to 88 years. A decrease in ventricular arrhythmias of >50% was observed in 72% of the studies for pre-mature ventricular complexes, 64% for ventricular tachycardia, and 33% for ventricular fibrillation. Electrocardiographic effects of mexiletine were small; only in a subset of patients with primary arrhythmia syndromes, a relative (desired) QTc decrease was reproducibly observed. As for adverse events, gastrointestinal complaints were most frequently observed (33% of the patients). In this systematic review, we present all the currently available knowledge of mexiletine in patients at risk for (recurrent) ventricular arrhythmias and show that mexiletine is both effective and safe.

Advances in the Management of Tachyarrhythmias

Recent developments of both diagnostic and therapeu tic techniques in the management of tachyarrhythmias have broadened the options available to physicians car ing for patients with tachyarrhythmias. Newer diag nostic methods allow more precise identification of the arrhythmia and better understanding of its mechanism. Long-term epidemiologic studies have identified groups of patients who do and do not require antiarrhythmic therapy. Antitachycardia pacemakers and automatic im plantable defibrillators allow effective treatment for pa tients for whom drugs were ineffective or in whom in tolerable side effects developed. Finally, several new antiarrhythmic agents have become available recently. Proper use of these new techniques and drugs requires greater understanding of the pathophysiology of cardiac arrhythmias.

Mexiletine in treatment of ventricular arrhythmias. A long-term follow-up

Maxiletine, a new drug effective in the treatment of ventricular arrhythmias, was given to 20 patients for approximately 2 years. The study was designed to investigate the nature and prevalence of side-effects during long-term therapy, and the degree of correlation between such effects and the serum levels of the drug. The methodology used to determine the serum level is described. Mexiletine was well tolerated and serious side-effects were not seen. In particular, antinuclear factor was not detected during the treatment period. The serum level of mexiletine was easily maintained within the therapeutic range, and most side-effects correlated closely with the drug level. Mexiletine appears to be an effective alternative to currently available antiarrhythmic agents.

Gas chromatography-electron ionization and chemical ionization mass spectrometric analysis of serum mexiletine concentration after derivatization with 2,2,2-trichloroethyl chloroformate: a novel derivative

Mexiletine (Mexitil) is an antiarrhythmic agent used in the treatment of ventricular arrhythmia. The drug has a narrow therapeutic window, and monitoring its serum concentration is recommended. The authors describe a gas chromatography-mass spectrometric (GC/MS) assay of mexiletine using selected ion monitoring. Mexiletine was extracted from alkaline serum with dichloromethane followed by derivatization with 2,2,2-trichloroethyl chloroformate. The reaction was completed in 30 minutes at 70 degrees C. N-propylamphetamine was used as the internal standard. The ions monitored were m/z 58, 102, 122, 232, and 234 for derivatized mexiletine and m/z 56, 91, 131, 260, and 262 for the derivatized internal standard. The within-run precision at a serum mexiletine concentration of 1 mg/l was 1.7% (mean = 0.981, SD = 0.017 mg/l, n = 8) and the between-run precision was 3.3% (mean = 0.983, SD = 0.033 mg/l, n = 6). The assay was linear for serum mexiletine concentrations of 0.2 to 2.5 mg/l. The detection limit was 0.1 mg/l. The authors observed no carry-over problem in their assay. They observed a good correlation between mexiletine concentrations measured by a reference laboratory (Associated Regional University Pathologists, Salt Lake City, UT, U.S.A.) and by the new GC/MS assay.

Gas chromatographic-mass spectrometric determination of serum mexiletine concentration after derivatization with perfluorooctanoyl chloride, a new derivative

Mexiletine is an antiarrhythmic agent used in the treatment of ventricular arrhythmia. The drug has a narrow therapeutic window which necessitates monitoring its serum concentrations. We describe a gas chromatographic-mass spectrometric analysis of mexiletine using selected ion monitoring. Mexiletine was extracted from alkaline serum with dichloromethane and then derivatized with perfluorooctanoyl chloride. The derivatization reaction was completed in 20 min at 80 degrees C. We used N-propylamphetamine as the internal standard. The ions monitored were m/z 122, 454 and 575 for the derivatized mexiletine and m/z 91, 118, 440 and 452 for the derivatized internal standard. The within-run precision at a serum mexiletine concentration of 1 mg/l was 1.9% (mean=0.98, S.D.=0.019 mg/l, n=7) and the between-run precision was 2.5% (mean=0.99, S.D.=0.025 mg/l, n=7). The assay was linear for serum mexiletine concentrations of 0.2 to 4 mg/l. The detection limit was 0.1 mg/l. The average recoveries of mexiletine and the internal standard were 80% and 84%, respectively at a mexiletine concentration of 1 mg/l. There was no carry over problem in our assay. We observed a good correlation between mexiletine concentrations measured by a reference laboratory (GC) and by our new GC-MS assay.

