| Dosing (adults):: Paroxysmal supraventricular tachycardia (PSVT): Initially 6 mg rapid bolus (over 1-2 seconds). If not effective within 1-2 minutes, 12 mg may be given; may repeat 12 mg bolus if needed; maximum single dose: 12 mg. (Each I.V. bolus of adenosine should be followed with normal saline flush.)
Pharmacologic stress agent (Adenoscan®): Continuous I.V. infusion: 140 mcg/kg/minute for 6 minutes using syringe or columetric infusion pump; total dose: 0.84 mg/kg. Thallium-201 is injected at midpoint (3 minutes) of infusion.
Mechanism of Action
Supplied: Adenocard®: 3 mg/ml (2 ml, 4 ml)
| Infusion: whenever possible administer through a central venous catheter. Also, an in-line filter should be used during administration. Cordarone I.V. concentrations greater than 3 mg/ml in D 5 W have been associated with a high incidence of peripheral vein phlebitis; however, concentrations of 2.5 mg/ml or less appear to be less irritating. Therefore, for infusions longer than 1 hour, Cordarone I.V. concentrations should not exceed 2 mg/ml unless a central venous catheter is used. Cordarone I.V. infusions exceeding 2 hours must be administered in glass or polyolefin bottles containing D5W. Use of evacuated glass containers for admixing Cordarone I.V. is not recommended as incompatibility with a buffer in the container may cause precipitation.
Amiodarone: I.V. DOSE RECOMMENDATIONS — FIRST 24 HOURS — Loading infusions. The recommended starting dose of Cordarone I.V. is about 1000 mg over the first 24 hours of therapy, delivered by the following infusion regimen:
First Rapid: 150 mg over the FIRST – 10 minutes (15 mg/min). Add 3 ml of Cordarone I.V. (150 mg) to 100 ml D 5 W. Infuse 100 ml over 10 minutes.
After the first 24 hours, the maintenance infusion rate of 0.5 mg/min (720 mg/24 hours) should be continued utilizing a concentration of 1 to 6 mg/ml (Cordarone I.V. concentrations greater than 2 mg/ml should be administered via a central venous catheter). In the event of breakthrough episodes of VF or hemodynamically unstable VT, Give 150-mg/100 ml D5W over 10 minutes to minimize potential for hypotension. The rate of the maintenance infusion may be increased to achieve effective arrhythmia suppression. The initial infusion rate should not exceed 30 mg/min. The maintenance infusion of up to 0.5 mg/min can be cautiously continued for 2 to 3 weeks regardless of the patient’s age, renal function, or Left-ventricular function. There is limited experience in patients receiving Cordarone I.V. > 3 weeks.
RECOMMENDATIONS FOR ORAL DOSAGE AFTER I.V. INFUSION
Duration of Cordarone I.V. Infusion: 1 to 3 weeks
Duration of Cordarone I.V. Infusion: >3 weeks
Restated: Duration of IV infusion < 1 week: 800-1600mg/day po initially x 1-2 weeks or complete current week; 1-3 weeks: 600-800mg/day po initially – total therapy ~ 1 month counting IV infusion ; >3 weeks: 400mg po qd initially.
Oral Loading – Half-life elimination: 40-55 days (range: 26-107 days);
Recommendations for conversion to intravenous amiodarone after oral administration: During long-term amiodarone therapy (ie, 4 months), the mean plasma-elimination half-life of the active metabolite of amiodarone is 61 days. Replacement therapy may not be necessary in such patients if oral therapy is discontinued for a period <2 weeks, since any changes in serum amiodarone concentrations during this period may not be clinically significant.
| Asystole: 1 mg IV – repeat in 3-5 minutes if asystole persists; total dose of 0.04 mg/kg.
Intratracheal: Administer 2 – 2.5 times the recommended I.V. dose; dilute in 10 ml NS.
Bradycardia: 0.5 mg I.V every 5 minutes, not to exceed a total of 3 mg or 0.04 mg/kg; may give intratracheal in 1 mg/10 ml dilution only, intratracheal dose should be 2-2.5 times the I.V. dose. (Doses <0.5 mg have been associated with paradoxical bradycardia.)
