Apo-Sotalol

Sotalol is indicated for:

Ventricular arrhythmias:

- Treatment of life-threatening ventricular tachyarrhythmias;

- Treatment of symptomatic non-sustained ventricular tachyarrhythmias;

Supraventricular arrhythmias:

- Prophylaxis of paroxysmal atrial tachycardia, paroxysmal atrial fibrillation, paroxysmal A-V nodal re-entrant tachycardia, paroxysmal A-V re-entrant tachycardia using accessory pathways, and paroxysmal supraventricular tachycardia after cardiac surgery;

- Maintenance of normal sinus rhythm following conversion of atrial fibrillation or atrial flutter.

Apo-Sotalol 40mg Tablets are indicated for:

1. Ventricular arrhythmias:

- Treatment of life-threatening ventricular tachyarrhythmias;

- Treatment of symptomatic non-sustained ventricular tachyarrhythmias

2. Supraventricular arrhythmias:

- Prophylaxis of paroxysmal atrial tachycardia, paroxysmal atrial fibrillation, paroxysmal A-V nodal re-entrant tachycardia, paroxysmal A-V re-entrant tachycardia using accessory pathways, and paroxysmal supraventricular tachycardia after cardiac surgery;

- Maintenance of normal sinus rhythm following conversion of atrial fibrillation or atrial flutter

Posology

Paediatric population

The safety and effectiveness of Sotalol in children under 18 has not been established.

There is no relevant use of Sotalol in the paediatric population.

As with other antiarrhythmic agents, it is recommended that sotalol be initiated and doses increased in a facility capable of monitoring and assessing cardiac rhythm. The dosage must be individualized and based on the patient's response. Proarrhythmic events can occur not only at initiation of therapy, but also with each upward dosage adjustment.

Method of administration

The following dosing schedule can be recommended:

The initial dose is 80 mg, administered either singly or as two divided doses.

Oral dosage of sotalol should be adjusted gradually allowing 2-3 days between dosing increments in order to attain steady-state, and to allow monitoring of QT intervals.).

Dosage in renally impaired patients

Because sotalol is excreted mainly in urine, the dosage should be reduced when the creatinine clearance is less than 60 ml/min according to the following table:

The creatinine clearance can be estimated from serum creatinine by the Cockroft and Gault formula:

When serum creatinine is given in µmol/l, divide the value by 88.4 (1mg/dl = 88.4 µmol/l).

Dosage in hepatically impaired patients

Since Sotalol is not subject to firstpass metabolism, patients with hepatic impairment show no alteration in clearance of Sotalol. No dosage adjustment is required in hepatically impaired patients.

Oral administration in adults:

As with other antiarrhythmic agents, it is recommended that Apo-Sotalol 40mg Tablets be initiated and doses increased in a facility capable of monitoring and assessing cardiac rhythm. The dosage must be individualized and based on the patient's response. Proarrhythmic events can occur not only at initiation of therapy, but also with each upward dosage adjustment.

In view of its β-adrenergic blocking properties, treatment with Apo-Sotalol 40mg Tablets should not be discontinued suddenly, especially in patients with ischaemic heart disease (angina pectoris, prior acute myocardial infarction) or hypertension, to prevent exacerbation of the disease (see 4.4 Warnings).

The initiation of treatment or changes in dosage with Apo-Sotalol should follow an appropriate medical evaluation including ECG control with measurement of the corrected QT interval, and assessment of renal function, electrolyte balance and concomitant medications (See 4.4 Warnings and precautions).

The following dosing schedule can be recommended:

The initial dose is 80 mg, administered either singly or as two divided doses.

Oral dosage of Apo-Sotalol should be adjusted gradually allowing 2-3 days between dosing increments in order to attain steady-state, and to allow monitoring of QT intervals. Most patients respond to a daily dose of 160 to 320 mg administered in two divided doses at approximately 12 hour intervals. Some patients with life-threatening refractory ventricular arrhythmias may require doses as high as 480 - 640 mg/day. These doses should be used under specialist supervision and should only be prescribed when the potential benefit outweighs the increased risk of adverse events, particularly proarrhythmias (see 4.4 Warnings).

