From the Guidelines
Multaq (dronedarone) 400mg twice daily is generally safe for atrial fibrillation management in patients without severe heart failure or permanent atrial fibrillation, but requires careful patient selection. According to the most recent and highest quality study 1, it is essential to consider the potential risks and benefits of dronedarone in the context of polypharmacy in older people with cardiovascular disease. The study highlights the importance of monitoring renal function, serum K+ and Mg2+, and ECG in patients taking antiarrhythmic drugs, including dronedarone.
Key considerations for the use of Multaq include:
- Avoiding its use in patients with NYHA Class III-IV heart failure, recent decompensated heart failure, permanent atrial fibrillation, significant liver or lung disease, or QT prolongation
- Monitoring for common side effects such as gastrointestinal issues, fatigue, and skin reactions
- Regular monitoring of liver function tests, ECG for QT prolongation, and assessment of kidney function
- Avoiding grapefruit products and certain medications that interact with dronedarone, including strong CYP3A inhibitors, certain antiarrhythmics, and some statins
The 2016 ESC guidelines for the management of atrial fibrillation 1 also provide valuable insights into the use of rate control therapy in atrial fibrillation, including the role of beta-blockers, calcium-channel blockers, and cardiac glycosides. However, the most recent and highest quality study 1 takes precedence in guiding clinical decision-making.
In terms of safety, dronedarone is generally considered safer than amiodarone regarding pulmonary and thyroid toxicity, but less effective at maintaining sinus rhythm. Overall, Multaq 400mg twice daily can be a reasonable option for appropriately selected patients with paroxysmal or persistent atrial fibrillation, but careful patient selection and monitoring are crucial to minimize potential risks.
From the FDA Drug Label
WARNING: INCREASED RISK OF DEATH, STROKE AND HEART FAILURE IN PATIENTS WITH DECOMPENSATED HEART FAILURE OR PERMANENT ATRIAL FIBRILLATION In patients with symptomatic heart failure and recent decompensation requiring hospitalization or NYHA Class IV heart failure; MULTAQ doubles the risk of death. In patients with permanent atrial fibrillation, MULTAQ doubles the risk of death, stroke and hospitalization for heart failure. MULTAQ is contraindicated in patients with symptomatic heart failure with recent decompensation requiring hospitalization or NYHA Class IV heart failure. MULTAQ is contraindicated in patients in atrial fibrillation (AF) who will not or cannot be cardioverted into normal sinus rhythm.
The safety of Multaq 400mg BID for atrial fibrillation is a concern due to the increased risk of:
- Death
- Stroke
- Heart failure in patients with decompensated heart failure or permanent atrial fibrillation. Multaq is contraindicated in patients with symptomatic heart failure with recent decompensation requiring hospitalization or NYHA Class IV heart failure, and in patients in atrial fibrillation who will not or cannot be cardioverted into normal sinus rhythm 2.
From the Research
Safety of Multaq 400mg BID for Atrial Fibrillation
- The FDA has approved dronedarone (Multaq) for the oral treatment of atrial fibrillation and flutter, as stated in 3.
- Dronedarone is chemically similar to amiodarone but has a modified structure and lacks an iodine moiety, which reduces its organ toxicity, including adverse thyroid and pulmonary effects, as mentioned in 4.
- Studies have shown that dronedarone is safer than amiodarone but less effective, with a different pattern of short-term adverse effects, including more gastrointestinal disorders but less frequent thyroid disorders, neurological disorders, hypersensitivity reactions, hypertension, and QT prolongation, as reported in 5 and 6.
- Common adverse effects of dronedarone include diarrhoea, nausea and vomiting, cutaneous disorders, and transient elevation of creatinine levels, with cases of renal failure also reported, as stated in 5.
- The efficacy of dronedarone has been investigated in several clinical trials, proving its effect in the prevention of AF recurrence, rate control in paroxysmal/persistent and permanent AF, reduction of cardiovascular hospitalization or death from any cause, as mentioned in 4 and 7.
- Dronedarone is recommended in patients with paroxysmal and persistent AF to achieve rate and rhythm control, excluding cases of severe or unstable congestive heart failure, as stated in 7.
- The official indication of dronedarone is to reduce the risk of hospitalization in patients with paroxysmal or persistent atrial fibrillation or atrial flutter and other cardiovascular risk factors, as mentioned in 6.