Ritalmex

Ritalmex (mexiletine hydrochloride, USP) is indicated for the treatment of documented ventricular arrhythmias, such as sustained ventricular tachycardia, that, in the judgement of the physician, are life-threatening. Because of the proarrhythmic effects of Ritalmex (mexiletine hcl) , its use with lesser arrhythmias is generally not recommended. Treatment of patients with asymptomatic ventricular premature contractions should be avoided.

Initiation of Ritalmex (mexiletine hcl) treatment, as with other antiarrhythmic agents used to treat life-threatening arrhythmias, should be carried out in the hospital.

Antiarrhythmic drugs have not been shown to enhance survival in patients with ventricular arrhythmias.

The dosage of Ritalmex (mexiletine hydrochloride, USP) must be individualized on the basis of response and tolerance, both of which are dose-related. Administration with food or antacid is recommended. Initiate Ritalmex (mexiletine hcl) therapy with 200 mg every eight hours when rapid control of arrhythmia is not essential. A minimum of two to three days between dose adjustments is recommended. Dose may be adjusted in 50 or 100 mg increments up or down.

As with any antiarrhythmic drug, clinical and electrocardiographic evaluation (including Holter monitoring if necessary for evaluation) are needed to determine whether the desired antiarrhythmic effect has been obtained and to guide titration and dose adjustment.

Satisfactory control can be achieved in most patients by 200 to 300 mg given every eight hours with food or antacid. If satisfactory response has not been achieved at 300 mg q8h, and the patient tolerates Ritalmex (mexiletine hcl) well, a dose of 400 mg q8h may be tried. As the severity of CNS side effects increases with total daily dose, the dose should not exceed 1200 mg/day.

In general, patients with renal failure will require the usual doses of Ritalmex (mexiletine hcl). Patients with severe liver disease, however, may require lower doses and must be monitored closely. Similarly, marked right-sided congestive heart failure can reduce hepatic metabolism and reduce the needed dose. Plasma level may also be affected by certain concomitant drugs (see PRECAUTIONS: DRUG INTERACTIONS).

Loading Dose

When rapid control of ventricular arrhythmia is essential, an initial loading dose of 400 mg of Ritalmex (mexiletine hcl) may be administered, followed by a 200 mg dose in eight hours. Onset of therapeutic effect is usually observed within 30 minutes to two hours.

Q12H Dosage Schedule

Some patients responding to Ritalmex (mexiletine hcl) may be transferred to a 12-hour dosage schedule to improve convenience and compliance. If adequate suppression is achieved on a Ritalmex (mexiletine hcl) dose of 300 mg or less every eight hours, the same total daily dose may be given in divided doses every 12 hours while carefully monitoring the degree of suppression of ventricular ectopy. This dose may be adjusted up to a maximum of 450 mg every 12 hours to achieve the desired response.

Transferring to Ritalmex (mexiletine hcl)

The following dosage schedule, based on theoretical considerations rather than experimental data, is suggested for transferring patients from other Class I oral antiarrhythmic agents to Ritalmex (mexiletine hcl) : Ritalmex (mexiletine hcl) treatment may be initiated with a 200 mg dose, and titrated to response as described above, 6-12 hours after the last dose of quinidine sulfate, 3-6 hours after the last dose of procainamide, 6-12 hours after the last dose of disopyramide or 8-12 hours after the last dose of tocainide.

In patients in whom withdrawal of the previous antiarrhythmic agent is likely to produce life-threatening arrhythmias, hospitalization of the patient is recommended.

When transferring from lidocaine to Ritalmex (mexiletine hcl) , the lidocaine infusion should be stopped when the first oral dose of Ritalmex (mexiletine hcl) is administered. The infusion line should be left open until suppression of the arrhythmia appears to be satisfactorily maintained.

Consideration should be given to the similarity of the adverse effects of lidocaine and Ritalmex (mexiletine hcl) and the possibility that they may be additive.

Ritalmex (mexiletine hydrochloride, USP) is contraindicated in the presence of cardiogenic shock or pre-existing second- or third-degree AV block (if no pacemaker is present).

