What is the use of sotalol (anti-arrhythmic medication)?

From the Guidelines

Sotalol is used as an anti-arrhythmic medication to prevent and treat atrial fibrillation (AF) and ventricular arrhythmias.

Uses of Sotalol

• Sotalol can be used to prevent recurrent AF, with efficacy comparable to other anti-arrhythmic drugs such as quinidine and verapamil, but less effective than amiodarone 1.
• It is also used to suppress ventricular arrhythmias (VA) in patients with coronary artery disease (CAD) without heart failure (HF) 1.
• Sotalol may be initiated in outpatients with little or no heart disease, as long as the baseline uncorrected QT interval is less than 450-460 ms, serum electrolytes are normal, and risk factors associated with class III drug-related proarrhythmia are considered 1.

Important Considerations

• Sotalol should be started at a relatively low dose and titrated based on response, with close monitoring of the ECG, particularly the QT interval 1.
• The risk of drug-induced torsade de pointes is lower with amiodarone than with 'pure' potassium channel blockers like sotalol, but careful monitoring for QT prolongation and abnormal TU waves is still mandatory 1.
• Sotalol should not be used in patients with left ventricular (LV) dysfunction after myocardial infarction unless an implantable cardioverter-defibrillator (ICD) has been implanted, due to the increased risk of ventricular pro-arrhythmias 1.

Administration and Monitoring

• Sotalol can be administered orally or intravenously, with a recommended dose that should be individualized based on the patient's response and renal function 1.
• The ECG should be reassessed after each dose change, and the heart rate should be monitored at approximately weekly intervals 1.
• Concomitant drug therapies should be monitored closely, and both the patient and the physician should be alert to possible deleterious interactions, particularly with digoxin and warfarin 1.

From the FDA Drug Label

Sotalol AF are indicated for the maintenance of normal sinus rhythm [delay in time to recurrence of atrial fibrillation/atrial flutter (AFIB/AFL)] in patients with symptomatic AFIB/AFL who are currently in sinus rhythm. Sotalol is also indicated for the treatment of documented life-threatening ventricular arrhythmias and is marketed under the brand name Betapace® (sotalol hydrochloride).

The use of sotalol is for:

• Maintenance of normal sinus rhythm in patients with symptomatic atrial fibrillation/atrial flutter (AFIB/AFL)
• Treatment of documented life-threatening ventricular arrhythmias 2

From the Research

Uses of Sotalol

• Sotalol is used to treat various cardiac arrhythmias, including atrial fibrillation, ventricular tachycardia, premature ventricular contractions, and supraventricular tachycardia 3, 4, 5
• It is effective in controlling paroxysmal supraventricular tachycardias and the ventricular response to atrial fibrillation/flutter in Wolff-Parkinson-White syndrome 3
• Sotalol is also used to maintain sinus rhythm after cardioversion of atrial fibrillation/flutter and to prevent initiation of supraventricular tachyarrhythmias following coronary artery bypass surgery 3
• It shows promise in the control of nonmalignant and life-threatening ventricular arrhythmias, particularly those associated with ischemic heart disease 3

Mechanism of Action

• Sotalol is a nonselective beta-adrenoceptor antagonist that prolongs cardiac repolarization independently of its antiadrenergic action (class III antiarrhythmic properties) 3, 6, 5
• The antiarrhythmic action of sotalol appears to arise predominantly from its class III properties, and the drug exhibits a broader antiarrhythmic profile than conventional beta-blockers 3
• Sotalol inhibits the rapid component of the delayed rectifier potassium current, which leads to a prolongation of the QT interval 4

Efficacy and Safety

• Sotalol has been shown to be effective in suppressing complex forms of ventricular ectopy and displaying superior antiectopic activity to propranolol and metoprolol 3
• The acute efficacy of sotalol in preventing reinduction of sustained ventricular tachyarrhythmias and suppressing spontaneous episodes of these arrhythmias on Holter monitoring is translated into long-term prophylactic efficacy against arrhythmia recurrence in approximately 55 to 85% of patients with refractory life-threatening ventricular arrhythmias 3
• However, the use of sotalol in patients with left ventricular dysfunction is not recommended due to inconclusive and conflicting results regarding safety 6
• Torsades de Pointes is a serious potential adverse effect of sotalol, particularly in women and heart failure patients 6, 5