Children

Apo-Sotalol is not intended for administration to children.

Dosage in renally impaired patients

Because Apo-Sotalol is excreted mainly in urine, the dosage should be reduced when the creatinine clearance is less than 60 ml/min according to the following table:

Creatinine clearance (ml/min)

Adjusted doses

The creatinine clearance can be estimated from serum creatinine by the Cockroft and Gault formula:

When serum creatinine is given in μmol/l, divide the value by 88.4 (1mg/dl = 88.4 μmol/l).

Dosage in hepatically impaired patients

No dosage adjustment is required in hepatically impaired patients.

Sotalol should not be used where there is evidence of:

- sick sinus syndrome;

- second and third degree AV heart block (unless a functioning pacemaker is present);

- congenital or acquired long QT syndromes;

- torsades de pointes;

- symptomatic sinus bradycardia;

- uncontrolled congestive heart failure;

- cardiogenic shock;

- anaesthesia that produces myocardial depression;

- untreated phaeochromocytoma;

- hypotension (except due to arrhythmia);

- Raynaud's phenomenon and severe peripheral circulatory disturbances;

- history of chronic obstructive airway disease or bronchial asthma (a warning will appear on the label);

- hypersensitivity to sotalol, other beta-blockers or any of the excipients in the tablet;

- metabolic acidosis;

- renal failure (creatinine clearance < 10 ml/min).

Apo-Sotalol should not be used where there is evidence of:

- sick sinus syndrome

- second and third degree AV heart block unless a functioning pacemaker is present

- congenital or acquired long QT syndromes

- torsades de pointes

- symptomatic sinus bradycardia

- uncontrolled congestive heart failure

- cardiogenic shock

- anaesthesia that produces myocardial depression

- untreated phaeochromocytoma

- hypotension (except due to arrhythmia)

- Raynaud's phenomenon and severe peripheral circulatory disturbances

- history of chronic obstructive airway disease or bronchial asthma

- hypersensitivity to Apo-Sotalol, other betablockers or any of the excipients in the formulation.

- metabolic acidosis

- renal failure (creatinine clearance < 10 ml/min).

- Contraindicated Combination: Apo-Sotalol should not be administered in combination with drugs like class Ia antiarrhythmics, class II antiarrhythmics such as amiodarone, dofetilide, Ibutilide etc; neuroleptics such as trimipramine, phenobarbitone, chlorpromazine etc; and antibiotics such as erythromycin IV and moxifloxacin.

Abrupt Withdrawal: Hypersensitivity to catecholamines is observed in patients withdrawn from beta-blocker therapy. Occasional cases of exacerbation of angina pectoris, arrhythmias, and in some cases, myocardial infarction have been reported after abrupt discontinuation of therapy. Patients should be carefully monitored when discontinuing chronically administered sotalol, particularly those with ischaemic heart disease. If possible the dosage should be gradually reduced over a period of one to two weeks, if necessary at the same time initiating replacement therapy. Abrupt discontinuation may unmask latent coronary insufficiency. In addition, hypertension may develop.

Proarrhythmias: The most dangerous adverse effect of Class I and Class III antiarrhythmic drugs (such as sotalol) is the aggravation of pre-existing arrhythmias or the provocation of new arrhythmias.). Females may be at increased risk of developing torsades de pointes. ECG monitoring immediately prior to or following the episodes usually reveals a significantly prolonged QT interval and a significantly prolonged QTc interval. In clinical trials, Sotalol generally has not been initiated to patients whose pretreatment QTc interval exceeded 450 msec. Sotalol should be titrated very cautiously in patients with prolonged QT intervals.

The incidence of torsades de pointes is dose dependent. Torsades de pointes usually occurs early after initiating therapy or escalation of the dose and can progress to ventricular fibrillation.