Antiarrhythmic drugs and polyneuropathy. The Collaborative Group for the Study of Polyneuropathy

A total of 151 patients on chronic treatment with amiodarone and other antiarrhythmic drugs were subjected to standard clinical and electrophysiological investigation to assess the prevalence and specificity of polyneuropathy. Twenty two untreated patients with cardiac disorders and 246 normal subjects served as controls. Abnormal electrophysiological findings supporting the diagnosis of polyneuropathy were present in 38 subjects (25%) given antiarrhythmic drugs, with even distribution among drugs, and four untreated patients (18%). Concurrent clinical abnormalities were present in five treated patients (one each with amiodarone, propafenone, and flecainide, and two with multiple drugs). Therefore, electrophysiological abnormalities are a common, although non-specific, feature in patients taking antiarrhythmic drugs. Amiodarone users do not seem at higher risk of polyneuropathy than subjects treated with other drugs or even untreated patients with cardiac disorders.

Gas chromatographic determination of mexiletine in human plasma with flame ionization detection after reaction with carbon disulphide

A gas chromatographic method for the determination of mexiletine in human plasma is described. Mexiletine was simultaneously extracted and derivatized with carbon disulphide for separation and quantitation on a glass column (1.5 m x 3 mm i.d.) packed with 1.5% OV-1 coated on 80-100 mesh Shimalite W (201D). The method required only 0.5 mL of plasma and could detect as little as 10 ng of mexiletine. It has been applied to the study of the pharmacokinetics of mexiletine in healthy volunteers.

The metabolism of mexiletine in relation to the debrisoquine/sparteine-type polymorphism of drug oxidation

1. The relationship between the metabolism of the antiarrhythmic drug mexiletine and the debrisoquine/sparteine-type polymorphism was studied in vitro, using microsomes from six human livers, and in vivo, in nine healthy drug-free volunteers with wide variation in their ability to hydroxylate debrisoquine. 2. There was a strong and similar correlation between the formation rate of both major mexiletine metabolites, p-hydroxymexiletine (PHM) and hydroxymethylmexiletine (HMM), and the high affinity component of dextromethorphan O-demethylase activity in human liver microsomes (rs = 0.94; P less than 0.01). 3. There were marked interindividual differences in the amounts of PHM and HMM excreted in the urine over 48 h after a single 200 mg oral dose of mexiletine hydrochloride. Recoveries of both metabolites were correlated inversely with the debrisoquine/4-hydroxydebrisoquine (D/HD) urinary metabolic ratio (rs = -0.83; P = 0.006 and rs = -0.85; P = 0.004, respectively) and were lower in poor metabolisers of debrisoquine (PM) than in extensive metabolisers (EM). Moreover, PM had the highest values of mexiletine/PHM and mexiletine/HMM urinary ratios. In addition, there was a strong correlation between these two indices of mexiletine hydroxylation and the D/HD metabolic ratios (rs = 0.92; P = 0.001 and rs = 0.90; P = 0.001, respectively). 4. After mexiletine pretreatment, the values for D/HD ratio were significantly increased in EM while corresponding values in PM were similar. 5. These findings are in accordance with previous in vitro data suggesting that PHM and HMM formation is predominantly catalyzed by the genetically variable human liver cytochrome P450IID6 isoenzyme responsible for the debrisoquine/sparteine-type polymorphism of drug oxidation.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of disopyramide and mexiletine used alone and in combination for ventricular arrhythmias in patients with and without overt heart disease

The efficacies and side effects of disopyramide and mexiletine used alone and in combination were assessed in 29 patients with chronic ventricular arrhythmias. In combination therapy, one half or two thirds of the conventional doses of each drug were administered. Each patient underwent Holter electrocardiographic monitoring during 4 different periods: baseline, disopyramide alone, mexiletine alone and combination of the two drugs. The mean baseline number of ventricular premature complex per hour was 783 +/- 521 (mean +/- SD), which was significantly reduced with all three therapies. Disopyramide alone significantly reduced the ventricular premature complex frequency in patients with organic heart disease (P less than 0.05), but did not significantly reduce the ventricular premature complex frequency in patients with no apparent heart disease. In contrast, mexiletine alone significantly decreased the ventricular premature complex frequency in no apparent heart disease patients (P less than 0.05), but did not significantly reduce the ventricular premature complex frequency in organic heart disease patients. With disopyramide alone, patients having a significant reduction in ventricular premature complexes (greater than or equal to 83% reduction in ventricular premature complexes) or elimination of ventricular tachycardias tended to be more frequently found in organic heart disease than in no apparent heart disease. The opposite was observed with mexiletine alone. QTc interval with disopyramide alone was significantly prolonged, and the prematurity index of ventricular premature complexes was significantly lowered as compared to mexiletine alone or combination therapy (P less than 0.01 for disopyramide versus mexiletine; P less than 0.05 for disopyramide versus combination therapy). During combination therapy, no patients withdrew from the study due to side effects. However, 3 patients receiving single drug therapy withdrew from the study due to severe side effects. Consequently, disopyramide is suggested to be more effective on ventricular premature complexes in organic heart disease than in no apparent heart disease patients, whereas the opposite was true for mexiletine. A combination of disopyramide and mexiletine in smaller doses may provide almost the same or enhanced antiarrhythmic effects, no aggravation of electrocardiographical parameters and less incidence of side effects when compared to the conventional dose of each drug alone.

