From the Research
Trelegy should be held in the setting of a second-degree type 2 atrioventricular (AV) block. The medication contains umeclidinium, a long-acting muscarinic antagonist (LAMA), which can potentially worsen cardiac conduction abnormalities. Second-degree type 2 AV block is a serious conduction disorder that can progress to complete heart block, and medications with potential cardiac effects should be avoided.
Rationale for Holding Trelegy
- The umeclidinium component in Trelegy can exacerbate existing conduction abnormalities due to its anticholinergic effects on the heart, as noted in various studies on the pharmacology of LAMAs 1, 2.
- Second-degree type 2 AV block is characterized by an all-or-none conduction without visible changes in the AV conduction time before and after the blocked impulse, and it is almost always infranodal, which carries a higher risk of progressing to complete heart block 3, 4.
- Given the potential risks, patients with this condition should consult their healthcare provider immediately for alternative respiratory management options, such as using an inhaled corticosteroid alone or in combination with a long-acting beta-agonist (without the LAMA component), depending on the underlying respiratory condition.
Clinical Considerations
- The diagnosis of second-degree AV block, particularly type 2, requires careful consideration of the electrocardiographic patterns and clinical context to differentiate it from other causes of pauses or pseudo-AV blocks 1, 4.
- The management of second-degree type 2 AV block involves avoiding medications that can worsen cardiac conduction and considering pacing for infranodal blocks, regardless of symptoms or QRS duration 1, 4.
Recommendation
Given the potential for umeclidinium to exacerbate cardiac conduction abnormalities, Trelegy should be avoided in patients with second-degree type 2 AV block, and alternative treatments should be considered to manage the underlying respiratory condition while minimizing the risk of worsening cardiac conduction. This approach prioritizes the patient's morbidity, mortality, and quality of life by avoiding potential exacerbation of a serious cardiac condition.