Clinical studies for arrhythmia: During clinical trials, 4.3% of 3257 patients with arrhythmias experienced a new or worsened ventricular arrhythmia, including sustained ventricular tachycardia (approximately 1%) and torsade de pointes (2.4%). In addition, in approximately 1% of patients, deaths were considered possibly drugrelated. In patients with other, less serious, ventricular arrhythmias and supraventricular arrhythmias, the incidence of torsade de pointes was 1% and 1.4%, respectively.

Serious proarrhythmias including torsade de pointes were dose related as indicated below:

*Torsade de Pointes or New Sustained VT/VF

In clinical trials of patients with sustained VT/VF the incidence of severe proarrhythmia (torsades de pointes or new sustained VT/VF) was <2% at doses up to 320 mg. The incidence more than doubled at higher doses.

Other risk factors for torsades de pointes were excessive prolongation of the QTc and history of cardiomegaly or congestive heart failure. Patients with sustained ventricular tachycardia and a history of congestive heart failure have the highest risk of serious proarrhythmia (7%).

Proarrhythmic events must be anticipated not only on initiating therapy but with every upward dose adjustment. Initiating therapy at 80 mg with gradual upward dose titration thereafter reduces the risk of proarrhythmia. In patients already receiving sotalol caution should be used if the QTc exceeds 500msec whilst on therapy, and serious consideration should be given to reducing the dose or discontinuing therapy when the QTc-interval exceeds 550 msec. Due to the multiple risk factors associated with torsades de pointes, however, caution should be exercised regardless of the QTc-interval.

Electrolyte Disturbances: Sotalol should not be used in patients with hypokalaemia or hypomagnesaemia prior to correction of imbalance; these conditions can exaggerate the degree of QT prolongation, and increase the potential for torsades de pointes. Special attention should be given to electrolyte and acid-base balance in patients experiencing severe or prolonged diarrhoea or patients receiving concomitant magnesium- and/or potassium-depleting drugs.

Congestive Heart Failure: Beta-blockade may further depress myocardial contractility and precipitate more severe heart failure. Caution is advised when initiating therapy in patients with left ventricular dysfunction controlled by therapy (i.e. ACE Inhibitors, diuretics, digitalis, etc); a low initial dose and careful dose titration is appropriate.

Recent MI: In post-infarction patients with impaired left ventricular function, the risk versus benefit of sotalol administration must be considered.

Careful monitoring and dose titration are critical during initiation and followup Of therapy. The adverse results of clinical trials involving antiarrhythmic drugs (i.e. apparent increase in mortality) suggest that Sotacor should be avoided in patients with left ventricular ejection fractions ≤40% without serious ventricular arrhythmias. In a large controlled trial in patients with a recent myocardial infarction without heart failure, who did not necessarily have ventricular arrhythmias, oral sotalol HCl treatment was associated with a nonstatistically significant risk reduction in mortality compared to the placebo group (18%). In this postinfarction study using a fixed dose of 320mg once daily and in a second small randomized trial in high risk postinfarction patients with left ventricular ejection fractions ≤40% treated with high doses (640 mg/day), there were suggestions of an excess of early sudden deaths.

Electrocardiographic Changes: Excessive prolongation of the QT-interval, >500 msec, can be a sign of toxicity and should be avoided (see Proarrhythmias above). Sinus bradycardia has been observed very commonly in arrhythmia patients receiving sotalol in clinical trials. Bradycardia increases the risk of torsades de pointes. Sinus pause, sinus arrest and sinus node dysfunction occur in less than 1% of patients. The incidence of 2nd- or 3rd-degree AV block is approximately 1%.

Anaphylaxis: Patients with a history of anaphylactic reaction to a variety of allergens may have a more severe reaction on repeated challenge while taking beta-blockers. Such patients may be unresponsive to the usual doses of adrenaline used to treat the allergic reaction.

Anaesthesia: As with other beta-blocking agents, sotalol should be used with caution in patients undergoing surgery and in association with anaesthetics that cause myocardial depression, such as cyclopropane or trichloroethylene.