Combination antiarrhythmic treatment among class Ia, Ib, and II agents for ventricular arrhythmias

Ventricular arrhythmia suppression trials were performed to compare the efficacies and side effects of disopyramide and mexiletine used alone and in combination, and to compare the efficacies and side effects of mexiletine and propranolol used alone and in combination, in patients with chronic ventricular premature contractions (VPCs, greater than or equal to 3000 beats/day). The study on the combination of disopyramide and mexiletine included 26 patients (19 men and 7 women). Disopyramide 100 mg tid or mexiletine 150 mg tid was administered as single-drug therapy, and disopyramide 50 mg plus mexiletine 100 mg tid was administered as combination therapy. Each patient underwent Holter monitoring during four different periods: baseline, disopyramide alone, mexiletine alone, and combination therapy. The mean number of VPCs/hr at baseline was 796 +/- 522 (mean +/- SD), which was significantly decreased with all three therapies (p less than 0.01 in each) to a) 415 +/- 480 with disopyramide alone, b) 341 +/- 368 with mexiletine alone, and c) 345 +/- 408 with the combination therapy. The number of patients demonstrating a significant reduction in VPCs (greater than or equal to 75%) and the elimination of ventricular tachycardia (VT; three or more consecutive VPCs) did not differ significantly among the three therapies. The prematurity index (PI), vulnerability index (VI), and QTc tended to be aggravated by disopyramide therapy alone, but these values were corrected by combination therapy. No patients withdrew from the study due to side effects during combination therapy, although three patients withdrew from the study due to severe side effects during single-drug therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Liquid chromatographic analysis of mexiletine in serum, with alternate application to tocainide, procainamide, and N-acetylprocainamide

A simple and precise high performance liquid chromatographic method for the determination of mexiletine in human serum or plasma is described. Following addition of N-propionylprocainamide as internal standard the specimens are extracted, under basic conditions, into methylene chloride. After removal of the aqueous layer the drug is back-extracted into dilute acid, which is then injected directly for analysis. The extraction efficiency is 79% for both mexiletine and internal standard, and the assay is linear to 4 mg/L (twice upper therapeutic concentration). Inter-run coefficients of variation are 3.0% or less. The relative retention time of mexiletine to internal standard averages 1.3. An adaptation of this method is described for an alternate application to the analysis of tocainide, procainamide and N-acetylprocainamide.

Mexiletine: pharmacology and therapeutic use

Mexiletine is a Class IB antiarrhythmic which has basic and clinical electrophysiologic properties similar to lidocaine. Like other Class I antiarrhythmic agents, mexiletine blocks the rapid inward sodium current responsible for phase 0 of the action potential. It has been noted in the clinical electrophysiology laboratory to have minimal effect on sinus node function and AV nodal and His-Purkinje system conduction. Pharmacokinetic studies have shown that oral absorption is rapid with bioavailability of 80-90%. Mexiletine is predominantly metabolized by the liver with elimination half-life of 9 to 12 hours. The antiarrhythmic effects of the primary drug's metabolites remain to be defined. Hemodynamic studies have shown mexiletine to have a lesser negative inotropic effect than procainamide or disopyramide. Although mexiletine as a single agent successfully suppresses 60 to 80% of spontaneous ventricular arrhythmias, it has lower efficacy in suppression of induced ventricular arrhythmias. Multiple studies have shown that as monotherapy mexiletine is effective in preventing the induction of ventricular tachycardia in approximately 20% of patients. When used in combination with a Class IA antiarrhythmic drug for suppression of induced ventricular arrhythmias, multiple investigators have reported greater efficacy. Neurological side effects (tremor, dizziness, memory loss) occur in approximately 10% of patients while gastrointestinal side effects (nausea, anorexia, gastric irritation) occur in up to 40% of patients. Proarrhythmia or other serious toxicity from the drug is uncommon.

Kinetics of oral and intravenous mexiletine: lack of effect of cimetidine and ranitidine

The pharmacokinetics of mexiletine, a Class I antiarrhythmic drug, was investigated in 6 healthy volunteers after single oral doses and 15 min intravenous infusions of 3 mg/kg. Cimetidine and ranitidine are commonly used H2-receptor antagonists, which interact adversely with many drugs, e.g. inhibition of the metabolism of Class I antiarrhythmics such as lidocaine and quinidine by cimetidine. To investigate the effects of the two drugs on the kinetics of mexiletine, cimetidine 800 mg.day-1 or ranitidine 600 mg.day-1 were administered orally for one week. Neither H2-receptor antagonist altered the distribution and elimination of mexiletine, nor did they affect its overall kinetics, or excretion of the metabolites para- and 4-OH-methylmexiletine after oral and intravenous administration of mexiletine.