WARNINGS

Mortality: In the National Heart, Lung and Blood Institute's Cardiac Arrhythmia Suppression Trial (CAST), a long-term, multicentered, randomized, double-blind study in patients with asymptomatic non-life-threatening ventricular arrhythmias who had a myocardial infarction more than six days but less than two years previously, an excessive mortality or non-fatal cardiac arrest rate (7.7%) was seen in patients treated with encainide or flecainide compared with that seen in patients assigned to carefully matched placebo-treated groups (3.0%). The average duration of treatment with encainide or flecainide in this study was ten months.

The applicability of the CAST results to other populations (e.g., those without recent myocardial infarction) is uncertain. Considering the known proarrhythmic properties of Ritalmex (mexiletine hcl) and the lack of evidence of improved survival for any antiarrhythmic drug in patients without life-threatening arrhythmias, the use of Ritalmex (mexiletine hcl) as well as other antiarrhythmic agents should be reserved for patients with life-threatening ventricular arrhythmia.

Acute Liver Injury

In post-marketing experience abnormal liver function tests have been reported, some in the first few weeks of therapy with Ritalmex (mexiletine hydrochloride, USP). Most of these have been observed in the setting of congestive heart failure or ischemia and their relationship to Ritalmex (mexiletine hcl) has not been established.

PRECAUTIONS

General

If a ventricular pacemaker is operative, patients with second or third degree heart block may be treated with Ritalmex (mexiletine hydrochloride, USP) if continuously monitored. A limited number of patients (45 of 475 in controlled clinical trials) with pre-existing first degree AV block were treated with Ritalmex (mexiletine hcl) ; none of these patients developed second or third degree AV block. Caution should be exercised when it is used in such patients or in patients with pre-existing sinus node dysfunction or intraventricular conduction abnormalities.

Like other antiarrhythmics Ritalmex (mexiletine hydrochloride, USP) can cause worsening of arrhythmias. This has been uncommon in patients with less serious arrhythmias (frequent premature beats or non-sustained ventricular tachycardia: see ADVERSE REACTIONS), but is of greater concern in patients with life-threatening arrhythmias such as sustained ventricular tachycardia. In patients with such arrhythmias subjected to programmed electrical stimulation or to exercise provocation, 10-15% of patients had exacerbation of the arrhythmia, a rate not greater than that of other agents.

Ritalmex (mexiletine hcl) should be used with caution in patients with hypotension and severe congestive heart failure because of the potential for aggravating these conditions.

Since Ritalmex (mexiletine hcl) is metabolized in the liver, and hepatic impairment has been reported to prolong the elimination half-life of Ritalmex (mexiletine hcl) , patients with liver disease should be followed carefully while receiving Ritalmex (mexiletine hcl). The same caution should be observed in patients with hepatic dysfunction secondary to congestive heart failure.

Concurrent drug therapy or dietary regimens which may markedly alter urinary pH should be avoided during Ritalmex (mexiletine hcl) therapy. The minor fluctuations in urinary pH associated with normal diet do not affect the excretion of Ritalmex (mexiletine hcl).

SGOT Elevation and Liver Injury

In three-month controlled trials, elevations of SGOT greater than three times the upper limit of normal occurred in about 1% of both mexiletine-treated and control patients. Approximately 2% of patients in the mexiletine compassionate use program had elevations of SGOT greater than or equal to three times the upper limit of normal. These elevations frequently occurred in association with identifiable clinical events and therapeutic measures such as congestive heart failure, acute myocardial infarction, blood transfusions and other medications. These elevations were often asymptomatic and transient, usually not associated with elevated bilirubin levels and usually did not require discontinuation of therapy. Marked elevations of SGOT ( > 1000 U/L) were seen before death in four patients with end-stage cardiac disease (severe congestive heart failure, cardiogenic shock).

Rare instances of severe liver injury, including hepatic necrosis, have been reported in association with Ritalmex (mexiletine hcl) treatment. It is recommended that patients in whom an abnormal liver test has occurred, or who have signs or symptoms suggesting liver dysfunction, be carefully evaluated. If persistent or worsening elevation of hepatic enzymes is detected, consideration should be given to discontinuing therapy.

