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Anti-arrhythmia drugs

Category: Medicines

Type

Involuntary

Introduction and description

 
 

Anti-arrhythmic agents are a group of pharmaceuticals that are used to suppress abnormal rhythms of the heart (cardiac arrhythmias), such as atrial fibrillation, atrial flutter, ventricular tachycardia, and ventricular fibrillation.

Heart arrythmia has a number of causes and the best line of treatment is to find the cause, but in emergency cases these drugs become an important treatment, until the cause can be found and corrected.  Long term use should not be necessary.

Types of drug

Many attempts have been made to classify antiarrhythmic agents. The problem arises from the fact that many of the antiarrhythmic agents have multiple modes of action, making any classification imprecise. 

 

In addition, more confusion is caused by the fact that there is a belief that drugs such as beta blockers , calcium channel blockers and blood thinners also have  antiarrhythmic action and can thus be substituted for this class of drugs. From the evidence amassing on the eHealthme website it would appear that this belief is unfounded and in fact all these drugs appear to be a cause of arrythmia not a cure.  This problem is explained in the section on Heart arrythmia

In the following description I have excluded these drugs as they have sections of their own.  Quite a number of anti-arrythmia drugs appear to produce hallucinations.

Clinical uses

The clinical uses are shown below 

Examples

Mechanism

Clinical uses

Quinidine

Procainamide

Disopyramide

(Na+) channel block (intermediate association/dissociation)

Ventricular arrhythmias

Prevention of paroxysmal recurrent atrial fibrillation

 

 

Mexiletine

Tocainide

(Na+) channel block (fast association/dissociation)

Treatment and prevention during and immediately after myocardial infarction, though this practice is now discouraged given the increased risk of asystole

ventricular tachycardia 

Atrial fibrillation

Flecainide

Propafenone

Moricizine

(Na+) channel block (slow association/dissociation)

Prevents paroxysmal atrial fibrillation

Treats recurrent tachyarrhythmias of abnormal conduction system.

contraindicated immediately post-myocardial infarction.

Ibutilide

Dofetilide

Dronedarone

E-4031

 

Amiodarone

K+ channel blocker

And miscellaneous

Ventricular tachycardias and atrial fibrillation

Atrial flutter and atrial fibrillation

Background

 

One of the drugs in the list above and for which very few experiences exist is Quinidine.  Quinidine is a stereoisomer of quinine [the stuff in tonic water] , originally derived from the bark of the cinchona tree.  The effects of cinchona was known long before our understanding of cardiac physiology arose. Jean-Baptiste de Sénac, in his 1749 work on the anatomy, function, and diseases of the heart, stated that,  "Long and rebellious palpitations have ceded to this febrifuge" and "Of all the stomachic remedies, the one whose effects have appeared to me the most constant and the most prompt in many cases is quinquina [Peruvian bark] mixed with a little rhubarb."

Sénac subsequently became physician to Louis XV of France. As a result of his influence, throughout the nineteenth century quinine was used to augment digitalis therapy. It was described as "das opium des herzens" (the opium of the heart).  But the use of quinidine to medically treat arrhythmias only came about when a physician listened to the observations of one of his patients.

In 1912, Karel Frederik Wenckebach saw a man with atrial fibrillation. The man had found by chance that when he took one gram of quinine during an attack it reliably halted it in 25 minutes: otherwise it would last for 2-14 days. Wenckebach often tried quinine again but he succeeded in only one other patient.   He made passing mention of it in his book on cardiac arrhythmias published in 1914. Four years later, Walter von Frey of Berlin reported in a leading Viennese medical journal that quinidine was the most effective of the four principle cinchona alkaloids in controlling atrial arrhythmias.

Side-effects

 

There are no typical side effects that one can list for these drugs, as each has a different profile, however, if we take an example - Multaq - the most common Multaq side effects according to the eHealthme site are :

  • Atrial Fibrillation/flutter in Multaq (1,042 reports)
  • Breathing Difficulty in Multaq (533 reports)
  • Fatigue in Multaq (293 reports)
  • Blood Creatinine Increased in Multaq (293 reports)
  • Diarrhea in Multaq (261 reports)
  • Nausea in Multaq (250 reports)
  • Dizziness in Multaq (232 reports)
  • Weakness in Multaq (232 reports)
  • Cardiac Failure in Multaq (226 reports)
  • Oedema Peripheral in Multaq (215 reports)

Given this class of drugs is intended to help with arrythmia, it appears this one, at least, is not all that successful.