Diabetes Mellitus: Sotalol should be used with caution in patients with diabetes (especially labile diabetes) or with a history of episodes of spontaneous hypoglycaemia, since beta-blockade may mask some important signs of the onset of acute hypoglycaemia, e.g. tachycardia.

Thyrotoxicosis: Beta-blockade may mask certain clinical signs of hyperthyroidism (e.g., tachycardia). Patients suspected of developing thyrotoxicosis should be managed carefully to avoid abrupt withdrawal of beta-blockade which might be followed by an exacerbation of symptoms of hyperthyroidism, including thyroid storm.

Hepatic Impairment: Since Sotalol is not subject to first-pass metabolism, patients with hepatic impairment show no alteration in clearance of Sotalol.

Renal Impairment: As sotalol is mainly eliminated via the kidneys the dose should be adjusted in patients with renal impairment.

Psoriasis: Beta-blocking drugs have been reported rarely to exacerbate the symptoms of psoriasis vulgaris.

Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Abrupt Withdrawal

Hypersensitivity to catecholamines is observed in patients withdrawn from beta-blocker therapy.).

Psoriasis

Beta-blocking drugs have been reported rarely to exacerbate the symptoms of psoriasis vulgaris.

There are no data available, but the occasional occurrence of side-effects such as dizziness and fatigue should be taken into account.

There are no data available, but the occasional occurrence of side effects such as dizziness and fatigue should be taken into account (see

Sotalol is well tolerated in the majority of patients, with the most frequent adverse effects arising from its betablockade properties. Adverse effects are usually transient in nature and rarely necessitate interruption of, or withdrawal from treatment. These include dyspnoea, fatigue, dizziness, headache, fever, excessive bradycardia and/or hypotension. If they do occur, they usually disappear when the dosage is reduced. The most significant adverse effects, however, are those due to proarrhythmia, including torsades de pointes.

Frequency is defined using the following convention: very common (> 1/10); common (> 1/100, < 1/10); uncommon (> 1/1,000, < 1/100); rare (> 1/10,000, < 1/1,000); very rare (< 1/10,000) including isolated reports. The following are adverse events considered related to therapy with Sotalol:

In clinical trials, 3256 patients with cardiac arrhythmias (1363 with sustained ventricular tachycardia) received oral Sotalol, of whom 2451 received the drug for at least two weeks.

The most significant adverse events were torsade de pointes and other serious new ventricular arrhythmias , which occurred at the following rates:

VT = ventricular tachycardia; VF = ventricular fibrillation; NSVT = nonsustained ventricular tachycardia; PVC = premature ventricular contraction; SVA = supraventricular arrhythmia.

Overall, discontinuation because of unacceptable adverse events was necessary in 18% of all patients in cardiac arrhythmia trials. The most common adverse events leading to discontinuation of Sotacor are listed in the table below:

Cold and cyanotic extremities, Raynaud's phenomenon, increase in existing intermittent claudication and dry eyes have been seen in association with other betablockers.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

The most frequent adverse effects of Apo-Sotalol arise from its beta-blockade properties. Adverse effects are usually transient in nature and rarely necessitate interruption of, or withdrawal from treatment. If they do occur, they usually disappear when the dosage is reduced. The most significant adverse effects, however, are those due to proarrhythmia, including torsades de pointes (see Warnings).

The following are adverse events considered related to therapy, occurring in 1% or more of patients treated with Apo-Sotalol.

Cardiovascular

Bradycardia, dyspnoea, chest pain, palpitations, oedema, ECG abnormalities, hypotension, proarrhythmia, syncope, heart failure, presyncope

Dermatologic

Rash

Gastro-intestinal

Nausea/vomiting, diarrhoea, dyspepsia, abdominal pain, flatulence

Musculoskeletal

Cramps

Nervous/psychiatric

Fatigue, dizziness, asthenia, lightheadedness, headache, sleep disturbances, depression, paresthesia, mood changes, anxiety

Urogenital

Sexual dysfunction

Special Senses

Visual disturbances, taste abnormalities, hearing disturbances

Body as a whole

Fever

In trials of patients with cardiac arrhythmia, the most common adverse events leading to discontinuation of Apo-Sotalol were fatigue 4%, bradycardia (<50 bpm) 3%, dyspnoea 3%, proarrhythmia 2%, asthenia 2%, and dizziness 2%.

