Likelihood of Medication-Induced Palpitations with Urbrelvy, Tysabri, and Emgality
Palpitations experienced by a patient taking Urbrelvy (rimegepant), Tysabri (natalizumab), and Emgality (galcanezumab) are unlikely to be medication-induced, as none of these medications have strong associations with cardiac arrhythmias or palpitations in clinical studies.
Evaluation of Individual Medications
Emgality (Galcanezumab)
- In phase 3 clinical trials (EVOLVE-1, EVOLVE-2, and REGAIN), galcanezumab showed no significant difference in cardiovascular treatment-emergent adverse events compared to placebo (2.6-3.3% vs 2.9%) 1
- No clinically meaningful differences were observed between galcanezumab and placebo groups for changes in blood pressure, pulse, or ECG parameters during 6-month treatment periods 1
- Cardiovascular monitoring during clinical trials showed that galcanezumab is well-tolerated from a cardiovascular perspective 2
Urbrelvy (Rimegepant) and Tysabri (Natalizumab)
- Neither medication appears in the comprehensive lists of drugs known to induce cardiac arrhythmias or palpitations in major guidelines 3
- These medications are not classified among drugs with known risk for inducing atrial fibrillation or other arrhythmias 3
General Considerations for Palpitations
Common Causes of Palpitations
- Palpitations are most often caused by cardiac arrhythmias or anxiety, though many patients with arrhythmias do not report palpitations 4
- Any arrhythmia can cause palpitations, including sinus tachycardia, atrial fibrillation, premature ventricular contractions, or ventricular tachycardia 4
- Non-cardiac causes include hyperthyroidism, vasovagal syncope, and hypoglycemia 4
- No cause for palpitations can be found in up to 16% of patients 4
Drug-Induced Arrhythmias
- Many medications can cause or exacerbate arrhythmias, including antiarrhythmic agents, antimicrobials, psychotropics, and methadone 5
- Drugs can trigger bradyarrhythmias, atrial fibrillation/flutter, atrial tachycardia, and various ventricular arrhythmias 5
- Risk factors for drug-induced arrhythmias include older age, female sex, structural heart disease, electrolyte abnormalities, and renal dysfunction 3
Diagnostic Approach
Initial Evaluation
- Ambulatory electrocardiographic (ECG) monitoring is indicated if the etiology cannot be determined from history, physical examination, and resting ECG 4
- For unpredictable or non-daily palpitations, a two-week course of continuous closed-loop event recording is recommended 4
- Holter monitoring for 24-48 hours may be appropriate for patients with daily palpitations 4
Risk Assessment
- Palpitations should be considered potentially more serious if associated with dizziness, near-syncope, or syncope 4
- Assess for pre-existing cardiac conditions that may predispose to arrhythmias, including ischemic heart disease, heart failure, or structural heart disease 3
- Evaluate for electrolyte disturbances, particularly hypokalemia or hypomagnesemia, which can increase arrhythmia risk 3
Management Recommendations
If Palpitations Persist
- Consider discontinuation of any non-essential medications that could potentially contribute to arrhythmias 5
- Evaluate for underlying cardiac or non-cardiac conditions that may be causing palpitations 4
- For patients with confirmed arrhythmias, follow specific treatment guidelines for the identified arrhythmia 5
Monitoring
- For patients with risk factors for arrhythmias, ECG monitoring may be beneficial for early detection and treatment 5
- Consider referral to a cardiologist if palpitations are associated with concerning symptoms or if there is evidence of structural heart disease 3
Clinical Pitfalls to Avoid
- Failing to consider other medications the patient may be taking that have stronger associations with arrhythmias 5
- Overlooking non-pharmacological causes of palpitations, such as caffeine, alcohol, or anxiety 4
- Not performing adequate cardiac monitoring in patients with persistent or concerning symptoms 4