Death

 

Another side effect worth exploring is that of the ultimate spiritual experience - death.  Again using the figures from eHealthme which provide a snapshot in time - [the up-to-date figures can found by following the links below], these are the figures for deaths caused by these drugs:

Disopyramide phosphate - On Aug, 20, 2015: 281 people reported to have side effects when taking Disopyramide phosphate. Among them, 2 people (0.71%) have Death

Mexiletine hydrochloride - On Aug, 1, 2015: 502 people reported to have side effects when taking Mexiletine hydrochloride. Among them, 17 people (3.39%) have Death

Flecainide acetate - On Jul, 29, 2015: 3,539 people reported to have side effects when taking Flecainide acetate. Among them, 44 people (1.24%) have Death

Tambocor - On Jul, 25, 2015: 1,376 people reported to have side effects when taking Tambocor. Among them, 20 people (1.45%) have Death

Rythmol sr. - On Aug, 6, 2015: 281 people reported to have side effects when taking Rythmol sr. Among them, 4 people (1.42%) have Death

Amiodarone hydrochloride - On Aug, 15, 2015: 2,605 people reported to have side effects when taking Amiodarone hydrochloride. Among them, 39 people (1.50%) have Death

Cordarone - On Aug, 5, 2015: 11,765 people reported to have side effects when taking Cordarone. Among them, 214 people (1.82%) have Death

Digoxin - On Jul, 31, 2015: 51,888 people reported to have side effects when taking Digoxin. Among them, 2,013 people (3.88%) have Death

Lanoxin- On Aug, 22, 2015: 16,278 people reported to have side effects when taking Lanoxin. Among them, 538 people (3.31%) have Death

Tikosyn - On Aug, 8, 2015: 5,484 people reported to have side effects when taking Tikosyn. Among them, 155 people (2.83%) have Death

Toprol - On Aug, 17, 2015: 39,648 people reported to have side effects when taking Toprol-xl. Among them, 830 people (2.09%) have Death

Sotalol - On Aug, 4, 2015: 1,936 people reported to have side effects when taking Sotalol hydrochloride. Among them, 23 people (1.19%) have Death

Quinidine sulfate - On Aug, 6, 2015: 183 people reported to have side effects when taking Quinidine sulfate. Among them, 1 people (0.55%) has Death

Multaq - On Aug, 22, 2015: 4,746 people reported to have side effects when taking Multaq. Among them, 107 people (2.25%) have Death

How it works

What causes the hallucinations?  The primary action appears to be mediated by potassium  or sodium channel blocking, which in turn produces hypoxia, however, they also seem to be acting as toxins and thus causing poisoning in some people. 

References and further reading

 

 

 

All the paintings and photos on this page are by Sonya Kanelstrand and were chosen because they add an air of spiritual optimism to an otherwise sad subject.

 

 

 

 

 

Observations

The table below provides a summary of the number of hallucinations experienced taking this class of drugs as of 2008 and as published on eHealthme.  The side effects for each drug can be found by following the link along wth up-to-date figures for the hallucinations and deaths

Observation no

Drug Name

No of hallucinations

005072

Procainamide

3

005073

Disopyramide

6

005074

Mexiletine

11

 

Tocainide

1

005075

Flecainide acetate sold under the trade name Tambocor

11

005076

Rythmol SR also known as Propafenone

7

005081

Amiodarone

64

005081

Cordarone

-

005082

Digoxin

429

017511

Lanoxin

155

015753

Tikosyn

4

015755 Toprol 301

 005090

 Sotalol

 8

 017508  Quinidine  4
017510 Multaq 18
     1,022

 There are a few drugs for which no figures exist.  I have listed these below however one should not take this as an indication of safety it may simply mean that they are rarely prescribed or the eHealthme site has no records of them

  • Moracizine - or moricizine, trade name Ethmozine,  was used for the prophylaxis and treatment of serious and life-threatening ventricular arrhythmias, but was withdrawn in 2007 “for commercial reasons”.
  •  Ibutilide is marketed as Corvert .  It is used for “acute cardioconversion of atrial fibrillation and atrial flutter of a recent onset to sinus rhythm”. It appears to show better results in atrial flutter as compared to atrial fibrillation.  Unlike the other antiarrhythmic drugs, ibutilide does not produce its effects via channel blocking as such, nor does it have antiadrenergic activity.  Instead it acts  “ on the slow sodium channel” and promotes the influx of sodium through these slower channels.  Although the potassium current seems to play a role, the interactions are complex and not well understood.  By acting on the slower sodium channels, it prolongs the action potential reducing flutter.  Like other antiarrhythmics, ibutilide can lead to arrhythmia.

Related observations