Cold and cyanotic extremities, Raynaud's phenomenon, increase in existing intermittent claudication and dry eyes have been seen in association with other beta-blockers.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal products is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.

Intentional or accidental overdosage with sotalol has rarely resulted in death. Haemodialysis results in a large reduction of plasma levels of sotalol.

Symptoms and treatment of overdosage: The most common signs to be expected are bradycardia, congestive heart failure, hypotension, bronchospasm and hypoglycaemia. In cases of massive intentional overdosage (2-16 g) of sotalol the following clinical findings were seen: hypotension, bradycardia, prolongation of QT-interval, premature ventricular complexes, ventricular tachycardia, torsades de pointes.

If overdosage occurs, therapy with sotalol should be discontinued and the patient observed closely. In addition, if required, the following therapeutic measures are suggested:

Bradycardia Atropine (0.5 to 2mg IV), another anticholinergic drug, a beta-adrenergic agonist (isoprenaline, 5 microgram per minute, up to 25 microgram, by slow IV injection) or transvenous cardiac pacing.

Heart Block (second and third degree) Transvenous cardiac pacing.

Hypotension Adrenaline rather than isoprenaline or noradrenaline may be useful, depending on associated factors.

Bronchospasm Aminophylline or aerosol beta-2-receptor stimulant.

Torsades de pointes DC cardioversion, transvenous cardiac pacing, adrenaline, and/or magnesium sulphate.

Intentional or accidental overdose with Apo-Sotalol has rarely resulted in death. Haemodialysis results in a large reduction of plasma levels of Apo-Sotalol.

Symptoms and treatment of overdose: The most common signs to be expected are bradycardia, congestive heart failure, hypotension, bronchospasm and hypoglycaemia. In cases of massive intentional overdose (2-16 g) of Apo-Sotalol the following clinical findings were seen: hypotension, bradycardia, prolongation of QT-interval, premature ventricular complexes, ventricular tachycardia, torsades de pointes.

If overdose occurs, therapy with Apo-Sotalol should be discontinued and the patient observed closely. In addition, if required, the following therapeutic measures are suggested:

Bradycardia

Atropine (0.5 to 2 mg IV), another anticholinergic drug, a beta-adrenergic agonist (isoprenaline, 5 microgram per minute, up to 25 microgram, by slow IV injection) or transvenous cardiac pacing

Heart Block (second and third degree)

Transvenous cardiac pacing

Hypotension

Adrenaline rather than isoprenaline or noradrenaline may be useful, depending on associated factors

Bronchospasm

Aminophylline or aerosol beta-2-receptor stimulant

Torsades de pointes

DC cardioversion, transvenous cardiac pacing, adrenaline, and/or magnesium sulphate

Pharmacotherapeutic group: Beta blocking agents, ATC code: C07AA07.

D,l-sotalol is a non-selective hydrophilic β-adrenergic receptor blocking agent, devoid of intrinsic sympathomimetic activity or membrane stabilizing activity.

Sotalol has both beta-adrenoreceptor blocking (Vaughan Williams Class II) and cardiac action potential duration prolongation (Vaughan Williams Class III) antiarrhythmic properties. Sotalol has no known effect on the upstroke velocity and therefore no effect on the depolarization phase.

Sotalol uniformly prolongs the action potential duration in cardiac tissues by delaying the repolarisation phase. Its major effects are prolongation of the atrial, ventricular and accessory pathway effective refractory periods.

The Class II and III properties may be reflected on the surface electrocardiogram by a lengthening of the PR, QT and QTc (QT corrected for heart rate) intervals with no significant alteration in the QRS duration.