Inhibit salivation and secretions (preanesthesia):
Organophosphate or carbamate poisoning:
| Dosing (adults):: Immediate life-threatening ventricular arrhythmias, ventricular fibrillation, unstable ventricular tachycardia:
5 mg/kg IVpush——shock——- Repeat in 5 minutes at 10 mg/kg. (maximum total: 30 to 35 mg/kg). Side effects: Bradycardia, hypotension, N&V. Continuous infusion: 1 to 2 mg/min (Range: 0.5 to 4 mg/min).
Drip preparation: Add 1 gram to 250ml of D5W or normal saline. Rate (ml/hr)= mg/min x 15
[Supplied: 500mg/ 10 ml syringe]
| Loading dose:
CHF: 8-12 mcg/kg in divided doses (q4-8h) over 12 to 24 hours. [Normally, give 50% of the total digitalizing dose in the initial dose, then give 25% of the total dose in each of the two subsequent doses at 8 to 12 hr intervals-Obtain EKG 6 hours after each dose to assess potential toxicity (AV block, sinus bradycardia, atrial or nodal ectopic beats, ventricular arrhythmias); Other: vision changes, confusion.]
Renal: If pt has renal insufficiency give 6 to 10 mcg/kg IBW.
A-fib: 10 to 15 mcg/kg IBW given as above. (If given IVPush-admin over at least 5 min).
Maintenance dose: Digoxin clearance= [CRCL + 40] x 1.44 (add 20 instead of 40 if pt has CHF). Predicted Css= (Dose) (0.65 to 0.8)/ Digoxin clearance. Alternatively, maint dose= Loading dose x [0.14 x crcl / 500 ] Avoid IM injections-can lead to severe pain (If it must be given by this route, give deep IM followed by massage).
Serum levels: 0.5 to 2.0 ng/ml. Obtain first level within 24 hours of digitalization. Monitor BUN and serum creatinine q2days (qd if unstable). Monitor apical pulse daily.. Onset/peak: IV: 5-30min/ 1-4hrs Oral: 1-2hrs/ 2-8 hrs. Time to steady state: 5-7 days (average) ESRD: 15-20 days. Half-life: 38-48 hrs. (anephric: 4-6 days).
Conversion from oral to IV: Decrease IV dose by 20 to 25%. When the maintenance dose is given IV, the onset and peak will occur earlier, however the duration of action is the same. Patients’ on the “floors” may receive once daily IV maintenance doses, however, IV loading regimens (multiple doses) are restricted to pts on a monitor- ICU’s. [Oral bioavailability (tablets): 70 to 80%].
Factors that increase likelihood of digoxin toxicity: Hypokalemia, hypomagnesaemia, hypothyroidism, renal dysfunction, interacting drugs (eg quinidine, verapamil).
Adverse reactions: sinus bradyarrhythmias; AV block; N/V/D; yellow vision and hallucinations; supra and ventricular arrhythmias. Contraindications: V-fibrillation; hypokalemia; WPW syndrome with wide complex.
| Reconstitution: Dissolve each vial with 4 ml sterile water (do not shake). May be further diluted with normal saline. Infuse over 30 minutes– must use 0.22 micron filter. If cardiac arrest is imminent, may give as a bolus.
The affinity of DIGIBIND for digoxin is in the range of 109 to 1011 M-1, which is greater than the affinity of digoxin for (sodium, potassium) ATPase, the presumed receptor for its toxic effects. The affinity of DIGIBIND for digitoxin is about 108 to 109 M-1.
DIGIBIND binds molecules of digoxin, making them unavailable for binding at their site of action on cells in the body. The Fab fragment-digoxin complex accumulates in the blood, from which it is excreted by the kidney. The net effect is to shift the equilibrium away from binding of digoxin to its receptors in the body, thereby reversing its effects.
Manifestations of life-threatening toxicity include severe ventricular arrhythmias such as ventricular tachycardia or ventricular fibrillation, or progressive bradyarrhythmias such as severe sinus bradycardia or second or third degree heart block not responsive to atropine.