High-performance liquid chromatographic assay for mexiletine hydroxylation in microsomes of human liver

A simple high-performance liquid chromatographic assay, using fluorescence detection, is described for determining simultaneously the production of the two major hydroxylated metabolites of mexiletine in human liver microsomes. The detection limits of hydroxymethylmexiletine and p-hydroxymexiletine are 0.35 and 0.08 nmol/ml, respectively. The assay is specific, reproducible and allows the simultaneous kinetic characterization of the reactions in small amounts of liver tissue. The assay may be used to acquire a better knowledge of the kinetic behaviour of mexiletine and of its metabolites, and to investigate if the large inter-individual variations of the mexiletine pharmacokinetics are of metabolic origin, due to variations of its hydroxylation processes.

[Treatment with mexiletine. Clinical and pharmacokinetic studies]

Pharmacokinetics of the antiarrhythmic agent mexiletine were found to be highly variable. Ineffective or toxic doses can be avoided by monitoring mexiletine concentrations in patients plasma. However, the success of antiarrhythmic therapy is mainly determined by the severity of the underlying disease. Therefore, the efficacy of treatment with mexiletine should be controlled by Holter monitoring.

Electrophysiologic effects and clinical efficacy of mexiletine used alone or in combination with class IA agents for refractory recurrent ventricular tachycardias or ventricular fibrillation

The electrophysiologic effects and clinical efficacy of mexiletine used alone or in combination with class IA agents were studied in 35 patients with recurrent sustained ventricular tachycardia (VT) or ventricular fibrillation refractory to nonexperimental antiarrhythmic agents. At baseline before therapy, all patients had inducible VT by programmed stimulation (1 to 3 extrastimuli) and frequent (at least 30/hour) ventricular premature complexes (VPCs) during Holter monitoring. Mexiletine therapy was effective by programmed stimulation (VT no longer inducible or 15 or less beats) in 8 and ineffective in 27 patients. Twenty patients were discharged with mexiletine (14 of whom took an additional class IA agent). The discharge regimen was effective by programmed stimulation in 6 of these 20 patients. In 14 patients the discharge regimen was ineffective by programmed stimulation, but all patients had a marked reduction of ventricular ectopic activity (at least 83% reduction of VPCs and abolition of non sustained VT). During the follow-up period of 18 +/- 13 months (mean +/- standard deviation), 4 patients had recurrences (3 with an ineffective regimen by programmed stimulation and 1 with an effective regimen by programmed stimulation). Arrhythmia-free survival rates at 12 and 24 months were 86% and 77%, as determined by the Kaplan-Meier method, in patients with an ineffective regimen by programmed stimulation, and 80% and 80% in patients with an effective regimen by programmed stimulation (p = 0.979 by log rank test).(ABSTRACT TRUNCATED AT 250 WORDS)

Intolerance and ineffectiveness of mexiletine in patients with serious ventricular arrhythmias

Fifty-one patients were treated with mexiletine over 10.4 +/- 16 months. The clinical arrhythmia in 25 (49%) was ventricular fibrillation (VF), 11 (22%) had sustained ventricular tachycardia (VT), and 15 (29%) had symptomatic nonsustained VT. Ischemic heart disease was present in 33 patients (66%), cardiomyopathy in nine (17%), and valvular or congenital heart disease in nine (17%). Only six (12%) remain on the drug. Arrhythmias recurred in 21 patients (41%): seven (14%) with VF, three (5%) with sustained VT, and 11 (22%) with symptomatic nonsustained VT. Intolerable side effects occurred in another 17 (33%). Seven patients (14%) died from nonarrhythmic-related deaths while taking mexiletine. Mexiletine was combined with a conventional type IA antiarrhythmic agent in 25 patients (49%). In 12 of these 25 patients (48%), ventricular arrhythmias recurred. These findings were not significantly different from those of the group treated with mexiletine alone, where arrhythmias recurred in 9 of 26 patients (35%) (p = NS). Thus mexiletine, alone or in combination with a type IA antiarrhythmic agent, has limited clinical utility in patients with life-threatening ventricular arrhythmias.

Discordance between ambulatory monitoring and programmed stimulation in assessing efficacy of mexiletine in patients with ventricular tachycardia

Programmed electrical stimulation (PES) and 24-hour Holter monitoring were compared in 30 patients with ventricular tachycardia (VT) or ventricular fibrillation (VF) before and during treatment with mexiletine. Before treatment, all patients had greater than or equal to 30 ventricular premature complexes (VPCs)/hr and 22 patients had nonsustained VT on Holter. All had inducible sustained VT by PES (one to three extrastimuli). Mexiletine was effective in only 23% by PES criteria (VT no longer inducible or less than or equal to 15 beats in duration and effective in 57%, 57%, and 73% by Holter criteria I, II, and III, respectively (Holter I greater than or equal to 50% reduction of VPCs, greater than or equal to 90% reduction of couplets and abolition of nonsustained VT; Holter II greater than or equal to 83% reduction of VPCs and abolition of VT; Holter III abolition of VT in patients who had VT during baseline Holter). Results of PES and Holter were discordant in 67%, 60%, and 55% (PES vs Holter I, II, and III, respectively). The majority (greater than or equal to 75%) of the discordance occurred due to mexiletine appearing effective by Holter criteria but ineffective by PES criteria (suggesting insensitivity of efficacy by Holter criteria and/or nonspecificity of induced VT during treatment with mexiletine).

