Expedited loading with IV Sotalol safe and feasible for atrial arrhythmias: PEAKS Registry

Antiarrhythmic drug therapy plays an important role in achieving rhythm control in atrial arrhythmias. In these patients, class III antiarrhythmic drugs are indicated for use. However, these drugs are linked to a nontrivial risk of QT interval prolongation and an associated risk of life-threatening ventricular arrhythmias. In this setting, initiation and dose titration of these drugs are often performed on an inpatient basis, typically needing hospitalization of up to 3 days.

Sotalol has been previously available in IV form, however, it has only been approved recently for initiation or dose increase among patients with atrial arrhythmias. This new dosing allows for shortening hospitalization stays for these patients, yet its approval was based on computer-based simulation modeling to predict sotalol concentrations. Knowledge gaps remain regarding the in vivo use of IV sotalol, specifically around real-world outcomes, as well as pharmacokinetic and pharmacodynamic profiles in adult patients.

To fill this knowledge gap, Benjamin A. Steinberg, Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, Utah, and colleagues presented results of the first multicenter evaluation of this recent labeling for IV sotalol.

The PEAKS Registry was a multicenter observational registry of patients undergoing elective IV sotalol load for atrial arrhythmias. Outcomes, measured from hospital admission until the first outpatient follow-up, included adverse arrhythmia events, length of stay, and efficacy.

The study led to the following findings:

· Among 167 consecutively enrolled patients, 23% were female, the median age was 68, and the median CHA2DS2-VASc was 3.

· 99% were admitted for sotalol initiation (1% for dose escalation), with a target oral sotalol dose of either 80 mg bid (51%) or 120 mg bid (47%); 37% had an estimated creatinine clearance <90 mL/min.

· On presentation, 40% of patients were in sinus rhythm, whereas 26% underwent cardioversion before sotalol infusion.

· Sotalol infusion was stopped in two patients for bradycardia or hypotension.

· In six subjects, sotalol was discontinued before discharge due to QTc prolongation (3), bradycardia (1), or recurrent atrial arrhythmia (2).

· The mean length of stay was 1.1 days, and 95% were discharged within one night.

The findings showed that IV sotalol loading is safe and feasible in the studied population, with low rates of adverse events.

"Health systems can expect a significant reduction in length-of-stay for IV versus oral sotalol loading," the researchers wrote.

"There is a need for more data on the minimal duration required for monitoring in-hospital, which will be informed by forthcoming pharmacodynamics and pharmacokinetic analyses," they concluded.

Reference:

Steinberg BA, Holubkov R, Deering T, Groh CA, Mittal S, Kennedy R, Pokharel P, Perez M, Savona S, Verma N, Watt K, Piccini JP, Bunch TJ. Expedited Loading with Intravenous Sotalol is Safe and Feasible - Primary Results of the Prospective Evaluation Analysis and Kinetics of IV Sotalol (PEAKS) Registry. Heart Rhythm. 2024 Feb 26:S1547-5271(24)00218-2. doi: 10.1016/j.hrthm.2024.02.046. Epub ahead of print. PMID: 38417598.