What is the maximum recommended dose of Flecainide (anti-arrhythmic medication) per day?

Maximum Recommended Dose of Flecainide

The maximum recommended daily dose of flecainide is 300 mg per day for patients with paroxysmal supraventricular arrhythmias (PSVT and PAF), and 400 mg per day for patients with sustained ventricular tachycardia (VT). 1

Dosing Guidelines by Indication

For Paroxysmal Supraventricular Arrhythmias (PSVT and PAF):

• Initial starting dose: 50 mg every 12 hours 2, 1
• Dose may be increased in increments of 50 mg twice daily every four days until efficacy is achieved 1
• Maximum recommended dose: 300 mg/day (typically 150 mg twice daily) 3, 1
• Substantial increase in efficacy without significant increase in adverse effects may be achieved by increasing from 50 mg to 100 mg twice daily 1

For Sustained Ventricular Tachycardia (VT):

• Initial starting dose: 100 mg every 12 hours 1
• Dose may be increased in increments of 50 mg twice daily every four days 1
• Most patients with sustained VT do not require more than 150 mg every 12 hours (300 mg/day) 1
• Maximum recommended dose: 400 mg/day 1

Important Monitoring Considerations

• PR and QRS intervals should be monitored during dose titration 3, 2
• Consider monitoring flecainide plasma levels, keeping trough plasma levels below 0.7-1.0 mcg/mL 3, 2
• For patients with sustained VT, flecainide should be initiated in-hospital with rhythm monitoring 1
• Steady-state plasma levels may not be achieved until after 3-5 days of therapy at a given dose 1
• Due to long half-life (12-27 hours), dosage increases should not be made more frequently than once every four days 1

Precautions and Contraindications

• Flecainide is contraindicated in patients with: 3, 2

  • Structural heart disease
  • Sinus or AV conduction disease (in absence of pacemaker)
  • Cardiogenic shock
  • Brugada syndrome
  • Atrial flutter without concomitant AV nodal blocking therapy

• Use cautiously in patients with: 1

  • History of CHF or myocardial dysfunction
  • Renal dysfunction (dose reduction required)
  • Hepatic dysfunction

Potential Adverse Effects

• Atrial flutter with 1:1 AV conduction 3
• QT prolongation and torsades de pointes 3, 2
• Worsening heart failure 2
• Bradycardia 2
• Hypotension 3

Special Populations

Patients with Renal Impairment:

• Dose reduction is necessary in patients with severe renal impairment 1

Children:

• Initial starting dose: approximately 50 mg/m² body surface area daily for children under six months 1
• For children over six months: initial dose may be increased to 100 mg/m² per day 1
• Maximum recommended dose for children: 200 mg/m² per day 1
• Treatment should be directly supervised by a pediatric cardiologist 1

Drug Interactions

• Reduce flecainide dose when administering with amiodarone (30-50% reduction) 3
• Monitor closely when used with digoxin, ritonavir, saquinavir, and tipranavir 2
• Use caution with other QT-prolonging drugs 2

Remember that higher initial doses and rapid dose adjustments have been associated with increased incidence of proarrhythmic events and CHF, particularly during the first few days of dosing 1. Therefore, gradual titration and careful monitoring are essential for safe and effective use of flecainide.