Quinidine Sulfate
Indications: Arrhythmia, AV junctional premature complex; Arrhythmia, junctional; Arrhythmia, premature supraventricular contraction; Arrhythmia, premature ventricular contraction; Arrhythmia, supraventricular; Arrhythmia, ventricular; Fibrillation, atrial; Flutter, atrial; Tachycardia, paroxysmal junctional; Tachycardia, paroxysmal supraventricular; Tachycardia, ventricular
DESCRIPTION:
Immediate-Release Tablets
Quinidine is an antimalarial schizonticide and an antiarrhythmic agent with class 1A activity; it is the d- isomer of quinine, and its molecular weight is 324.43.
Quinidine sulfate is the sulfate salt of quinidine; its chemical name is cinchonan-9-ol, 6-methoxy-,(9S)-, sulfate (2:1) dihydrate.
The molecular formula for quinidine sulfate is C40H48N4O4Β·H2SO4Β·2H2O; and its molecular weight is 782.96, of which 82.9% is quinidine base.
Quinidine sulfate occurs as fine needle-like, white crystals, frequently cohering in masses, or fine, white powder. It is odorless, has a very bitter taste, and darkens on exposure to light. It is slightly soluble in water, soluble in alcohol and in chloroform, and insoluble in ether.
Each tablet, for oral administration, contains 100 mg of quinidine sulfate (equivalent to 83 mg of quinidine base), 200 mg of quinidine sulfate (equivalent to 166 mg of quinidine base) and 300 mg of quinidine sulfate (equivalent to 249 mg of quinidine base). In addition, each tablet contains the following inactive ingredients: calcium stearate, colloidal silicon dioxide, microcrystalline cellulose, pregelatinized starch, sodium starch glycolate.
Extended-Release Tablets
Quinidine sulfate extended-release are constructed to release one-third of their alkaloidal salt, quinidine sulfate (100 mg), on reaching the stomach, to begin absorption in the upper intestinal tract. The remaining two-thirds of the active drug (200 mg) is evenly distributed throughout a homogenous core which slowly dissolves as it moves along the intestinal tract, releasing the quinidine sulfate for continuous absorption over an 8-12 hour period.
Each quinidine sulfate extended-release tablet contains 300 mg of quinidine sulfate, the equivalent of 248.6 mg of the anhydrous quinidine alkaloid. Quinora Inactive Ingredients: Acacia, acetylated monoglycerides, calcium sulfate, carnauba wax, edible tax, FD&C blue 2, gelatin, guar gum, magnesium oxide, magnesium stearate, polysorbates, shellac, sucrose, titanium dioxide, white wax and other ingredients, one of which is a corn derivative. may contain FD&C red 40 and yellow 6 aluminum lakes.
Chemically, quinidine sulfate is cinchonan-9-ol,6'-methoxy-,(9s)- sulfate (2:1) (salt) dihydrate.
CLINICAL PHARMACOLOGY:
Immediate Release Tablets
Pharmacokinetics and Metabolism
The absolute bioavailability of quinidine from quinidine sulfate tablets is about 70%, but this varies widely (45-100%) between patients. The less-than-complete bioavailability is the result of first-pass metabolism in the liver. Peak serum levels generally appear about 2 hours after dosing; the rate of absorption is somewhat slowed when the drug is taken with food, but the extent of absorption is not changed.
The volume of distribution of quinidine is 2-3 L/kg in healthy young adults, but this may be reduced to as little as 0.5 L/kg in patients with congestive heart failure, or increased to 3-5 L/kg in patients with cirrhosis of the liver. At concentrations of 2-5 mg/L (6.5-16.2 mumol/L), the fraction of quinidine bound to plasma proteins (mainly to alpha1-acid glycoprotein and to albumin) is 80-88% in adults and older children, but it is lower in pregnant women, and in infants and neonates it may be as low as 50-70%. Because alpha1-acid glycoprotein levels are increased in response to stress, serum levels of total quinidine may be greatly increased in settings such as acute myocardial infarction, even though the serum content of unbound (active) drug may remain normal. Protein binding is also increased in chronic renal failure, but binding abruptly descends toward or below normal when heparin is administered for hemodialysis.
Quinidine clearance typically proceeds at 3-5 ml/min/kg in adults, but clearance in children may be twice or 3 times as rapid. The elimination half-life is 6-8 hours in adults and 3-4 hours in children. Quinidine clearance is unaffected by hepatic cirrhosis, so the increased volume of distribution seen in cirrhosis leads to a proportionate increase in the elimination half-life.
Most quinidine is eliminated hepatically via the action of cytochrome P450IIIA4 ; there are several different hydroxylated metabolites, and some of these have antiarrhythmic activity.