Ingestion of more than 10 mg of digoxin in previously healthy adults or 4 mg of digoxin in previously healthy children, or ingestion causing steady-state serum concentrations greater than 10 ng/mL, often results in cardiac arrest. Digitalis-induced progressive elevation of the serum potassium concentration also suggests imminent cardiac arrest. If the potassium concentration exceeds 5 mEq/L in the setting of severe digitalis intoxication, therapy with DIGIBIND is indicated.
Digoxin Immune Fab
Fab dose based on serum drug level postdistribution:
Digitoxin: No. of vials = digitoxin (ng/mL) x body weight (kg) divided by 1000
If neither amount ingested nor drug level are known, dose empirically as follows:
For chronic toxicity: 6 vials; for infants and small children </=( 20kg), a single vial may be sufficient
DigiFab™: 40 mg
Number of vials needed =[(steady state serum digoxin level (ng/ml) x weight (kg)] / 100. Each vial contains 38 mg which will bind approximately 0.5 mg of digoxin. Dosage for acute ingestion of unknown amount: 20 vials (760mg) of Digibind is adequate to treat most life-threatening ingestions. May consider giving 10 vials, observing the patient’s response, and following with an additional 10 vials.
| Dosing (adults)::
<50 kg: 100 mg orally every 6 hours or 200 mg every 12 hours (controlled release)
>50 kg: 150 mg every 6 hours or 300 mg every 12 hours (controlled release); if no response, may increase to 200 mg every 6 hours; maximum dose required for patients with severe refractory ventricular tachycardia is 400 mg every 6 hours.
| Class III antiarrhythmic agent
Warnings: Review package insert for additional comments. Consult cardiology.
A-fib/Flutter: Dosing (adults)::
Continued monitoring for doses 2-5: QTc interval must be determined 2-3 hours after each subsequent dose of dofetilide for in-hospital doses 2-5. If the measured QTc is >500 msec (550 msec in patients with ventricular conduction abnormalities) dofetilide should be stopped.
Supplied: 125 mcg, 250 mcg, 500 mcg capsule
| WARNING: HEART FAILURE
MULTAQ is contraindicated in patients with NYHA Class IV heart failure, or NYHA Class II – III heart failure with a recent decompensation requiring hospitalization or referral to a specialized heart failure clinic [see Contraindications].
In a placebo-controlled study in patients with severe heart failure requiring recent hospitalization or referral to a specialized heart failure clinic for worsening symptoms (the ANDROMEDA Study), patients given dronedarone had a greater than two-fold increase in mortality. Such patients should not be given dronedarone.
INDICATIONS AND USAGE
DOSAGE AND ADMINISTRATION
Treatment with Class I or III antiarrhythmics (e.g., amiodarone, flecainide, propafenone, quinidine, disopyramide, dofetilide, sotalol) or drugs that are strong inhibitors of CYP3A (e.g., ketoconazole) must be stopped before starting MULTAQ
| Dosing (adults):
Asystole: 1 mg IV every 3-5 minutes. Intratracheal: Administer 2-2.5 times the recommended I.V. dose; dilute in 10 ml NS or distilled water.
Bronchospasm: 0.1-0.5 mg IM, SQ (1:1000): every 10-15 minutes to 4 hours.
Hypotension (refractory to dopamine/dobutamine): Initial (continuous infusion): 1 mcg/minute (range: 1-10 mcg/minute); titrate to desired effect; severe cardiac dysfunction may require doses >10 mcg/minute (up to 0.1 mcg/kg/minute).
Hypersensitivity reaction: 0.2-0.5 mg IM, SQ every 20 minutes to 4 hours (maximum single dose: 1 mg)
| Beta-1 Selective Blocker.
Supraventricular tachycardia or gradual control of postoperative tachycardia/hypertension: (note: IV beta blockers should not be given within 30 minutes of verapamil): 500 mcg/kg IV loading dose over 1 minute, followed by 50 mcg/kg/minute over 4 minutes. If ineffective, repeat load of 500 mcg/kg, followed by 100 mcg/kg/min. If needed, may repeat process of loading dose plus increase infusion by another 50 mcg/kg/min (up to max of 200 mcg/kg/min). Titration interval: max q4 min.
