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Flecainide

Flecainide acetate is a class Ic antiarrhythmic agent used to prevent and treat tachyarrhythmias (abnormal fast rhythms of the heart). It is used to treat a variety of cardiac arrhythmias including paroxysmal atrial fibrillation (episodic irregular heartbeat originating in the upper chamber of the heart), paroxysmal supraventricular tachycardia (episodic rapid but regular heartbeat originating in the atrium), and ventricular tachycardia (rapid rhythms of the lower chambers of the heart). Flecainide works by regulating the flow of sodium in the heart, thus slowing nerve impulses. more...

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Flecainide was originally sold under the trade name Tambocor^® (manufactured by 3M pharmaceuticals). Flecainide went off-patent on February 10^th, 2004, and is now available under the trade names Almarytm^®, Apocard^®, Ecrinal^®, and Flécaine^®. It is also available generically.

Uses

Flecainide is used in the treatment of many types of supraventricular tachycardias, including AV nodal reciprocating tachycardia (AVNRT) and Wolff-Parkinson-White syndrome (WPW). This is because of the action of flecainide on the His-Purkinje system.

It also has limited use in the treatment of certain forms of ventricular tachycardia (VT). In particular, flecainide has been useful in the treatment of ventricular tachycardias that are not in the setting of an acute ischemic event. It has use in the treatment of right ventricular outflow tract (RVOT) tachycardia¹ and in the suppression of arrhythmias in arrhythmogenic right ventricular dysplasia (ARVD)². However, studies have shown an increased mortality when flecainide is used to suppress ventricular extrasystoles in the setting of acute myocardial infarction.^3,4

In individuals suspected of havings the Brugada syndrome, the administration of flecainide may help reveal the ECG findings that are characteristic of the disease process. This may help make the diagnosis of the disease in equivocal cases.⁵

Flecainide has been introduced into the treatment of arrhythmias in the pediatric population.

Dosing

The dosing of flecainide is varied, with consideration made to the individual's other medications and comorbid conditions and how they may affect the metabolism of flecainide. Individuals with significant renal impairment may require measurement of the plasma level of flecainide to insure that the drug level remains within the therapeutic range (ie: that toxic levels do not occur). In addition, lower drug levels may be sought for the treatment of benign arrhythmias, to lower the chance of inducing a toxic effect of the drug. When used in the pediatric population, the dose of flecainide may be adjusted to the individual's body surface area.

Given the variable half life of flecainide and the characteristic QT prolongation on ECG elicited in flecainide toxicity, starting flecainide or changing the level of the drug is done under telemetry monitoring (preferably in a hospital telemetry unit) until a steady state plasma level has been achieved, typically three to five days after the dose has been increased.

For the treatment of supraventricular tachycardias and paroxysmal atrial fibrillation or flutter in individuals without significant structural heart disease, a starting dose of 50 mg twice a day may be appropriate. The dose may be increased (once a steady state level has been reached) if breakthrough arrhythmias occur.

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Flecainide: Test your drug IQ
From Nursing, 12/1/04 by Gever, Marcy Portnoff

Make sure you can administer this antiarrhythmic drug safely.

Flecainide (Tambocor) is a Class IC antiarrhythmic agent used to suppress and prevent lifethreatening ventricular arrhythmias such as sustained ventricular tachycardia in patients without structural heart disease. It's also indicated to prevent paroxysmal supraventricular tachycardias (PSVTs) and paroxysmal atrial fibrillation and flutter in patients with disabling symptoms. Because of its potentially life-threatening adverse effects, flecainide is reserved for patients whose arrhythmias haven't responded to other therapies. For complete drug information, see the package insert.

Q. How is flecainide administered and what's the usual dosage?

A. Flecainide is available as 50-mg, 100-mg, and 150-mg tablets. The usual initial adult dosage to treat sustained ventricular tachycardia is 100 mg P.O. every 12 hours, increased by 50 mg every 12 hours every 4 days. The daily maintenance dosage is 200 to 400 mg orally; the maximum daily dosage is 400 mg orally.

To treat PSVT or atrial fibrillation, the usual initial adult dosage is 50 mg orally every 12 hours, increased 50 mg every 12 hours every 4 days. The maximum daily dosage is 300 mg orally. In patients with severe renal impairment (creatinine clearance less than 20 ml/minute), reduce the initial dosage 25% to 50%.

Q. What adverse reactions should I watch for?

A. Like other antiarrhythmics, flecainide can produce new supraventricular or ventricular arrhythmias, worsen heart failure, or cause heart block. Because of these potentially serious adverse reactions, flecainide therapy should be started in the hospital, where the patient's cardiac rhythm can be monitored. Common adverse reactions are dizziness, visual disturbances, headache, fatigue, weakness, palpitations, nausea, and shortness of breath.

Q. When is flecainide contraindicated?

A. Flecainide is contraindicated in patients with second- or third-degree atrioventricular block or with right bundle-branch block when associated with a left hemiblock (bifascicular block) unless the patient has a pacemaker. Flecainide is also contraindicated in patients who are in cardiogenic shock and those hypersensitive to the drug.

Q. Which drugs interact with flecainide?

A. Flecainide may increase blood levels of digoxin and propranolol; patients taking propranolol and flecainide also may have increased flecainide levels. Cimetidine can increase flecainide blood levels 30%, so tell your patient to avoid taking over-the-counter products containing cimetidine.

Amiodarone also increases flecainide blood levels by an average of 60% (range, 5% to 190%). Disopyramide or verapamil, when taken with flecainide, can cause additive negative inotropic effects. These drugs shouldn't be given together unless the benefits outweigh the risks. Patients taking quinidine and flecainide may have increased flecainide concentrations.

Q. How should I monitor a patient who's receiving flecainide?

A. Initiate flecainide while your patient is hospitalized and monitor cardiac rate and rhythm, electrocardiogram, blood pressure, and kidney and liver function. Monitor his potassium and electrolyte levels to avoid imbalance-induced arrhythmias. Flecainide trough plasma levels should stay between 0.2 and 1 mcg/ml. Monitoring flecainide trough levels is especially important in patients with severe kidney or liver disease; slow elimination can result in toxic blood levels and adverse reactions.

Tell your patient to report any new or worsening symptoms, such as chest pain, palpitations, or dizziness.

SELECTED REFERENCES

American Hospital Formulary Service. Bethesda, Md., American Hospital Formulary Service, 2002.

Flecainide prescribing information. Northridge, Calif., 3M Pharmaceuticals, 1998.

Nursing2004 Drug Handbook, 24th edition. Ambler, Pa., Lippincott Williams & Wilkins, 2004.

By Marcy Portnoff Gever, PharmD, MEd

Marcy Portnoff Gever is an independent pharmacist consultant and educator in Ringoes, N.J.

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