CONCLUSIONS

PES and Holter are discordant in assessing efficacy of mexiletine (p less than 0.05). Efficacy of mexiletine by Holter criteria is easier to achieve than efficacy by PES. The discordance between the two methods, both with very good reported predictive values, calls for randomized clinical follow-up studies to determine sensitivity and specificity of each method in assessing efficacy of mexiletine.

Comparative antiarrhythmic efficacy of verapamil, 17-monochloracetylajmaline, mexiletine and amiodarone in patients with severe chagasic myocarditis: relation with the underlying arrhythmogenic mechanisms

The antiarrhythmic effects of verapamil, 17-monochloracetylajmaline, mexiletine and amiodarone were compared in 14 patients with chagasic myocarditis. Drugs and placebo were administered orally in the following order: placebo and verapamil, placebo and 17-monochloracetylajmaline, placebo and mexiletine (1 week each) and placebo and amiodarone (4 weeks each). A 24 hour ambulatory electrocardiographic recording was obtained after administration of each placebo and drug. Verapamil had no effect on the number of ventricular premature complexes, ventricular couplets and runs of ventricular tachycardia. 17-Monochloracetylajmaline did not reduce the number of ventricular premature complexes and ventricular couplets but caused a moderate reduction in runs of ventricular tachycardia. Mexiletine failed to significantly reduce ventricular premature complexes but caused a moderate decrease in both ventricular couplets and runs of ventricular tachycardia. Amiodarone was the only one of the four drugs that caused a substantial reduction of ventricular premature complexes (logarithmic mean 97.8%; p less than 0.001), total suppression of runs of ventricular tachycardia in 11 of 11 patients and suppression of ventricular couplets in 8 of 14 patients and a significant reduction in the remaining 6 patients. The much greater efficacy of amiodarone as compared with the two sodium channel modifiers (17-monochloracetylajmaline and mexiletine) and one calcium channel blocker (verapamil) suggests that its potent antiarrhythmic activity is probably related to other peculiar and still undefined electrophysiologic and pharmacologic properties.

Pharmacology and clinical use of mexiletine

Mexiletine is an antiarrhythmic agent with structural and electrophysiologic properties similar to those of lidocaine. Mexiletine decreases ventricular automaticity while shortening both action potential duration and effective refractory period. The drug may be administered orally or intravenously. Hepatic metabolism is the major route of elimination. The elimination half-life is approximately 10 hours, but longer in patients with acute myocardial infarction, chronic congestive heart failure or hepatic insufficiency. Mexiletine suppresses ventricular ectopy in the acute phase of myocardial infarction. The drug is effective for some patients in whom lidocaine has failed. It suppresses chronic ventricular ectopy and is well tolerated in approximately two-thirds of stable outpatients treated with this agent. In that population, mexiletine is comparable in efficacy to quinidine, procainamide and disopyramide. It is effective in 30-50% of patients with ventricular arrhythmias refractory to other antiarrhythmic drugs. In patients with refractory arrhythmias, the efficacy of mexiletine may be enhanced by combination with propranolol, quinidine or amiodarone. Adverse reactions limit use of mexiletine in approximately 20% of patients. Gastrointestinal and central nervous system side effects are the most common. Mexiletine does not depress myocardial function. Aggravation of arrhythmias is uncommonly observed. The usual intravenous dose of mexiletine is 150-250 mg over at least 10 minutes. Long-term oral dosages are usually 200-300 mg 3 or 4 times daily.

Mexiletine: double-blind comparison with procainamide in PVC suppression and open-label sequential comparison with amiodarone in life-threatening ventricular arrhythmias

The antiarrhythmic effects of mexiletine (n = 14) were compared to procainamide (n = 16) by a double-blind parallel protocol in 30 patients (group I) with frequent premature ventricular contractions (PVCs) (greater than 20/hr), and to amiodarone by an open-label sequential approach in 25 patients (mean left ventricular ejection fraction of 32.6 +/- 13.4%) with life-threatening ventricular arrhythmias (group II) resistant to two or more conventional agents. The predetermined end point of therapy in group I patients was met in 6 of 14 (43%) given mexiletine, with 7 (50%) requiring drug discontinuation for severe gastrointestinal or central nervous system side effects and only 3 of 16 patients (19%) given procainamide, with 5 (31%) developing limiting side effects. Increases in dose led to a higher efficacy rate for PVC suppression with a corresponding increase in side effects with mexiletine; with procainamide, the higher dose was not associated with greater PVC suppression. In group II patients, mexiletine was effective in 4 (16%), with one patient discontinuing the drug during long-term therapy; mexiletine was ineffective in 16 (64%) and early side effects developed in 5 (20%). Patients not responding to or not tolerating mexiletine were given amiodarone; 20 of 21 (95%) responded with arrhythmia control after the loading dose. During a mean follow-up period of 2 years, sudden death occurred in two patients, death from heart failure in two, and death from subarachnoid hemorrhage in one patient; 15 (75%) patients are alive and free of arrhythmia.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of oral mexiletine therapy in the treatment of ventricular arrhythmias