Blood Dyscrasias

Among 10,867 patients treated with mexiletine in the compassionate use program, marked leukopenia (neutrophils less than 1000/mm³) or agranulocytosis were seen in 0.06% and milder depressions of leukocytes were seen in 0.08%, and thrombocytopenia was observed in 0.16%. Many of these patients were seriously ill and receiving concomitant medications with known hematologic adverse effects. Rechallenge with mexiletine in several cases was negative. Marked leukopenia or agranulocytosis did not occur in any patient receiving Ritalmex (mexiletine hcl) alone; five of the six cases of agranulocytosis were associated with procainamide (sustained release preparations in four) and one with vinblastine. If significant hematologic changes are observed, the patient should be carefully evaluated, and, if warranted, Ritalmex (mexiletine hcl) should be discontinued. Blood counts usually return to normal within one month of discontinuation. (See ADVERSE REACTIONS).

Convulsions (seizures) did not occur in Ritalmex (mexiletine hcl) controlled clinical trials. In the compassionate use program, convulsions were reported in about 2 of 1000 patients. Twenty-eight percent of these patients discontinued therapy. Convulsions were reported in patients with and without a prior history of seizures. Mexiletine should be used with caution in patients with known seizure disorder.

Carcinogenesis, Mutagenesis and Impairment of Fertility

Studies of carcinogenesis in rats (24 months) and mice (18 months) did not demonstrate any tumorigenic potential. Ritalmex (mexiletine hcl) was found to be non-mutagenic in the Ames test. Ritalmex (mexiletine hcl) did not impair fertility in the rat.

Pregnancy

Teratogenic Effects

Pregnancy Category C

Reproduction studies performed with Ritalmex (mexiletine hydrochloride, USP) in rats, mice and rabbits at doses up to four times the maximum human oral dose (24 mg/kg in a 50 kg patient) revealed no evidence of teratogenicity or impaired fertility but did show an increase in fetal resorption. There are no adequate and well-controlled studies in pregnant women; this drug should be used in pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers

Ritalmex (mexiletine hcl) appears in human milk in concentrations similar to those observed in plasma. Therefore, if the use of Ritalmex (mexiletine hcl) is deemed essential, an alternative method of infant feeding should be considered.

Pediatric Use

Safety and effectiveness in the pediatric population have not been established.

Ritalmex (mexiletine hydrochloride, USP) commonly produces reversible gastrointestinal and nervous system adverse reactions but is otherwise well tolerated. Ritalmex (mexiletine hcl) has been evaluated in 483 patients in one-month and three-month controlled studies and in over 10,000 patients in a large compassionate use program. Dosages in the controlled studies ranged from 600-1200 mg/day; some patients (8%) in the compassionate use program were treated with higher daily doses (1600-3200 mg/day). In the three-month controlled trials comparing Ritalmex (mexiletine hcl) to quinidine, procainamide and disopyramide, the most frequent adverse reactions were upper gastrointestinal distress (41%), lightheadedness (10.5%), tremor (12.6%) and coordination difficulties (10.2%). Similar frequency and incidence were observed in the one-month placebo-controlled trial. Although these reactions were generally not serious, and were dose-related and reversible with a reduction in dosage, by taking the drug with food or antacid or by therapy discontinuation, they led to therapy discontinuation in 40% of patients in the controlled trials. Table 1 presents the adverse events reported in the one-month placebo-controlled trial.

Table 1 : Comparative Incidence (%) of Adverse Events Among Patients Treated with Mexiletine and Placebo in the 4- Week, Double-blind Crossover Trial

Table 2 presents the adverse reactions occurring in one percent or more of patients in the three-month controlled studies.

Table 2: Comparative Incidence (%) of Adverse Events Among Patients Treated with Mexiletine or Control Drugs in the 12-Week Double-blind Trials

Less than 1%: Syncope, edema, hot flashes, hypertension, short-term memory loss, loss of consciousness, other psychological changes, diaphoresis, urinary hesitancy/retention, malaise, impotence/decreased libido, pharyngitis, congestive heart failure.

