Safety and effect on length of stay of intravenous sotalol initiation for arrhythmia management

Abstract

Sotalol is a class III antiarrhythmic drug with beta-adrenergic blocking activity, used to manage both supraventricular and ventricular arrhythmias. It is available in both oral and intravenous formulations. 1 The Food and Drug Administration approved intravenous Sotalol in March 2020. Sotalol is known to cause corrected QT interval (QTc) prolongation with serum sotalol concentration linearly correlating with QTc length regardless of the route of administration, 2,3 with women being at higher risk than men. 4 QTc interval prolongation is one of many parameters that is associated with cardiovascular mortality. 5 QTc prolongation may lead to polymorphic ventricular tachycardia/Torsade de Pointes which is a potentially lethal condition that is acquired from medications or due to an underlying channelopathy predisposing to sudden cardiac arrest. 6 Additional adverse effects of sotalol may include hypotension, bradycardia, and atrioventricular block. 7,8 Nevertheless, since its approval, intravenous (IV) sotalol has been successfully and safely used in both adult and pediatric patient populations for the management of arrhythmias in acute and chronic settings. 9-12 Initiation of sotalol therapy with per os (PO) loading requires five successive oral doses over a 3-day hospital stay for monitoring, at an estimated cost of $2931.55 per day. 13 In 2020, a protocol for IV loading of sotalol was developed using data modeling. This protocol was hypothesized to allow a significant reduction in the length of hospitalization, and, thus in the incurred costs. 14 However, there has not been any large-scale implementation of this protocol, nor any comparison of its safety profile and efficacy to that of the traditional oral loading protocol. This study by Liu et al. is a nonrandomized clinical trial in which 29 patients underwent IV sotalol loading. They were compared by Second, the sample size was small, with no long-term follow-up. Lastly, patients with significantly depressed glomerular filtration rate or LVEF, particularly prone to developing adverse effects with sotalol use, were excluded from the study. Randomized clinical trials examining the short-term and long-term safety of IV sotalol loading and the optimal length of hospitalization are needed, and such efforts are already underway.