What is the typical dosing of Sotalol (beta blocker) twice daily (BID)?

Sotalol BID Dosing

The typical dosing of Sotalol is 40-80 mg twice daily (BID) for initiation, with a maintenance dose of up to 160 mg twice daily, requiring careful QT interval monitoring during titration. 1

Initial Dosing

• Starting dose: 40-80 mg every 12 hours (BID) 1
• For patients with normal renal function (creatinine clearance >60 mL/min): 80 mg BID 2
• For patients with moderate renal impairment (creatinine clearance 40-60 mL/min): 80 mg once daily 2
• Contraindicated in patients with severe renal impairment (creatinine clearance <40 mL/min) 2

Titration and Maintenance Dosing

• Maximum maintenance dose: 160 mg BID 1, 2
• Dose increases should be made gradually (every 3 days) with continuous ECG monitoring 2
• During initiation and titration, QT interval should be monitored 2-4 hours after each dose 1
• If QT interval prolongs to ≥500 ms, the dose must be reduced or the drug discontinued 1

Monitoring Requirements

• Initial therapy requires continuous ECG monitoring for a minimum of 3 days 2
• QT interval should be measured 2-4 hours after each dose during initiation and titration 1
• Patients should not be discharged within 12 hours of conversion to normal sinus rhythm 2
• Baseline QT interval must be ≤450 msec to start therapy 2

Important Precautions

• QT prolongation risk: The primary safety concern with sotalol is QT prolongation and risk of torsades de pointes 1, 3
• Renal function: Dose must be adjusted based on creatinine clearance 2
• Contraindications: Avoid in patients with:
  • Prolonged QT interval
  • Severe renal dysfunction
  • Hypokalemia (correct before initiating)
  • Sinus or AV nodal dysfunction (without pacemaker)
  • Decompensated heart failure
  • Cardiogenic shock
  • Reactive airway disease 1
  • Concomitant use of other QT-prolonging drugs 1

Clinical Pearls

• Sotalol has both Class III antiarrhythmic and beta-blocking properties 3
• More effective than conventional beta-blockers for controlling arrhythmias due to its additional Class III properties 3
• Patients with low body mass index or impaired renal function are at higher risk for QT prolongation 3
• Hypokalemia should be corrected before initiation of therapy 2
• Unlike some other antiarrhythmics (e.g., amiodarone), sotalol has no significant pharmacokinetic drug-drug interactions 4

Sotalol is not metabolized and is entirely renally excreted, making renal function assessment critical before initiating therapy 4. While higher starting doses (120-160 mg BID) have been studied, they showed marginally increased risk of cardiac and non-cardiac side effects without shortening hospitalization or improving efficacy 5.