Intraoperative tachycardia and/or hypertension (immediate control): Initial bolus: 80 mg IV (~1 mg/kg) over 30 seconds, followed by a 150 mcg/kg/minute infusion, if necessary. Adjust infusion rate as needed to maintain desired heart rate and/or blood pressure, up to 300 mcg/kg/minute.
Half life: 9 minutes. Onset of action: 2-10 minutes. Contraindicated in: sinus bradycardia; > 1st degree heart block; overt cardiac failure.
| Dosing (adults): Life-threatening ventricular arrhythmias: Oral:
Initial: 100 mg every 12 hours; increase by 50-100 mg/day (given in 2 doses/day) every 4 days; maximum: 400 mg/day. For patients receiving 400 mg/day who are not controlled and have trough concentrations <0.6 mcg/ml, dosage may be increased to 600 mg/day.
Prevention of paroxysmal supraventricular arrhythmias: Oral: (In patients with disabling symptoms but no structural heart disease) Initial: 50 mg every 12 hours; increase by 50 mg twice daily at 4-day intervals; maximum: 300 mg/day.
Renal Dosing: CRCL <10 ml/minute: Decrease usual dose by 25% to 50% in severe renal impairment.
| FDA-approved for acute termination of A-flutter/A-fib (may be alternative to cardioversion): 1mg IV over 10min. May repeat x 1 in 10 minutes if needed. Approved for acute termination. Monitor ECG for at least 4hr . Effective in @30% of patients.
Major adverse reactions: proarrhythmic events: VT, PVC’s, BC, AV block, torsades de pointes, etc.
| Beta1/Beta2 agonist
Dosing (adults): Cardiac arrhythmias: Initial: 2 mcg/minute IV; titrate to patient response (2-10 mcg/minute).
Supplied: 0.02 mg/ml (10 ml); 0.2 mg/ml (1:5000) (1 ml, 5 ml).
| Dosing (adults):
Ventricular arrhythmia: 1-1.5 mg/kg IV bolus over 2-3 minutes; may repeat doses of 0.5-0.75 mg/kg in 5-10 minutes up to a total of 3 mg/kg; continuous infusion: 1-4 mg/minute. Intratracheal: 2 to 2.5 times the recommended I.V. dose; dilute in 10 ml NS or distilled water.
Prevention of ventricular fibrillation: Initial bolus: 0.5 mg/kg; repeat every 5-10 minutes to a total dose of 2 mg/kg. Refractory ventricular fibrillation: Repeat 1.5 mg/kg bolus may be given 3-5 minutes after initial dose.
Note: Decrease dose in patients with CHF, elderly, hepatic disease.
| Class IB Antiarrhythmic Agent
Dosing (adults): Arrhythmias: Oral: Initial: 200 mg every 8 hours with food (may load with 400 mg if necessary); adjust dose every 2-3 days; usual dose: 200-300 mg every 8 hours; maximum: 1.2 g/day (some patients respond to every 12-hour dosing). When switching from another antiarrhythmic, initiate a 200 mg dose 6-12 hours after stopping former agents, 3-6 hours after stopping procainamide.
Supplied: 150 mg, 200 mg, 250 mg capsule.
| Dosing (adults): — Ventricular arrhythmias: Oral: 200-300 mg every 8 hours, adjust dosage at 150 mg/day at 3-day intervals. Hospitalization required to start therapy. Renal or hepatic impairment: Start at 600 mg/day or less.
Supplied: 200 mg, 250 mg, 300 mg tablet
| VENTRICULAR FIBRILLATION/ PULSELESS V-tach: Give 20-30 mg/minute until (maximum total of 17 mg/kg) or side effects occur or arrhythmia subsides.
Side effects: Severe hypotension with rapid infusion; bradycardia; AV block; V-fib. Loading regimen: 20-30 mg/min.
Add 1 gram/250 ml D5W. Rate: 20 mg/min= 300 ml/hr; 30 mg/min= 450 ml/hr. Continuous infusion: 1 to 4 mg/min (monitor levels). Add 1 gram/250 ml D5W.
Rate (ml/hr)= mg/min x 15
Note: Reduce to 12 mg/kg in setting of cardiac or renal dysfunction.