The effect of oral mexiletine therapy on ventricular arrhythmias was evaluated in 58 patients in whom conventional drugs had been unsuccessful. Mean daily dose of mexiletine was 652 mg (range 250 to 1,500) and mean duration of therapy was 14.4 months (range 0.1 to 34.4). Mexiletine was associated with a decrease of 52% in total premature ventricular complexes in 24 hours compared with control (6,841 +/- 1,053 [SEM] versus 3,248 +/- 734, p less than 0.005) and 19 patients (36.5%) had a greater than 83% decrease in ventricular ectopic rhythm. The drug was discontinued in 6 of these 19 patients because 5 of them (26%) experienced side effects after a mean period of 29.6 weeks (range 0.83 to 63.2) and sudden death occurred in 1 patient (5%); this indicates effective suppression of ventricular ectopic rhythm without significant side effects in 13 (25%) of 52 patients during long-term therapy. Adjustment of drug dosage to achieve therapeutic blood levels resulted in an efficacy on ventricular ectopic rhythm similar to that obtained with the maximal tolerated dose. There was no correlation between drug dose and therapeutic effectiveness. Mexiletine was associated with a 48% decrease in episodes of ventricular tachycardia (345.5 versus 179.3/24 h) and 5 of 10 patients with a history of cardiac arrest remained free of symptomatic ventricular tachyarrhythmias for 14.8 months (range 3.7 to 24.3).(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness and safety of cimetidine in patients receiving mexiletine for ventricular arrhythmia

Cimetidine, a commonly used H2 receptor antagonist, was found to adversely interact with many drugs metabolized by the liver, including class I antiarrhythmic agents, lidocaine and quinidine. Mexiletine is a new class I antiarrhythmic agent similar to lidocaine which when used orally may have significant gastric side effects. Since some patients with peptic ulcer disease or gastric hyperacidity on mexiletine may benefit from the addition of cimetidine, it was important to rule out any significant adverse interaction between the two drugs in such patients. Eleven patients currently receiving long-term oral mexiletine for the treatment of complex ventricular arrhythmia underwent a double-blind crossover trial where they were maintained on their usual dose of mexiletine, and cimetidine, 300 mg orally every 6 hours, or placebo were added for a 1-week period each. Peak and trough mexiletine blood levels were not significantly altered by cimetidine. Similarly, there was no significant change in the frequency and severity of ventricular arrhythmia when cimetidine was added to mexiletine. Cimetidine reduced gastric side effects of mexiletine in 50% of patients who had complained of such symptoms on mexiletine alone or on mexiletine and placebo. We conclude that cimetidine can effectively reduce gastric side effects of mexiletine in many patients without adversely affecting the plasma concentration or the efficacy of the drug.

International mexiletine and placebo antiarrhythmic coronary trial: I. Report on arrhythmia and other findings. Impact Research Group

The antiarrhythmic effects of the sustained release form of mexiletine (Mexitil-Perlongets) were evaluated in a double-blind placebo trial in 630 patients with recent documented myocardial infarction. The primary response variable was based on central reading of 24 hour ambulatory electrocardiographic recordings and was defined as the occurrence of 30 or more single premature ventricular complexes in any two consecutive 30 minute blocks or one or more runs of two or more premature ventricular complexes in the entire 24 hour electrocardiographic recording. Large differences, regarded as statistically significant, between the mexiletine and placebo groups were noted in that end point at months 1 and 4, but only trends were observed at month 12. These differences were observed even though the serum mexiletine levels obtained in this study were generally lower than those observed in studies that have used the regular form of the drug. There were more deaths in the mexiletine group (7.6%) than in the placebo group (4.8%); the difference was not statistically significant. The incidence of coronary events was similar in both groups. Previously recognized side effects, particularly tremor and gastrointestinal problems, were more frequent in the mexiletine group than in the placebo group.