The most important of quinidine's metabolites is 3-hydroxyquinidine (3HQ), serum levels of which can exceed those of quinidine in patients receiving conventional doses of quinidine sulfate. The volume of distribution of 3HQ appears to be larger than that of quinidine, and the elimination half-life of 3HQ is about 12 hours.
As measured by antiarrhythmic effects in animals, by QTC prolongation in human volunteers, or by various in vitro techniques, 3HQ has at least half the antiarrhythmic activity of the parent compound, so it may be responsible for a substantial fraction of the effect of quinidine sulfate in chronic use.
When the urine pH is less than 7, about 20% of administered quinidine appears unchanged in the urine, but this fraction drops to as little as 5% when the urine is more alkaline. Renal clearance involves both glomerular filtration and active tubular secretion, moderated by (pH-dependent) tubular reabsorption. The net renal clearance is about 1 ml/min/kg in healthy adults. When renal function is taken into account, quinidine clearance is apparently independent of patient age.
Assays of serum quinidine levels are widely available, but the results of modern assays may not be consistent with results cited in the older medical literature. The serum levels of quinidine cited in this prescribing information are those derived from specific assays, using either benzene extraction or (preferably) reverse-phase high-pressure liquid chromatography. In matched samples, older assays might unpredictably have given results that were as much as 2 or 3 times higher. A typical "therapeutic" concentration range is 2-6 mg/L (6.2-18.5 mumol/L).
Mechanism of Action
In patients with malaria, quinidine acts primarily as an intra-erythrocytic schizonticide, with little effect upon sporozites or upon pre-erythrocytic parasites. Quinidine is gametocidal to Plasmodium vivax and P. malariae , but not to P. falciparum .
In cardiac muscle and in Purkinje fibers, quinidine depresses the rapid inward depolarizing sodium current, thereby slowing phase-0 depolarization and reducing the amplitude of the action potential without affecting the resting potential. In normal Purkinje fibers, it reduces the slope of phase-4 depolarization, shifting the threshold voltage upward toward zero. The result is slowed conduction and reduced automaticity in all parts of the heart, with increase of the effective refractory period relative to the duration of the action potential in the atria, ventricles, and Purkinje tissues. Quinidine also raises the fibrillation thresholds of the atria and ventricles, and it raises the ventricular de fibrillation threshold as well. Quinidine's actions fall into class 1A in the Vaughan-Williams classification.
By slowing conduction and prolonging the effective refractory period, quinidine can interrupt or prevent reentrant arrhythmias and arrhythmias due to increased automaticity, including atrial flutter, atrial fibrillation, and paroxysmal supraventricular tachycardia.
In patients with the sick sinus syndrome, quinidine can cause marked sinus node depression and bradycardia. In most patients, however, use of quinidine is associated with an increase in the sinus rate.
Quinidine prolongs the QT interval in a dose-related fashion. This may lead to increased ventricular automaticity and polymorphic ventricular tachycardias, including torsades de pointes (see WARNINGS).
In addition, quinidine has anticholinergic activity, it has negative inotropic activity, and it acts peripherally as an alpha-adrenergic antagonist (that is, as a vasodilator).
CLINICAL STUDIES:
Immediate Release Tablets
Maintenance of Sinus Rhythm After Conversion From Atrial Fibrillation: In six clinical trials (published between 1970 and 1984) with a total of 808 patients, quinidine (418 patients) was compared to nontreatment (258 patients) or placebo (132 patients) for the maintenance of sinus rhythm after cardioversion from chronic atrial fibrillation. Quinidine was consistently more efficacious in maintaining sinus rhythm, but a meta-analysis found that mortality in the quinidine-exposed patients (2.9%) was significantly greater than mortality in the patients who had not been treated with active drug (0.8%). Suppression of atrial fibrillation with quinidine has theoretical patient benefits (e.g., improved exercise tolerance; reduction in hospitalization for cardioversion; lack of arrhythmia-related palpitations, dyspnea, and chest pain; reduced incidence of systemic embolism and/or stroke), but these benefits have never been demonstrated in clinical trials. Some of these benefits (e.g., reduction in stroke incidence) may be achievable by other means (anticoagulation).
By slowing the rate of atrial flutter/fibrillation, quinidine can decrease the degree of atrioventricular block and cause an increase, sometimes marked, in the rate at which supraventricular impulses are successfully conducted by the atrioventricular node, with a resultant paradoxical increase in ventricular rate (see WARNINGS).
