A Nurses Guide to Managing

1. A Nurses Guide to Managing Tikosyn and Sotalol By Rebecca Knowles RN

2. What is Tikosyn and Sotalol Medication Class and Therapeutic Indication

3. Class III AntiArrythmic Medications • Class III Antiarrythmic medications are used for the treatment of Adults with life-threatening ventricular arrhythmias not responding to any other medications. • Used for the conversion of Atrial Fibrillation/Flutter to normal sinus rhythm; maintenance of normal sinus rhythm after conversion for adults.

4. How do they work Heart Function and Action Potentials of Antiarrythmics • Phase O- cell reaches a point of stimulation. Sodium gates open and rushes to cell. + flow of electrons causes DEPOLARIZATION • Phase 1- sodium concentration equalizes in and out of cell • Phase 2- cell becomes less permeable to sodium, Na+ into cell, K+ leaves cell and goes to its resting state = REPOLARIZATION. • Phase 3- rapid repolarization, Na+ gate close and K+ flows out of cell. • Phase 4- cell comes to rest; Na+ and K+ pump returns the membrane to its resting potential and spontaneous depolarization occurs

5. Dofetillide(Tikosyn) • Blocks cardiac ion channels responsible for transport of potassium. • Increases monophasic action potential duration. • Increases effective refractory period. Therapeutic Effects: •   Prevention of recurrent AF/AFl. •   Conversion of AF/AFl to normal sinus rhythm.

6. Tikosyn Contraindications • Contraindicated in: • Hypersensitivity. • Congenital or acquired prolonged QT syndromes. • Creatinine clearance (CCr) <20 mL/min. • Concurrent use of verapamil,cimetidine, ketoconazole, trimethoprim/sulfamethoxazole, megestrol or prochlorperazine. • Concurrent use ofhydrochlorothiazide.

7. Betapace (Sotalol) • Used for the management of life-threatening ventricular arrhythmias. • Patients should be hospitalized and monitored for arrhythmias during initiation of therapy and dose increases.

8. Tikosyn and Sotalol Potential Side Effects Tikosyn • CNS: dizziness, headache. • CV: ventricular arrhythmias, chest pain, QT interval prolongation Sotalol: • CNS: dizziness, headache, fatigue, weakness, anxiety, dizziness, drowsiness, insomnia, memory loss, mental depression, mental status changes, nervousness, nightmares. • EENT: blurred vision, dry eyes, nasal stuffiness. • CV: bradycardia, chf, pulmonary edema, orthostatic hypotension, peripheral vasoconstriction., • Resp: bronchospasm, wheezing. • GI: constipation, diarrhea, nausea. • GU: erectile dysfunction, decreased libido.

9. Why Initiate Tikosyn and Sotalol in Hospital? • Tikosyn and Sotalol must be initiated or reinitiated in a setting that provides continuous ECG monitoring and has personnel trained in the management of serious ventricular arrhythmias. Due to the potential for life-threatening ventricular arrhythmias, these medications are usually used for patients with highly symptomatic AF/AFl. • PO: Administer at the same time each day without regard to food.

10. Initiation of Medication • Usually prescribed by Cardiologist or EP for inpatient monitoring for approx. 3 days. • EP requests dosing to be administered either at 0800 or 0900 and 2000 or 2100.(if different time noted on MAR contact provider for clarification.)per Dr. Taylor and Kelly Cough PA • Verify initial EKG has been done, and orders for EKG’s to be done 2 hours after medication has been given. • EKG Verification Form placed on front of chart. • Pt to be on unit and on telemetry at all times.

11. Nursing Assessments • Monitor ECG prior to and periodically during therapy. May cause life threatening ventricular tachycardia associated with QT interval prolongation. • Evaluate QTc prior to initiation of therapy • Verify EKG done 2 hours after dose, If long QT documented on EKG (QTC > 490 on EKG ), hold medication and call provider immediately for further administration clarification. • Monitor blood pressure and pulse frequently during dose adjustment period and periodically throughout therapy. Assess for orthostatic hypotension when assisting patient up from supine position.

12. Sample EKG’s Elongated QTc QTc >490 Hold Medication and call provider ASAP for further administration clarification!!!!!

14. Sample EKG of Elongated QTc

15. Nursing Assessment • Monitor intake and output ratios and daily weight. Assess patient routinely for evidence of fluid overload (peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, jugular venous distention • If blood pressure <100 systolic or HR < 45 contact provider. • EP recommends that therapy be continued unless they are experiencing symptomatic dizziness or associated with decr. BP or HR.

16. Nursing Assessment • Monitor Labs- BUN ,Creat and K+. Any significant changes contact provider immediately. • Verify all home medications with patient, special precautions if taking HCTZ or Verapamil (see Tikosyn Contraindication). These are contraindicated with Tikoysn and provider to be contacted immediately.

17. Nursing Orders • Medication: Administer only if EKG has been signed off by provider. • Provider EKG Verification form: On admission to unit Tikosyn/Sotalol EKG verification form is to be obtained and placed on front of chart. • PA or Resident are required to document with their initials on the form as well as on EKG after reviewing EKG. (this is mandatory per EP)

18. Nursing Interventions • Take apical pulse prior to administering. If <45 bpm or if arrhythmia occurs, notify health care professional. • For Sotalol: verify if medication should be administer on an empty stomach, 1 hr before or 2 hr after meals. Administration with food, especially milk or milk products, reduces absorption by approximately 20%. ›   Avoid administering antacids containing aluminum or magnesium within 2 hr before administration of sotalol.

19. Patient Teaching • Verify patient understanding on admission and medication management. • Teach client to contact provider before starting of any new medications or OTC. • Teach client common side effects and instruct them to tell health team if they experience any episodes of CP, SOB, dizziness, lightheadedness, vision changes, or palpitations. • Unit procedures , continuous tele monitoring and EKG’s 2 hours after medication administration. • Medication use and outcome goals.

20. Patient Teaching • Teach patient and family how to check pulse and blood pressure. Instruct them to check pulse daily and blood pressure biweekly. Advise contact physician or other health care professional if pulse is <50 bpm or if blood pressure changes significantly. • Advise patients to change positions slowly to minimize orthostatic hypotension, especially during initiation of therapy or when dose is increased. Sotolol : Diabetic patients should closely monitor blood glucose, especially if weakness, malaise, irritability, or fatigue occurs. Medication may mask tachycardia and increased blood pressure as signs of hypoglycemia, but dizziness and sweating may still occur.

21. References • www.skyscape.com. • www.tikosyn.com • Karch, A. M. (2011). Focus on Nursing Pharmacology (5th ed.). Philadelphia: WoltersKluwer/ Lippincott Williams & Wilkins. • Yao, J., and Hickey, K.P. (2010). Long QT Syndrome A Case Report, Genomics and Clinical Implications. Clinical Scholars Review , 31-35. • Sarah Taylor M.D. and Kelly Cough P.A.