Evaluation of the pharmacokinetics and bioavailability of intravenously and orally administered amiodarone in horses

Fundamentals of arrhythmogenic mechanisms and treatment strategies for equine atrial fibrillation

Atrial fibrillation (AF) is the most common pathological arrhythmia in horses. Although it is not usually a life-threatening condition on its own, it can cause poor performance and make the horse unsafe to ride. It is a complex multifactorial disease influenced by both genetic and environmental factors including exercise training, comorbidities or ageing. The interactions between all these factors in horses are still not completely understood and the pathophysiology of AF remains poorly defined. Exciting progress has been recently made in equine cardiac electrophysiology in terms of diagnosis and documentation methods such as cardiac mapping, implantable electrocardiogram (ECG) recording devices or computer-based ECG analysis that will hopefully improve our understanding of this disease. The available pharmaceutical and electrophysiological treatments have good efficacy and lead to a good prognosis for AF, but recurrence is a frequent issue that veterinarians have to face. This review aims to summarise our current understanding of equine cardiac electrophysiology and pathophysiology of equine AF while providing an overview of the mechanism of action for currently available treatments for equine AF.

Cardiac Arrhythmias in Horses

Arrhythmias are common in horses. Sinus arrhythmia and first- and second-degree atrioventricular block are frequently found physiologic arrhythmias, but should immediately disappear after stress or exercise. Atrial premature depolarizations are usually not associated with poor performance, but are a potential trigger for atrial fibrillation. Atrial fibrillation results in an abnormal ventricular response during exercise and poses a risk for collapse in some horses. This arrhythmia can usually be treated by quinidine sulfate or transvenous electrical cardioversion. Ventricular premature depolarizations, especially when associated with structural heart disease, may be a risk factor for ventricular tachycardia or even ventricular fibrillation.

Pharmacokinetics and electrophysiological effects of sotalol hydrochloride in horses

BACKGROUND

Arrhythmias in horses may require long-term anti-arrhythmic therapy. Unfortunately, oral anti-arrhythmic drugs for use in horses are currently scarce. In human patients and small animals, sotalol, a β-blocker with class III anti-arrhythmic properties, is often used for long-term treatment.

OBJECTIVES

To determine the pharmacokinetics of sotalol at multiple oral dosages in unfasted horses, as well as the effects on electro- and echocardiographic measurements, right atrial and ventricular monophasic action potential (MAP) and effective refractory period (ERP).

STUDY DESIGN

Placebo controlled, double-blinded experiment.

MATERIALS AND METHODS

Six healthy, unfasted Warmblood horses were given either 0, 2, 3 or 4 mg/kg bodyweight (bwt) sotalol orally (PO) twice daily (bid) for 9 days in a randomised cross-over design. Echocardiography and surface electrocardiography were performed and plasma concentrations of sotalol and right atrial and right ventricular MAPs and ERPs were determined at steady-state conditions. Statistical analysis was performed using a repeated measures univariate analysis with post hoc Bonferroni corrections.

RESULTS

Calculated mean steady-state plasma concentrations determined by nonlinear mixed-effect modelling were 287 (range 234-339), 409 (359-458) and 543 (439-646) ng/mL for 2, 3 and 4 mg/kg bwt sotalol PO bid respectively. Sotalol significantly increased the QT interval and ERPs, but, despite increasing plasma concentrations, higher dosages did not result in a progressive increase in QT interval or ERPs. Echocardiographic and other electrocardiographic measurements did not change significantly. MAP durations at 90% repolarisation were not significantly different during sotalol treatment. Besides transient local sweating, no side effects were noted.

MAIN LIMITATIONS

Study size and ad libitum feeding of hay.

CONCLUSIONS

Sotalol at a dose of 2, 3 and 4 mg/kg bwt PO bid increases the QT interval and ERP and might be a useful drug for long-term anti-arrhythmic therapy in horses.

Risk factors for recurrence of atrial fibrillation in horses after cardioversion to sinus rhythm

Background

Although atrial fibrillation (AF) can be successfully treated in horses, recurrence occurs frequently. In humans, atrial function after cardioversion can predict recurrence.

Objectives

To examine the prognostic value of atrial mechanical function at 24 hours after cardioversion and other potential predictor variables for AF recurrence in horses.

Animals

117 horses treated for AF at 4 referral centers.

Methods

Retrospective study. Inclusion criteria were successful cardioversion, echocardiography at 24 hours after cardioversion and ≥4 months follow‐up. To determine factors associated with AF recurrence, a multivariable survival model was built.

