Therapeutic use and major side effects of sotalol
- Elsa-Grace Giardina, MD, MS, FACC, FACP, FAHA
Elsa-Grace Giardina, MD, MS, FACC, FACP, FAHA
- Professor of Medicine
- Director, Center for Women’s Health
- Columbia University Medical Center
- Section Editors
- Mark S Link, MD
Mark S Link, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- UT Southwestern Medical Center
- Hugh Calkins, MD
Hugh Calkins, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Johns Hopkins Medical Institutions
Sotalol, a methanesulfonanilide, is a class III antiarrhythmic drug (table 1) that is used for the treatment of both atrial and ventricular arrhythmias.
This topic will review the electrophysiology and mechanisms of action of sotalol, and will discuss dosing, the different settings in which sotalol has been used as an antiarrhythmic drug, and major side effects. Recommendations for the role of sotalol in the treatment of atrial and ventricular arrhythmias are presented separately. (See "Antiarrhythmic drugs to maintain sinus rhythm in patients with atrial fibrillation: Recommendations" and "Pharmacologic therapy in survivors of sudden cardiac arrest", section on 'Choice of pharmacologic therapy'.)
ELECTROPHYSIOLOGY AND MECHANISM OF ACTION
Sotalol consists of a racemic mixture of d and l isomers in an approximate ratio of 1:1; this mixture is often called dl-sotalol. Racemic, dl-sotalol was approved by the US Food and Drug Administration (FDA) for use in the treatment of ventricular tachycardia (VT) in October of 1992 and subsequently for atrial fibrillation (AF) in February of 2000. Since the patent for dl-sotalol has expired, generic dl-sotalol preparations are now available. D- and l-stereoisomers of sotalol have been studied individually, but only dl-sotalol is commercially available. The two isomers contribute to the unique antiarrhythmic properties of sotalol [1-4]:
●The d isomer prolongs repolarization by blocking IKr, the rapid component of the delayed rectifier potassium current that is responsible for phase 3 repolarization of the action potential (figure 1) [5,6]. This represents a class III effect. (See "Myocardial action potential and action of antiarrhythmic drugs".)
●The l isomer has two actions: it prolongs repolarization and it has beta blocking activity. The latter effect is dose-dependent, is not cardioselective, and is not associated with membrane stabilizing activity or intrinsic sympathomimetic activity.
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- ELECTROPHYSIOLOGY AND MECHANISM OF ACTION
- Class III activity
- - d-Sotalol
- Beta blockade
- Effects on the ECG
- Oral sotalol
- - Changing from other antiarrhythmic drugs
- - Renal insufficiency
- - Elderly
- - Children
- - Pregnancy
- - Post-operative atrial fibrillation
- Intravenous sotalol
- QT interval prolongation
- CLINICAL INDICATIONS
- Ventricular arrhythmias
- Atrial arrhythmias
- Fetal arrhythmias
- MAJOR SIDE EFFECTS
- Cardiac toxicity
- - Proarrhythmia
- - Bradycardia
- - Heart failure
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS