From the Guidelines
Dofetilide can be used in patients with hypotension, but it should be done with caution and close monitoring, as it may worsen hypotension, especially during initiation of therapy. Dofetilide is an antiarrhythmic medication primarily used to maintain normal sinus rhythm in patients with atrial fibrillation or flutter. The concern with hypotensive patients is that dofetilide can potentially worsen hypotension, especially during initiation of therapy. Before starting dofetilide, the patient's blood pressure should be stabilized if possible. According to the most recent guidelines 1, dofetilide requires dose adjustment based on kidney function, with lower doses needed for patients with reduced creatinine clearance.
Key Considerations
- Dofetilide should be used with caution in patients with hypotension, and it may not be appropriate for those with severe hypotension.
- The medication requires hospitalization for initiation (typically 3 days) with continuous cardiac monitoring due to its risk of causing QT prolongation and potentially life-threatening ventricular arrhythmias.
- During this monitoring period, blood pressure should be closely observed.
- If a patient with hypotension must receive dofetilide, they should be monitored more intensively for blood pressure changes, and the treating physician should be prepared to manage any further drop in blood pressure that may occur.
Dosage and Administration
- The dosage of dofetilide is based on creatinine clearance, with the following recommended doses:
- More than 60 mL/min: 500 μg twice a day
- 40 to 60 mL/min: 250 μg twice a day
- 20 to 40 mL/min: 125 μg twice a day
- Less than 20 mL/min: Contraindicated As noted in the guidelines 1, dose adjustment is crucial to minimize the risk of adverse effects, including QT prolongation and torsades de pointes.
From the FDA Drug Label
In hemodynamic studies, TIKOSYN had no effect on ... systemic vascular resistance ... There was no increase in heart failure in patients with significant left ventricular dysfunction ... In the overall clinical program, TIKOSYN did not affect blood pressure
The patient with hypotension can take dofetilide, as the drug label states that TIKOSYN did not affect blood pressure in the overall clinical program. However, it is crucial to consider the patient's overall clinical condition and other potential risk factors before initiating treatment with dofetilide 2.
From the Research
Dofetilide Use in Hypotensive Patients
- Dofetilide is a class III antiarrhythmic agent used to treat atrial fibrillation and atrial flutter [(3,4,5,6)].
- There is evidence that dofetilide can be used in patients with hypotension, but caution is advised 3.
- A case study found that a patient with hypotension was able to continue dofetilide therapy after discontinuing a thiazide diuretic and adding a low-dose calcium channel blocker 3.
- However, dofetilide can cause potentially life-threatening arrhythmias, such as Torsade de pointes, and should be used with caution in patients with hypotension [(7,5,6)].
Important Considerations
- Patients with hypotension should be closely monitored when initiating dofetilide therapy [(3,7,6)].
- Dofetilide should not be given or discontinued if the QTc interval is greater than 500 ms 5.
- Dose adjustment is required in patients with impaired renal function, as dofetilide is primarily excreted by the kidneys [(5,6)].
- Hospitalization for at least 3 days is recommended when starting or restarting dofetilide to monitor for potential adverse effects [(7,6)].