The d- and l-isomers of sotalol have similar Class III antiarrhythmic effects while the l-isomer is responsible for virtually all of the beta-blocking activity. Although significant beta-blockade may occur at oral doses as low as 25 mg, Class III effects are usually seen at daily doses of greater than 160 mg.

Its β-adrenergic blocking activity causes a reduction in heart rate (negative chronotropic effect) and a limited reduction in the force of contraction (negative inotropic effect). These cardiac changes reduce myocardial oxygen consumption and cardiac work. Like other β-blockers, sotalol inhibits renin release. The renin-suppressive effect of sotalol is significant both at rest and during exercise. Like other beta adrenergic blocking agents, sotalol produces a gradual but significant reduction in both systolic and diastolic blood pressures in hypertensive patients. Twenty-four-hour control of blood pressure is maintained both in the supine and upright positions with a single daily dose.

ATC Code - C70A A07

D,l-Apo-Sotalol is a non-selective hydrophilic β-adrenergic receptor blocking agent, devoid of intrinsic sympathomimetic activity or membrane stabilizing activity.

Apo-Sotalol has both beta-adrenoreceptor blocking (Vaughan Williams Class II) and cardiac action potential duration prolongation (Vaughan Williams Class III) antiarrhythmic properties. Apo-Sotalol has no known effect on the upstroke velocity and therefore no effect on the depolarisation phase.

Apo-Sotalol uniformly prolongs the action potential duration in cardiac tissues by delaying the repolarisation phase. Its major effects are prolongation of the atrial, ventricular and accessory pathway effective refractory periods.

The Class II and III properties may be reflected on the surface electrocardiogram by a lengthening of the PR, QT and QTc (QT corrected for heart rate) intervals with no significant alteration in the QRS duration.

The d- and l-isomers of Apo-Sotalol have similar Class III antiarrhythmic effects while the l-isomer is responsible for virtually all of the beta-blocking activity. Although significant beta-blockade may occur at oral doses as low as 25 mg, Class III effects are usually seen at daily doses of greater than 160 mg.

Its β-adrenergic blocking activity causes a reduction in heart rate (negative chronotropic effect) and a limited reduction in the force of contraction (negative inotropic effect). These cardiac changes reduce myocardial oxygen consumption and cardiac work. Like other β-blockers, Apo-Sotalol inhibits renin release. The renin-suppressive effect of Apo-Sotalol is significant both at rest and during exercise. Like other beta adrenergic blocking agents, Apo-Sotalol produces a gradual but significant reduction in both systolic and diastolic blood pressures in hypertensive patients. Twenty-four-hour control of blood pressure is maintained both in the supine and upright positions with a single daily dose.

The bioavailability of oral sotalol is essentially complete (greater than 90%).). Age does not significantly alter the pharmacokinetics, although impaired renal function in geriatric patients can decrease the excretion rate, resulting in increased drug accumulation.

The bioavailability of oral Apo-Sotalol is essentially complete (greater than 90%). After oral administration, peak levels are reached in 2.5 to 4 hours, and steady-state plasma levels are attained within 2-3 days. The absorption is reduced by approximately 20% when administered with a standard meal, in comparison to fasting conditions. Over the dosage range 40-640 mg/day Apo-Sotalol displays dose proportionality with respect to plasma levels. Distribution occurs to a central (plasma) and a peripheral compartment, with an elimination half-life of 10-20 hours. Apo-Sotalol does not bind to plasma proteins and is not metabolised. There is very little inter-subject variability in plasma levels. Apo-Sotalol crosses the blood brain barrier poorly, with cerebrospinal fluid concentrations only 10% of those in plasma. The primary route of elimination is renal excretion. Approximately 80 to 90% of a dose is excreted unchanged in the urine, while the remainder is excreted in the faeces. Lower doses are necessary in conditions of renal impairment (see Dosage and Administration in patients with renal dysfunction). Age does not significantly alter the pharmacokinetics, although impaired renal function in geriatric patients can decrease the excretion rate, resulting in increased drug accumulation.

No special requirement.

None