IV sotalol loading safe and feasible in adult patients with atrial fibrillation: DASH-AF trial

"Our findings support a practice shift from conventional 3-day PO loading to 1-day intravenous sotalol loading," the researchers wrote. However, they recommend caution in light of the nonrandomized study's nature and relatively small sample size, which may under-represent possible complications, and more extensive prospective studies are indicated.

Previous studies have recommended inpatient initiation of sotalol owing to its proarrhythmic effects. In the DASH-AF trial, Dhanunjaya Lakkireddy, Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA, and colleagues evaluated the feasibility and safety of IV (intravenous) sotalol, achieving a steady state with maximum QTc prolongation within 6 hours compared to the traditional 5-dose inpatient oral (PO) titration.

DASH-AF is a nonrandomized, prospective, open-label, multicenter trial that comprised patients who underwent IV sotalol loading dose to initiate rapid oral therapy for atrial arrhythmias. The IV dose was calculated based on the target oral dose (indicated by baseline renal function and QTc). Measurement of patients' QTc (in sinus) was done via electrocardiography at intervals of 15 minutes and after IV loading.

Four hours after the first oral dose, patients were discharged. Patients' monitoring was done via mobile cardiac outpatient telemetry for 72 hours. The control group comprised patients admitted for the traditional 5 PO doses. In both groups, safety outcomes were assessed.

The study led to the following findings:

• From 2021 to 2022, one hundred twenty patients from 3 centres were enrolled in the IV loading group (compared with the type of atrial fibrillation– and renal function–matched patients in the conventional PO loading cohort).
• There was no significant change in ΔQTc in both group, with a remarkably lower number of patients requiring dose adjustment in the IV versus the PO arm (4.1% vs 16.6%). This led to potential cost savings of up to $3,500.68 per admission.

"The DASH-AF study showed that rapid loading of sotalol using an IV starter regimen is safe and feasible compared with the conventional oral loading protocols," the researchers wrote.

There are many overall benefits of IV loading, including notably lower overall costs in the IV loading arm due to savings in hospitalization and associated healthcare resource utilization and the ability of the patient to go home and get back to work quickly.

Reference:

Lakkireddy D, Ahmed A, Atkins D, Bawa D, Garg J, Bush J, Charate R, Bommana S, Pothineni NVK, Kabra R, Darden D, Koreber S, Tummala R, Vasamreddy C, Park P, Mohanty S, Gopinathannair R, Seo BW, Natale A, Kennedy R. Feasibility and Safety of Intravenous Sotalol Loading in Adult Patients With Atrial Fibrillation (DASH-AF). JACC Clin Electrophysiol. 2023 Jan 7:S2405-500X(22)01058-1. doi: 10.1016/j.jacep.2022.11.026. Epub ahead of print. PMID: 37014289.