Mexiletine for recurring ventricular arrhythmias: assessment by long-term electrocardiographic recordings and sequential electrophysiologic studies

Mexiletine, an oral lidocaine-like drug, was initially thought to be effective treatment for recurring ventricular arrhythmias. Recent work has cast doubt on its efficacy. We administered mexiletine to 32 patients with chronically recurring ventricular arrhythmias. In 22 patients with no history of syncope or documented sustained ventricular arrhythmia (group 1), mexiletine was effective in only 27% (six patients) as assessed by 24-hour ambulatory ECG recordings before and during mexiletine treatment. Ten other patients had a history of syncope or documented sustained ventricular tachycardia or ventricular fibrillation. Only 10% (one patient) responded to mexiletine based on sequential electrophysiologic studies with programmed ventricular stimulation. Four of the seven patients responding to mexiletine had not received prior antiarrhythmic therapy. We conclude that mexiletine has limited efficacy in the treatment of recurring drug-refractory ventricular arrhythmias.

New directions in antiarrhythmic drug therapy

Cardiac arrhythmia causing sudden cardiac death is a serious worldwide public health problem. Antiarrhythmic agents have been available for therapy, but the conventional agents cause a high degree of intolerable side effects. The recent development of many new experimental antiarrhythmic agents has increased our capacity to effectively treat cardiac arrhythmias. Using a multifaceted approach of programmed electrical stimulation studies, drug level determinations, exercise testing and 24-hour ambulatory Holter monitoring, it can reasonably be decided which patient needs therapy and if therapy is going to be effective. Both aspects of the sudden death equation, ectopy frequency (triggering mechanism) and the ability to propagate sustained ventricular tachycardia (substrate), may be examined. Careful follow-up is needed to determine continued drug efficacy and the presence of side effects that may compromise patient compliance with therapy. If side effects intervene that may cause continued therapy to be intolerable, changing the antiarrhythmic agent, as opposed to decreasing the dosage to an ineffective range, may be appropriate. A comprehensive approach to arrhythmia management may begin to reduce the high incidence of sudden death due to fatal arrhythmias.

Oral mexiletine in the treatment of refractory ventricular arrhythmias: the role of electrophysiologic techniques

Mexiletine is a useful antiarrhythmic agent for the treatment of ventricular arrhythmias. Its efficacy in suppressing ventricular arrhythmias during serial electrophysiologic evaluation has come under investigation only recently. Experience to date in more than 300 patients suggests that suppression of inducible ventricular arrhythmias by mexiletine either alone or in combination with another antiarrhythmic agent may be achieved in approximately 30% of patients. Furthermore, suppression sometimes may be achieved when mexiletine is tested in combination with a type IA antiarrhythmic or beta-adrenergic blocking agent in patients for whom neither agent alone has been effective. The likelihood of suppressing inducible ventricular tachycardia (VT) with mexiletine therapy alone or in combination may vary as a function of the spontaneous ventricular arrhythmia with which a patient presents at the time of electrophysiologic study; patients presenting with sustained VT appear to have inducible arrhythmias that are more difficult to suppress. A significant incidence of adverse effects attributable to mexiletine has been observed, particularly gastrointestinal and neurologic effects. These side effects, although common, are frequently eliminated by reducing the dosage of the drug and administering the drug with food. A facilitation of arrhythmia induction has also been observed in a small percentage of patients. Early experience suggests that selected patients with ventricular arrhythmias that are refractory to conventional antiarrhythmic agents may derive long-term benefit from chronic therapy with oral mexiletine.

Long-term clinical experience with mexiletine

Mexiletine was given to 12 patients for different periods of time varying from 4 to 96 months, with a mean of 47.8 months. At the latest follow-up in August 1983, five patients had been taking mexiletine for 74 to 96 months (mean 85 months). Mexiletine was well tolerated and serious side effects were not seen. In particular, there was no rise in antinuclear factor titer. The serum level of mexiletine was easily maintained within the therapeutic range, and most side effects correlated closely with the drug level. It is concluded that mexiletine can be administered for a long time as a safe alternative to other antiarrhythmic drugs.

Hemodynamic effects of mexiletine

A review of studies of mexiletine, a class I antiarrhythmic drug, supports its use in patients with ventricular arrhythmias or in sinus rhythm. Studies include patients likely to receive the drug in clinical use--patients with and without coronary disease and patients who have suffered acute myocardial infarction. Some studies are open and others are controlled to compare mexiletine to placebo or to lidocaine. Mexiletine in therapeutic ranges was shown not to affect arterial pressure; to prolong aortic ball travel time, indicating depression of myocardial contractility; and not to adversely affect cardiac function. Adverse effects occurred as often in patients taking placebo as in mexiletine-treated patients, even in those with impaired cardiac function. Studies bear out early reports of mexiletine as an effective antiarrhythmic drug nearly devoid of adverse hemodynamic effects when administered intravenously or orally in a dosage to maintain a therapeutic plasma concentration.