An additional group of over 10,000 patients has been treated in a program allowing administration of Ritalmex (mexiletine hydrochloride, USP) under compassionate use circumstances. These patients were seriously ill with the large majority on multiple drug therapy. Twenty-four percent of the patients continued in the program for one year or longer. Adverse reactions leading to therapy discontinuation occurred in 15 percent of patients (usually upper gastrointestinal system or nervous system effects). In general, the more common adverse reactions were similar to those in the controlled trials. Less common adverse events possibly related to Ritalmex (mexiletine hcl) use include:

Cardiovascular System: Syncope and hypotension, each about 6 in 1000; bradycardia, about 4 in 1000; angina/angina-like pain, about 3 in 1000; edema, atrioventricular block/conduction disturbances and hot flashes, each about 2 in 1000; atrial arrhythmias, hypertension and cardiogenic shock, each about 1 in 1000.

Central Nervous System: Short-term memory loss, about 9 in 1000 patients; hallucinations and other psychological changes, each about 3 in 1000; psychosis and convulsions/seizures, each about 2 in 1000; loss of consciousness, about 6 in 10,000.

Digestive: Dysphagia, about 2 in 1000; peptic ulcer, about 8 in 10,000; upper gastrointestinal bleeding, about 7 in 10,000; esophageal ulceration, about 1 in 10,000. Rare cases of severe hepatitis/acute hepatic necrosis.

Skin: Rare cases of exfoliative dermatitis and Stevens-Johnson Syndrome with Ritalmex (mexiletine hydrochloride, USP) treatment have been reported.

Laboratory:Abnormal liver function tests, about 5 in 1000 patients; positive ANA and thrombocytopenia, each about 2 in 1000; leukopenia (including neutropenia and agranulocytosis), about 1 in 1000; myelofibrosis, about 2 in 10,000 patients.

Other: Diaphoresis, about 6 in 1000; altered taste, about 5 in 1000; salivary changes, hair loss and impotence/decreased libido, each about 4 in 1000; malaise, about 3 in 1000; urinary hesitancy/retention, each about 2 in 1000; hiccups, dry skin, laryngeal and pharyngeal changes and changes in oral mucous membranes, each about 1 in 1000; SLE syndrome, about 4 in 10,000.

Hematology

Blood dyscrasias were not seen in the controlled trials but did occur among 10,867 patients treated with mexiletine in the compassionate use program (see PRECAUTIONS).

Myelofibrosis was reported in two patients in the compassionate use program: one was receiving long-term thiotepa therapy and the other had pretreatment myeloid abnormalities.

In post-marketing experience, there have been isolated, spontaneous reports of pulmonary changes including pulmonary infiltration and pulmonary fibrosis during Ritalmex (mexiletine hcl) therapy with or without other drugs or diseases that are known to produce pulmonary toxicity. A causal relationship to Ritalmex (mexiletine hcl) therapy has not been established. In addition, there have been isolated reports of drowsiness, nystagmus, ataxia, dyspepsia, hypersensitivity reaction, and exacerbation of congestive heart failure in patients with pre-existing compromised ventricular function. There have been rare reports of pancreatitis associated with Ritalmex (mexiletine hcl) treatment.

Clinical findings associated with Ritalmex (mexiletine hydrochloride, USP) overdosage have included drowsiness, confusion, nausea, hypotension, sinus bradycardia, paresthesia, seizures, bundle branch block, AV heart block, asystole, ventricular tachyarrhythmia, including ventricular fibrillation, cardiovascular collapse and coma. The lowest known dose in a fatality case was 4.4g with postmortem serum mexiletine level of 34-37 mcg/ml (Jequier P. et al. Lancet 1976: 1 (7956): 429). Patients have recovered from ingestion of 4g to 18g of mexiletine (Frank S. E. et al. Am J Emerg Med 1991: 9:43-48).

There is no specific antidote for Ritalmex (mexiletine hcl). Management of Ritalmex (mexiletine hcl) overdosage includes general supportive measures, close observation and monitoring of vital signs. In addition, the use of pharmacologic interventions (e.g., pressor agents, atropine or anticonvulsants) or transvenous cardiac pacing is suggested, depending on the patient's clinical condition.