page116
must be available during intravenous use;
interac-
tions: Appendix 1 (flecainide)
Contra-indications
heart failure;
abnormal left
ventricular function;
history of myocardial infarction
and either asymptomatic ventricular ectopics or
asymptomatic non-sustained ventricular tachycardia;
long-standing atrial fibrillation where conversion to
sinus rhythm not attempted;
haemodynamically sig-
nificant valvular heart disease; avoid in sinus node
dysfunction, atrial conduction defects, second-degree
or greater AV block,
bundle branch block or distal
block unless pacing rescue available
Hepatic impairment
avoid (or reduce dose) in severe
liver disease
Renal impairment
reduce initial oral dose to max.
100 mg daily or reduce intravenous dose by 50%,
if
eGFR less than 35 mL/minute/1.73 m
2
Pregnancy
used in pregnancy to treat maternal
and
fetal arrhythmias in specialist centres;
toxicity
reported in
animal
studies; infant hyperbilirubinaemia
also reported
Breast-feeding
significant amount present in milk but
not known to be harmful
Side-effects
oedema,
pro-arrhythmic effects;
dys-
pnoea;
dizziness,
asthenia,
fatigue,
fever; visual dis-
turbances;
rarely
pneumonitis,
hallucinations,
depression,
confusion,
amnesia,
dyskinesia,
con-
vulsions, peripheral neuropathy;
also reported
gastro-
intestinal disturbances, anorexia, hepatic dysfunction,
flushing,
syncope,
drowsiness,
tremor,
vertigo,
head-
ache,
anxiety,
insomnia,
ataxia, paraesthesia,
anae-
mia, leucopenia, thrombocytopenia, corneal deposits,
tinnitus,
increased antinuclear antibodies,
hyper-
sensitivity reactions (including rash,
urticaria,
and
photosensitivity),
increased sweating
Dose
. By mouth (initiated under direction of hospital con-
sultant),
ventricular arrhythmias,
initially 100 mg
twice daily (max.
400 mg daily usually reserved for
rapid control or in heavily built patients),
reduced
after 3–5 days to the lowest dose that controls
arrhythmia
Supraventricular arrhythmias,
50 mg twice daily,
increased if required to max.
300 mg daily
.
By slow intravenous injection (in hospital), 2 mg/kg
over 10–30 minutes,
max.
150 mg,
with ECG moni-
toring;
followed if required by infusion at a rate of
1.5 mg/kg/hour for 1 hour,
subsequently reduced to
100–250 micrograms/kg/hour for up to 24 hours;
max.
cumulative dose in first 24 hours, 600 mg;
transfer to
oral
treatment,
as above
Flecainide
(Non-proprietary) A
Tablets
,
flecainide acetate 50 mg,
net price 60-tab
pack = £6.04;
100 mg,
60-tab pack = £8.95
Tambocor
c
(3M) A
Tablets
,
flecainide acetate 50 mg,
net price 60-tab
pack = £11.57; 100 mg (scored), 60-tab pack = £16.53
Injection
, flecainide acetate 10 mg/mL, net price 15-
mL amp = £4.40
Modified release
Tambocor
c
XL
(Meda) A
Capsules
, m/r, grey/pink, flecainide acetate 200 mg,
net price 30-cap pack = £14.77.
Label:
25
Dose
supraventricular arrhythmias, 200 mg once daily
Note
Not to be used to control
arrhythmias in acute situations;
patients stabilised on 200 mg daily immediate-release flecainide
may be transferred to
Tambocor
c
XL
PROPAFENONE HYDROCHLORIDE
Indications
ventricular arrhythmias; paroxysmal
supraventricular tachyarrhythmias which include
paroxysmal atrial flutter or fibrillation and paroxysmal
re-entrant tachycardias involving the AV node or
accessory pathway,
where standard therapy ineffec-
tive or contra-indicated
Cautions
heart failure;
elderly;
pacemaker patients;
potential for conversion of paroxysmal atrial fibrilla-
tion to atrial flutter with 2:1 or 1:1 conduction block;
great caution in obstructive airways disease owing to
beta-blocking activity (contra-indicated if severe);
interactions: Appendix 1 (propafenone)
Driving
May affect performance of skilled tasks e.g. driving
Contra-indications
uncontrolled congestive heart
failure,
cardiogenic shock (except arrhythmia
induced),
severe bradycardia, electrolyte distur-
bances,
severe obstructive pulmonary disease,
marked hypotension;
myasthenia gravis;
unless ade-
quately paced avoid in sinus node dysfunction,
atrial
conduction defects,
second degree or greater AV
block,
bundle branch block or distal block
Hepatic impairment
reduce dose
Pregnancy
manufacturer advises avoid—no informa-
tion available
Breast-feeding
manufacturer advises avoid—no
information available
Side-effects
gastro-intestinal disturbances,
dry
mouth,
bitter taste,
anorexia,
jaundice,
cholestasis,
hepatitis;
chest pain,
bradycardia, sino-atrial,
atrio-
ventricular,
or intraventricular blocks,
hypotension
(including postural hypotension), dizziness,
syncope,
pro-arhythmic effects;
anxiety,
confusion,
ataxia,
restlessness,
headache,
sleep disorders,
paraesthesia,
fatigue,
seizures,
extrapyramidal symptoms;
impo-
tence,
reduced sperm count;
blood disorders;
lupus
syndrome; blurred vision;
hypersensitivity (including
skin reactions)
Dose
. Body-weight 70 kg and over,
initially 150 mg 3 times
daily after food under direct hospital supervision with
ECG monitoring and blood pressure control (if QRS
interval prolonged by more than 20%, reduce dose or
discontinue until ECG returns to normal limits); may
be increased at intervals of at least 3 days to 300 mg
twice daily and,
if necessary,
to max.
300 mg 3 times
daily; body-weight under 70 kg,
reduce dose;
ELDERLY
may respond to lower doses
Arythmol
c
(Abbott) A
Tablets
,
f/c,
propafenone hydrochloride 150 mg,
net
price 90-tab pack = £7.37;
300 mg,
60-tab pack =
£9.34.
Label:
21, 25,
counselling,
driving
Ventricular arrhythmias
Intravenous lidocaine can be used for the treatment of
ventricular
tachycardia
in haemodynamically
stable
patients (section 2.3.1),
and ventricular fibrillation and
pulseless
ventricular
tachycardia
in
cardiac
arrest
refractory to defibrillation (section 2.7.3),
however it is
no longer the anti-arrhythmic drug of first choice.
Drugs for both supraventricular and ventricular arrhy-
thmias include amiodarone,
beta-blockers,
disopyr-
amide,
flecainide,
procainamide (available from ‘spe-
cial-order’
manufacturers
or
specialist
importing
96
2.3.2 Drugs for arrhythmias
BNF 61
2
Cardiovascular system