What is the relationship between Sotalol (Anti-arrhythmic medication) and Acute Kidney Injury (AKI)?

From the Guidelines

Sotalol should be used with extreme caution in patients with acute kidney injury (AKI) due to the increased risk of QT prolongation and potentially fatal torsades de pointes arrhythmia, and consideration should be given to alternative antiarrhythmic medications with less renal elimination 1. When managing patients with AKI, it is crucial to assess renal function and adjust the sotalol dose accordingly. For patients with AKI, the dose of sotalol should be reduced by 50% if creatinine clearance is 30-60 mL/min and by 75% if clearance is 10-30 mL/min 1. Key considerations in the management of AKI include:

• Monitoring of serum creatinine and urine output to assess renal function
• Avoidance of medications that can exacerbate kidney injury, such as nonsteroidal anti-inflammatory drugs
• Timely identification and treatment of underlying causes of AKI, such as hypovolemia or obstructive uropathy
• Consideration of alternative antiarrhythmic medications with less renal elimination, such as amiodarone or lidocaine, in patients with significant kidney dysfunction 1. The half-life of sotalol increases significantly in patients with renal impairment, from 12 hours in normal renal function to over 24 hours in severe renal impairment, which further increases the risk of QT prolongation and torsades de pointes arrhythmia 1. Electrolyte abnormalities common in AKI, such as hypokalemia and hypomagnesemia, also increase the risk of QT prolongation with sotalol, emphasizing the need for careful monitoring and management of electrolyte levels in these patients 1. In patients with severe AKI, defined as stage 3B, 4, or 5 CKD (i.e., eGFR < 45 mL/min/1.73m2) or KDIGO stage 2 or 3 AKI, extracorporeal treatment (ECTR) may be considered in addition to standard care for severe sotalol poisoning, particularly in the presence of refractory bradycardia, hypotension, and/or recurrent torsade de pointes 1.

From the FDA Drug Label

PRECAUTIONS Renal Impairment Sotalol AF is eliminated principally via the kidneys through glomerular filtration and to a small degree by tubular secretion. There is a direct relationship between renal function, as measured by serum creatinine or creatinine clearance, and the elimination rate of Sotalol AF. The relationship between Sotalol and Acute Kidney Injury (AKI) suggests that impaired renal function can affect the elimination rate of Sotalol.

• Key points:
  • Sotalol is eliminated principally via the kidneys.
  • There is a direct relationship between renal function and the elimination rate of Sotalol. Given the information, it can be inferred that renal impairment (such as AKI) may lead to reduced elimination of Sotalol, potentially increasing the risk of toxicity. 2

From the Research

Sotalol and Acute Kidney Injury (AKI)

• Sotalol is a class III antiarrhythmic that is renally eliminated, with a dose-related propensity to cause adverse drug reactions (ADR) potentially leading to life-threatening arrhythmias 3.
• In patients with renal impairment, twice daily dosing of sotalol may result in ADR and therapy change rates consistent with rates seen in clinical practice for non-renally impaired patients, with minimal length of stay 3.
• However, reduced renal function can lead to increased serum levels of sotalol, potentially causing torsade de pointes ventricular tachycardia and sudden death 4.
• In the context of AKI, management consists of treating the underlying cause, reviewing serum creatinine levels, administering crystalloids, and eliminating nephrotoxic agents, including potentially sotalol 5, 6.
• Appropriate drug dosing in critically ill patients with AKI is a challenge, and therapeutic drug monitoring (TDM) can be a promising solution to titrate drugs to their clinical response, but it is available only for a few drugs 7.

Considerations for Sotalol Use in AKI

• The use of sotalol in patients with AKI requires careful consideration of the potential risks and benefits, including the risk of torsade de pointes and other arrhythmias 4.
• Close monitoring of serum creatinine levels and adjustment of sotalol dosing may be necessary to minimize the risk of ADR 3, 7.
• The treatment of AKI often consists of treating patients in emergency departments, and renal pharmacologic management in an acute care setting consists of identifying the cause of AKI, reviewing serum creatinine levels, administration of crystalloids, and the elimination of nephrotoxic agents 5, 6.