Results

133 AF episodes in 117 horses were included. AF recurred in 36/100 horses with a first AF episode and in 57/133 AF episodes overall. Factors associated with recurrence in horses with a first episode were previous unsuccessful treatment attempt (hazard ratio HR 2.36, 95% confidence interval CI 1.11–4.99, P = .025) and mild or moderate mitral regurgitation (HR 2.70, 95% CI 1.23–5.91, P = .013). When the last AF episode of all horses was included, previous AF (HR 2.53, 1.33–4.82, P = .005) and active left atrial fractional area change ≤9.6% (HR 3.43, 1.22–9.67, P = .020) were significant predictors.

Conclusions and Clinical Importance

The only echocardiographic variable of left atrial function with significant prognostic value for recurrence was low active left atrial fractional area change. Further research is necessary to evaluate whether echocardiography at a later timepoint could provide more prognostic information.

Effects of an adapted intravenous amiodarone treatment protocol in horses with atrial fibrillation

REASON FOR PERFORMING STUDY

Good results have been obtained with a human amiodarone (AD) i.v. protocol in horses with chronic atrial fibrillation (AF) and a pharmacokinetic study is required for a specific i.v. amiodarone treatment protocol for horses.

OBJECTIVES

To study the efficacy of this pharmacokinetic based i.v. AD protocol in horses with chronic AF.

METHODS

Six horses with chronic AF were treated with an adapted AD infusion protocol. The protocol consisted of 2 phases with a loading dose followed by a maintenance infusion. In the first phase, horses received an infusion of 6.52 mg AD/kg bwt/h for 1 h followed by 1.1 mg/kg bwt/h for 47 h. In the second phase, horses received a second loading dose of 3.74 mg AD/kg bwt/h for 1 h followed by 1.31 mg/kg bwt/h for 47 h. Clinical signs were monitored, a surface ECG and an intra-atrial electrogram were recorded. AD treatment was discontinued when conversion or any side effects were observed.

RESULTS

Three of the 6 horses cardioverted successfully without side effects. The other 3 horses did not convert and showed adverse effects, including diarrhoea. In the latter, there were no important circulatory problems, but the diarrhoea continued for 10-14 days. The third horse had to be subjected to euthanasia because a concomitant Salmonella infection worsened the clinical signs.

CONCLUSION

The applied treatment protocol based upon pharmacokinetic data achieved clinically relevant concentrations of AD and desethylamiodarone.

POTENTIAL RELEVANCE

Intravenous AD has the potential to be an alternative pharmacological treatment for AF in horses, although AD may lead to adverse drug effects, particularly with cumulative dosing.

Determination of amiodarone and desethylamiodarone in horse plasma and urine by high-performance liquid chromatography combined with UV detection and electrospray ionization mass spectrometry

A rapid method for the quantification of amiodarone and desethylamiodarone in animal plasma using high-performance liquid chromatography combined with UV detection (HPLC-UV) is presented. The sample preparation includes a simple deproteinisation step with acetonitrile. In addition, a sensitive method for the quantification of amiodarone and desethylamiodarone in horse plasma and urine using high-performance liquid chromatography combined with electrospray ionization tandem mass spectrometry (LC-ESI-MS/MS) is described. The sample preparation includes a solid-phase extraction (SPE) with a SCX column. Tamoxifen is used as an internal standard for both chromatographic methods. Chromatographic separation is achieved on an ODS Hypersil column using isocratic elution with 0.01% diethylamine and acetonitrile as mobile phase for the HPLC-UV method and with 0.1% formic acid and acetonitrile as mobile phase for the LC-MS/MS method. For the HPLC-UV method, good linearity was observed in the range 0-5 microg ml(-1), and in the range 0-1 microg ml(-1) for the LC-MS/MS method. The limit of quantification (LOQ) was set at 50 and 5 ng ml(-1) for the HPLC-UV method and the LC-MS/MS method, respectively. For the UV method, the limit of detection (LOD) was 15 and 10 ng ml(-1) for amiodarone and desethylamiodarone, respectively. The LODs of the LC-MS/MS method in plasma were much lower, i.e. 0.10 and 0.04 ng ml(-1) for amiodarone and desethylamiodarone, respectively. The LODs obtained for the urine samples were 0.16 and 0.09 ng ml(-1) for amiodarone and desethylamiodarone, respectively. The methods were shown to be of use in horses. The rapid HPLC-UV method was used for therapeutic drug monitoring after amiodarone treatment, while the LC-MS/MS method showed its applicability for single dose pharmacokinetic studies.