Non-life-threatening Ventricular Arrhythmias: In studies of patients with a variety of ventricular arrhythmias (mainly frequent ventricular premature beats and non-sustained ventricular tachycardia), quinidine (total N=502) has been compared to flecainide (N=141), mexiletine (N=246), propafenone (N=53), and tocainide (N=67). In each of these studies, the mortality in the quinidine group was numerically greater than the mortality in the comparator group. When the studies were combined in a meta-analysis, quinidine was associated with a statistically significant threefold relative risk of death.
At therapeutic doses, quinidine's only consistent effect upon the surface electrocardiogram is an increase in the QT interval. This prolongation can be monitored as a guide to safety, and it may provide better guidance than serum drug levels (see WARNINGS).
INDICATIONS AND USAGE:
Immediate Release Tablets
Conversion of Atrial Fibrillation/Flutter: In patients with symptomatic atrial fibrillation/flutter whose symptoms are not adequately controlled by measures that reduce the rate of ventricular response, quinidine sulfate is indicated as a means of restoring normal sinus rhythm. If this use of quinidine sulfate does not restore sinus rhythm within a reasonable time (see DOSAGE AND ADMINISTRATION), then quinidine sulfate should be discontinued.
Reduction of Frequency of Relapse into Atrial Fibrillation/Flutter: Chronic therapy with quinidine sulfate is indicated for some patients at high risk of symptomatic atrial fibrillation/flutter, generally patients who have had previous episodes of atrial fibrillation/flutter that were so frequent and poorly tolerated as to outweigh, in the judgment of the physician and the patient, the risks of prophylactic therapy with quinidine sulfate. The increased risk of death should specifically be considered. Quinidine sulfate should be used only after alternative measures (e.g., use of other drugs to control the ventricular rate) have been found to be inadequate.
In patients with histories of frequent symptomatic episodes of atrial fibrillation/flutter, the goal of therapy should be an increase in the average time between episodes. In most patients, the tachyarrhythmia will recur during therapy, and a single recurrence should not be interpreted as therapeutic failure.
Suppression of Ventricular Arrhythmias: Quinidine sulfate is also indicated for the suppression of recurrent documented ventricular arrhythmias, such as sustained ventricular tachycardia, that in the judgment of the physician are life-threatening. Because of the proarrhythmic effects of quinidine, its use with ventricular arrhythmias of lesser severity is generally not recommended, and treatment of patients with asymptomatic ventricular premature contractions should be avoided. Where possible, therapy should be guided by the results of programmed electrical stimulation and/or Holter monitoring with exercise.
Antiarrhythmic drugs (including quinidine sulfate) have not been shown to enhance survival in patients with ventricular arrhythmias.
Treatment of Malaria: Quinidine sulfate is also indicated in the treatment of life-threatening Plasmodium falciparum malaria.
Extended Release Tablets
Quinidine Sulfate is Indicated in the Treatment of:
1. Premature atrial and ventricular contractions.
2. Paroxysmal atrial tachycardia.
3. Paroxysmal atrioventricular (A-V) junctional rhythm.
4. Atrial flutter.
5. Paroxysmal atrial fibrillation.
6. Established atrial fibrillation when therapy is appropriate.
7. Paroxysmal ventricular tachycardia when not associated with complete heartblock.
8. Maintenance therapy after electrical conversion of atrial fibrillation and/or flutter.
CONTRAINDICATIONS:
Immediate-Release Tablets: Quinidine is contraindicated in patients who are known to be allergic to it, or who have developed thrombocytopenic purpura during prior therapy with quinidine or quinine.
In the absence of a functioning artificial pacemaker, quinidine is also contraindicated in any patient whose cardiac rhythm is dependent upon a junctional or idioventricular pacemaker, including patients in complete atrioventricular block.
Quinidine is also contraindicated in patients who, like those with myasthenia gravis, might be adversely affected by an anticholinergic agent.
Extended-Release Tablets: Intraventricular conduction defects. Complete A-V block, A-V conduction disorders caused by digitalis intoxication. Aberrant impulses and abnormal rhythms due to escape mechanisms. Idiosyncrasy or hypersensitivity to quinidine or related cinchona derivatives. Myasthenia gravis.
WARNINGS:
Immediate Release Tablets
Mortality
In many trials of antiarrhythmic therapy for non-life-threatening arrhythmias, active antiarrhythmic therapy has resulted in increased mortality; the risk of active therapy is probably greatest in patients with structural heart disease.
In the case of quinidine used to prevent or defer recurrence of atrial flutter/fibrillation, the best available data come from a meta-analysis described in CLINICAL STUDIES. In the patients studied in the trials there analyzed, the mortality associated with the use of quinidine was more than 3 times as great as the mortality associated with the use of placebo.
