Flecainide toxicity in renal failure

Subedi, Rogin; Dean, Ryan; Chaudhary, Arbind; Szombathy, Tamás

doi:10.1080/08998280.2018.1463042

Cited by 10 publications

(17 citation statements)

References 17 publications

(19 reference statements)

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“…Approximately 30% of an oral dose of flecainide is excreted in urine as unchanged drug, and in patients with renal impairment, the total clearance of this drug might fall by approximately 40% [1]. Our patient had ESRD requiring intermittent hemodialysis, and a daily dose of 150 mg flecainide was likely excessive.…”

Section: Discussionmentioning

confidence: 98%

“…Toxicity is less easily recognized in case of chronic therapy. Ventricular arrhythmias and decreased cardiac contractility in relationship with conduction disturbances are the main complications of flecainide overdose [1]. When the usual cardiopulmonary resuscitation with sodium bicarbonate and catecholamines is failing, rescue therapy with extracorporeal cardiac life support (ECLS) should be promptly considered.…”

Section: Introductionmentioning

confidence: 99%

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Cardiogenic Shock in a Hemodialyzed Patient on Flecainide: Treatment with Intravenous Fat Emulsion, Extracorporeal Cardiac Life Support, and CytoSorb® Hemoadsorption

Schryver

Hantson

Haufroid

et al. 2019

Case Reports in Cardiology

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A 67-year-old woman with a history of end-stage renal disease on hemodialysis received a therapeutic dose (150 mg daily) of flecainide for three weeks. She was admitted to the Emergency Department for malaise and dizziness, and the electrocardiogram revealed ventricular tachycardia treated by amiodarone. Hemodynamic condition remained stable, and the toxicity of flecainide was initially not suspected until she developed within 8 hours a cardiogenic shock requiring vasopressors. The patient then received sodium bicarbonate (300 mmol) and dobutamine but experienced cardiac arrest two hours later. The administration of intravenous fat emulsion (IFE) was associated with return of spontaneous circulation, but there was a relapse of cardiovascular shock at the end of IFE infusion. The patient was placed on extracorporeal cardiac life support (ECLS), continuous hemofiltration, and hemoadsorption using the CytoSorb® cartridge. Serial determinations of serum flecainide concentration were obtained during the course of hemoadsorption, with a terminal half-life of 3.7 h during the first four hours and a global plasma clearance of 40.3 ml/min over the first 22 hours. The weaning of ECLS was possible on day 7. Intravenous fat emulsion infusion was followed by a significant increase in serum flecainide concentration. In addition, while conventional techniques of extrarenal epuration usually appear as poorly effective for flecainide removal, a mean plasma clearance of 40.3 ml/min was observed using the hemoadsorption technique based on CytoSorb® cartridge. However, the impact on the clinical course was probably extremely modest in comparison with ECLS.

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Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Cardiogenic Shock in a Hemodialyzed Patient on Flecainide: Treatment with Intravenous Fat Emulsion, Extracorporeal Cardiac Life Support, and CytoSorb® Hemoadsorption

Schryver

Hantson

Haufroid

et al. 2019

Case Reports in Cardiology

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show abstract

“…ECG findings of flecainide toxicity are similar to commonly used Na channelblocking agents like tricyclic antidepressants and include PR prolongation, QRS widening, and QTc prolongation, with eventual progression to monomorphic VT, as demonstrated in our patient. 7 In the adult population where polypharmacy is common, drug interactions with tricyclic antidepressants and amphetamines can enhance toxicity by additive sodium channel blockade. 6,8 As flecainide levels become supratherapeutic, cardiogenic shock ensues rapidly and can be refractory to chronotropic and inotropic therapies.…”

Section: Discussionmentioning

confidence: 99%

Flecainide toxicity in renal tubular acidosis type IV treated with extracorporeal membrane oxygenation

Bhimani

Rao

Nadorlik

et al. 2020

HeartRhythm Case Reports

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“…The use of sodium bicarbonate has also been proposed because it can theoretically be used to overcome sodium blockade by displacing flecainide from its receptor sites to reverse the action of sodium channel blockade. 7,25 Alkalinization also converts flecainide to its inactive nonionized form. 7,25 Indeed, in several studies, researchers have reported successful treatment with the use of sodium bicarbonate.…”

Section: Discussionmentioning

confidence: 99%

“…7,25 Alkalinization also converts flecainide to its inactive nonionized form. 7,25 Indeed, in several studies, researchers have reported successful treatment with the use of sodium bicarbonate. 6,7,25 Our patient was effectively treated with ECMO, which is consistent with other published case reports, 26,27 revealing that ECMO can be an effective means for restoring circulation and allowing drug clearance.…”

Section: Discussionmentioning

confidence: 99%

Complete Heart Block Secondary to Flecainide Toxicity: Is It Time for CYP2D6 Genotype Testing?

Poh¹,

Lee

Haium

et al. 2020

Pediatrics

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Flecainide acetate is a Vaughan-Williams class IC antiarrhythmic drug prescribed for the treatment of supraventricular arrhythmias. It has a narrow therapeutic index and proarrhythmic effects even at therapeutic doses. Flecainide is metabolized by a CYP2D6 enzyme that exhibits polymorphism. In this case report, we present, to our best knowledge, the first case of toxicity contributed by genetic polymorphism in an infant. Our patient with recurrent supraventricular tachycardia was treated with a therapeutic dose of flecainide but developed heart block requiring extracorporeal membrane oxygenation support and subsequent treatment with lipid emulsion therapy. He was found to have supratherapeutic serum flecainide concentration, and gene testing revealed the patient to be an intermediate metabolizer. With this case report, we reinforce the importance of evaluating the CYP2D6 genotype before drug initiation in the neonatal population and recommend regular monitoring of serum flecainide levels and electrocardiograms in these patients.

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Flecainide toxicity in renal failure

Cited by 10 publications

References 17 publications

Cardiogenic Shock in a Hemodialyzed Patient on Flecainide: Treatment with Intravenous Fat Emulsion, Extracorporeal Cardiac Life Support, and CytoSorb® Hemoadsorption

Cardiogenic Shock in a Hemodialyzed Patient on Flecainide: Treatment with Intravenous Fat Emulsion, Extracorporeal Cardiac Life Support, and CytoSorb® Hemoadsorption

Flecainide toxicity in renal tubular acidosis type IV treated with extracorporeal membrane oxygenation

Complete Heart Block Secondary to Flecainide Toxicity: Is It Time for CYP2D6 Genotype Testing?

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