Long-term mexiletine for ventricular arrhythmia

Use of mexiletine was evaluated in 313 patients with ventricular tachyarrhythmias refractory to conventional antiarrhythmic drugs. Therapy with mexiletine was continued long term in 107 patients who responded to the drug and were free of side effects during a short-term evaluation in hospital. During an average follow-up of 22.8 months (0.1 to 70 months), 19 patients died (17.8%). Eleven patients had sudden death (3.6% per year), while six patients died of progressive congestive heart failure and two of noncardiac causes. Nonfatal ventricular arrhythmia recurred in 14 patients (4.9% per year). Overall, 25 patients had recurrent arrhythmia (incidence of 5.5% per year). Side effects occurred in 13 patients after an average of 5.1 months and were primarily gastrointestinal and neurologic. Sixty-one patients (57%) have continued on mexiletine therapy for an average of 32.2 months (1 to 70 months). Outcome during long-term therapy was not related to drug dose, blood level, or presenting arrhythmia. We conclude that if therapy with mexiletine is carefully evaluated and individualized, the drug is effective and well tolerated during long-term use.

Efficacy of mexiletine in the medium-term treatment of ventricular arrhythmias. A randomized, double-blind, crossover trial against placebo in ambulatory patients

A double-blind, crossover study was designed to compare the safety and efficacy of mexiletine with that of placebo in reducing premature ventricular complexes (PVC) in ambulatory patients and to find out the dose which gives a good therapeutic response with a minimal incidence of side-effects. Twenty-six patients, who had on average 427.9 PVCs/hour, were admitted to the study. The doses given were designed to reduce the frequency of PVCs by 50% or more from the baseline value. Two out of the twenty-six patients stopped treatment because of major side-effects. In the remaining twenty-four patients the 3 weeks of treatment with mexiletine significantly reduced the rate of PVCs by comparison with placebo (-63.8% versus +7.5%). In the nineteen responders (per cent reduction of PVCs over 50%) the dose of mexiletine was 600 mg daily (200 mg every 8 hours). In the non-responders plasma levels of mexiletine proved to be in the therapeutic range, not in any way different from responders. The most frequent side-effects were digestive difficulties (fifteen patients taking mexiletine and six taking placebo). These results show that mexiletine is an effective anti-arrhythmic drug in the management of ventricular arrhythmias occurring in ambulatory patients. In the majority of patients mexiletine was found to be effective even at the lowest dose studied of 600 mg/day.

Mexiletine for control of drug-resistant ventricular tachycardia: clinical and electrophysiologic results in 44 patients

The antiarrhythmic efficacy of mexiletine was evaluated in 44 patients with drug-resistant ventricular tachyarrhythmias. In 33 of these patients, the efficacy of mexiletine was assessed on the basis of the results of programmed ventricular stimulation. Mexiletine did not alter the ventricular effective refractory period, the Q-Tc interval, or the methods of tachyarrhythmia induction and termination during programmed stimulation. The mean cycle length of ventricular tachycardia (VT) increased from 270 +/- 49 to 313 +/- 80 ms in 21 patients in whom VT remained inducible on mexiletine alone (p less than 0.002). Overall, VT remained inducible with methods similar to control (no drugs) inductions in 25 patients receiving mexiletine alone or in combination with a type I agent. VT induction was prevented in only 8 patients, 3 on mexiletine alone and 5 receiving mexiletine combined with another drug. Mexiletine alone (in 2 patients) or with another agent (in 3) suppressed clinical recurrence of VT in an additional 5 of 11 patients who did not undergo electrophysiologic study. These 13 patients were discharged on mexiletine alone (5 patients) or in combination with other drugs (8 patients), and remained arrhythmia-free over a mean follow-up period of 7.7 +/- 4.1 months. Adverse effects occurred in 27 of 44 patients (61%) and were gastrointestinal in 17 and/or neurologic in 22. The drug was discontinued because of adverse effects in 6 patients (14%). Thus, mexiletine has limited efficacy when used alone, but when combined with other drugs it may be useful in up to 30% of patients with drug-resistant ventricular arrhythmias. Adverse effects are relatively common.

Ventricular ectopy: etiology, evaluation, and therapy

Ventricular ectopy occurs commonly. Its significance is related to the degree of complexity and the associated cardiac substrate. Coronary artery disease is the most frequent underlying cause, followed by cardiomyopathy and valvular disease. Symptomatic ventricular arrhythmias require treatment, whereas benign simple ventricular ectopy does not; however, the treatment of asymptomatic high-grade ventricular ectopy remains controversial. Therapy first must be directed toward the cardiac disease. Evaluation of the patient includes Holter monitoring, echocardiography, radionuclide studies, exercise testing, cardiac catheterization, and electrophysiologic testing. Programmed stimulation is useful in the diagnosis and prognosis of ventricular tachycardia, as well as in the evaluation of drug regimen efficacy. After treatment of ischemia and/or failure, specific antiarrhythmic agents, conventional and investigational, alone or in combination, are systematically selected. Should medical therapy alone be insufficient, consideration is given to surgical procedures such as subendocardial resection or ventriculotomy, often in combination with bypass grafting, aneurysmectomy, or valvular replacement. Electronic devices, including pacemakers or automatic internal defibrillators, may also be useful in certain selected cases. Suggested guidelines are proposed for a standardized approach, although therapy for each patient must still be individualized.