Another metaanalysis, also described in CLINICAL STUDIES, showed that in patients with various non-life-threatening ventricular arrhythmias, the mortality associated with the use of quinidine was consistently greater than that associated with the use of any of a variety of alternative antiarrhythmics.
Proarrhythmic Effects
Like many other drugs (including all other class IA antiarrhythmics), quinidine prolongs the QTC interval, and this can lead to torsades de pointes, a life-threatening ventricular arrhythmia (see OVERDOSAGE). The risk of torsades is increased by bradycardia, hypokalemia, hypomagnesemia, hypocalcemia, or high serum levels of quinidine, but it may appear in the absence of any of these risk factors. The best predictor of this arrhythmia appears to be the length of the QTC interval, and quinidine should be used with extreme care in patients who have preexisting long-QT syndromes, who have histories of torsades de pointes of any cause, or who have previously responded to quinidine (or other drugs that prolong ventricular repolarization) with marked lengthening of the QTC interval. Estimation of the incidence of torsades in patients with therapeutic levels of quinidine is not possible from the available data.
Other ventricular arrhythmias that have been reported with quinidine include frequent extrasystoles, ventricular tachycardia, ventricular flutter, and ventricular fibrillation.
Paradoxical Increase in Ventricular Rate in Atrial Flutter/Fibrillation
When quinidine is administered to patients with atrial flutter/fibrillation, the desired pharmacologic reversion to sinus rhythm may (rarely) be preceded by a slowing of the atrial rate with a consequent increase in the rate of beats conducted to the ventricles. The resulting ventricular rate may be very high (greater than 200 beats per minute) and poorly tolerated. This hazard may be decreased if partial atrioventricular block is achieved prior to initiation of quinidine therapy, using conduction-reducing drugs such as digitalis, verapamil, diltiazem, or a beta-receptor blocking agent.
Exacerbated Bradycardia in Sick Sinus Syndrome
In patients with the sick sinus syndrome, quinidine has been associated with marked sinus node depression and bradycardia.
Pharmacokinetic Considerations
Renal or hepatic dysfunction causes the elimination of quinidine to be slowed, while congestive heart failure causes a reduction in quinidine's apparent volume of distribution. Any of these conditions can lead to quinidine toxicity if dosage is not appropriately reduced. In addition, interactions with coadministered drugs can alter the serum concentration and activity of quinidine, leading either to toxicity or to lack of efficacy if the dose of quinidine is not appropriately modified (see DRUG INTERACTIONS).
Vagolysis
Because quinidine opposes the atrial and A-V nodal effects of vagal stimulation, physical or pharmacological vagal maneuvers undertaken to terminate paroxysmal supraventricular tachycardia may be ineffective in patients receiving quinidine.
Extended Release Tablets
In the treatment of atrial flutter, reversion to sinus rhythm may be preceded by a progressive reduction in the degree of A-V block to a 1:1 ratio, which results in extremely rapid ventricular rate. This possible hazard may be reduced by digitalization prior to administration of quinidine.
In susceptible individuals, such as those with marginally compensated cardiovascular disease, quinidine may produce clinically important depression of cardiac function manifested by hypotension, bradycardia, or heart block. Quinidine, therapy should be carefully monitored in such individuals.
Evidence of quinidine cardiotoxicity (excessive prolongation of Q-T interval, widening of QRS complex, and ventricular tachyarrhythmias) mandates immediate discontinuation of the drug and subsequent close clinical and electrocardiographic monitoring of the patient.
Quinidine should be used with extreme caution when there is incomplete A-V block, since complete block and asystole may result. The drug may cause unpredictable abnormalities of rhythm in digitalized hearts, and it should be used with special caution in the presence of digitalis intoxication.
The cardiotoxic effect of quinidine is increased by hyperkalemia and decreased by hypokalemia.
Patients taking quinidine occasionally have syncopal episodes which usually result from ventricular tachycardia or fibrillation. This syndrome has not been shown to be related to dose or serum levels. Syncopal episodes frequently terminate spontaneously or in response to treatment, but sometimes are fetal.
Recent reports have described increased, potentially toxic, digoxin serum levels when quinidine is administered concurrently. When concurrent use is necessary, reduction of digoxin dosage may have to be considered, its serum concentration should be monitored and the patient observed closely for digitalis intoxication.
Caution should be used when quinidine is administered concurrently with coumarin anticoagulants. This combination may reduce prothrombin levels and cause bleeding.
Quinidine should be used with caution in patients exhibition renal, cardiac or hepatic insufficiency because of potential accumulation of quinidine in serum leading to toxicity.