Anti–Arrhythmic Drugs

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

Cardiac Arrhythmias in Coronary Heart Disease (SIGN 152, September 2018) provides information on the use of anti-arrhythmic medicines.

Class 1 Anti-Arrhythmics (Membrane Stabilising Drugs)

Specialist initiation (S1)

FLECAINIDE

  • Recommended doses should be reduced by half if FLECAINIDE is prescribed in combination with AMIODARONE.

DISOPYRAMIDE

  • Patients controlled on doses equal to or greater than 500mg daily of DISOPYRAMIDE may be transferred to the modified release twice daily preparation which is also more cost-effective.

PROPAFENONE

Specialist use only (S2)

LIDOCAINE

Prescribing Notes:

  • All Class 1 anti-arrhythmic drugs have the potential to prolong the QT interval and prescribers should carefully review other medicines patients may be taking to avoid an additive effect and potential adverse drug reaction. Where prescribing of a Class 1 anti-arrhythmic in combination with another drug known to carry a risk of QT prolongation is considered necessary, ECG monitoring should be undertaken.

Class 2 Anti-Arrhythmics (Beta-Blockers)

Preferred list (P)

ATENOLOL

 

Total list (T)

METOPROLOL

Class 3 Anti-Arrhythmics

Specialist initiation (S1)

SOTALOL

  • May prolong the QT interval and can occasionally cause life threatening ventricular arrhythmias.

  • Care must be taken to avoid and correct any electrolyte disturbances, particularly hypokalaemia and hypomagnesaemia.

  • Extreme caution should be used if co-administration of drugs known to prolong the QT interval or increase the risk of hypokalaemia.

  • Patients should have ECG and electrolyte monitoring undertaken prior to and periodically during treatment with SOTALOL.

AMIODARONE

  • May cause corneal microdeposits, thyroid dysfunction, pneumonitis, peripheral neuropathy and hepatotoxicity.

  • Liver function and thyroid function tests should be performed before treatment, and 6 monthly thereafter; chest X-ray should be done before treatment.

  • Patients receiving AMIODARONE should avoid exposure of the skin to direct sunlight or sun lamps; a wide-spectrum sunscreen should be applied if AMIODARONE is prescribed.

  • AMIODARONE interacts with many drugs. Special precaution should be made when patients are prescribed WARFARIN with AMIODARONE. There is a potential for drug interactions to occur for several weeks (or even months) after treatment with it has been stopped.

DRONEDARONE

  • For maintenance of sinus rhythm where alternative treatments are unsuitable.

Class 4 Anti-Arrhythmics (Rate-Limiting Calcium-Channel Blockers)

Preferred list (P)

VERAPAMIL

  • Use of VERAPAMIL in combination with a beta-blocker should be avoided due to risk of severe bradycardia or AV block.

Total list (T)

DILTIAZEM

  • Brand prescribing is recommended for modified-release preparations containing more than 60mg DILTIAZEM HYDROCHLORIDE.
    Currently ZEMTARD XL® is the most cost-effective brand within Primary Care.

Anti-Arrhythmic (Other)

Specialist use only (S2)

ADENOSINE

  • Indication: Rapid reversion to sinus rhythm of paroxysmal supraventricular tachycardias.

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.