Oral: 250-500 mg/dose every 3-6 hours or 500 mg to 1 g every 6 hours extended release; usual dose: 50 mg/kg/24 hours; maximum: 4 g/24 hours.
Supplied: 250 mg, 500 mg capsule.
| Dosing (adults): Ventricular arrhythmias: Immediate release tablet: Initial: 150 mg every 8 hours, increase at 3- to 4-day intervals up to 300 mg every 8 hours. Extended release capsule: Initial: 225 mg every 12 hours; dosage increase may be made at a minimum of 5-day intervals; may increase to 325 mg every 12 hours; if further increase is necessary, may increase to 425 mg every 12 hours. Note: Patients who exhibit significant widening of QRS complex or second- or third-degree AV block may need dose reduction.
Supplied: 225 mg, 325 mg, 425 mg extended release cap. 150 mg, 225 mg, 300 mg tablet.
| Dosing (adults): Antiarrhythmic: (Oral) Sulfate: 100-600 mg/dose every 4-6 hours; begin at 200 mg/dose and titrate to desired effect (maximum daily dose: 3-4 g) Gluconate: 324-972 mg every 8-12 hours.
( 267 mg of quinidine gluconate = 275 mg of quinidine polygalacturonate = 200 mg of quinidine sulfate. )
Renal Dosing Crcl <10 ml/minute: Administer 75% of normal dose.
Supplied: 200 mg, 300 mg tab (sulfate). 300mg extended release tablet (sulfate). 324 mg extended release tab (gluconate). Injection: 80 mg/ml (10 ml) (gluconate)
| Dosing (adults): Ventricular arrhythmias – Initial: 80 mg orally twice daily; dose may be increased gradually to 240-320 mg/day; allow 3 days between dosing increments (to attain steady-state plasma concentrations and to allow monitoring of QT intervals). Usual range: Most patients respond to 160-320 mg/day in 2-3 divided doses. Atrial fibrillation / atrial flutter: Initial: 80 mg orally twice daily. Note: If the initial dose does not reduce the frequency of relapses of atrial fibrillation/flutter and is tolerated without excessive QT prolongation (not >520 msec) after 3 days, the dose may be increased to 120 mg twice daily. This may be further increased to 160 mg twice daily if response is inadequate and QT prolongation is not excessive.
Atrial fibrillation/flutter (Betapace AF®):
Supplied: 80 mg, 120 mg, 160 mg, 240 mg tablet
U.S. Approval: 2014
Mechanism of Action: Sotalol has both beta-adrenoreceptor blocking (Vaughan Williams Class II) and cardiac action potential duration prolongation (Vaughan Williams Class III) antiarrhythmic properties. Sotalol hydrochloride is a racemic mixture of two isomers, both of which have similar Class III antiarrhythmic effects, while the l-isomer is responsible for virtually all of the beta-blocking activity. The beta-blocking effect of sotalol is non-cardioselective, half maximal at an oral dose of about 80 mg/day and maximal at doses between 320 and 640 mg/day. Sotalol does not have partial agonist or membrane stabilizing activity. Although significant beta-blockade occurs at oral doses as low as 25 mg, significant Class III effects are seen only at daily doses of 160 mg and above.
In children, a Class III electrophysiological effect can be seen at daily doses of 210 mg/m2 body surface area (BSA). A reduction of the resting heart rate due to the beta-blocking effect of sotalol is observed at daily doses >/=90 mg/m2 in children.
INDICATIONS AND USAGE:
| Dosing (adults): Ventricular arrhythmias: Oral: 1200-1800 mg/day in 3 divided doses, up to 2400 mg/day
Renal Dosing: Crcl <30 ml/min: Administer 50% of normal dose or 600 mg once daily. Hepatic impairment: Maximum daily dose: 1200 mg
Supplied: 400, 600mg tab.
| PSVT: 2.5 to 5 mg IV over 2 minutes. May repeat dose of 5-10mg 15-30 minutes after 1st dose. Alternative initial choice in stable patients.
Decrease dose by 30-50% in hepatic insufficiency.
Adverse reactions: Severe hypotension; bradycardia; ventricular standstill in digitalized patients; asystole; respiratory failure.
National Institutes of Health, U.S. National Library of Medicine, DailyMed Database.
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