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Increased AAI mode pacing threshold after termination of atrial fibrillation by acute administration of disopyramide phosphate.

AIMS: We studied changes in atrial pacing threshold after termination of atrial fibrillation (AF) by acute administration of disopyramide phosphate (DP) to elucidate the suitable setting for atrial pacing output before AF termination. METHODS AND RESULTS: Four patients with sick sinus syndrome implanted with AAI mode pacemakers were examined. Disopyramide phosphate (2 mg/kg body weight) was injected intravenously for termination of a total of eight AF episodes. The maximal pacing threshold after AF termination (5.2+/-0.8 V at 0.45 ms) was significantly higher than that at baseline (1.3+/-0.2 V at 0.45 ms; P<0.01) and the average increment was 433+/-68%. During a period free from AF, an acute administration of DP did not increase the atrial pacing threshold and serum disopyramide levels were not toxic. CONCLUSION: The increased atrial pacing threshold observed after AF termination cannot be explained by the action of DP alone. However, our results suggest that atrial pacing output should be set at the maximum value before DP is administered to induce AF termination in patients with AAI pacemaker-dependent bradyarrhythmias.

Aged↗

Saliva concentrations of disopyramide cannot substitute the drug's plasma concentrations.

For many drugs the salivary concentration corresponds to the free plasma drug concentration, which may be more closely related to drug activity or toxicity than the total plasma drug concentration. In this study a preliminary investigation was undertaken to determine the feasibility of monitoring saliva levels of disopyramide, an antiarrhythmic drug, for clinical and toxicological purposes. Single oral doses of this compound were administered to healthy volunteers. Stimulated mixed saliva and plasma levels were measured by the EMIT technique. The concentrations of disopyramide in the stimulated mixed saliva tended to be lower than those found in the corresponding plasma sample (fp 0.3-0.5), and the saliva-to-plasma concentration ratio increased with a decreasing salivary pH (pH 6.89, S/P = 0.25; pH 8.15, S/P = 0.08). The correlation between the saliva and the total plasma concentrations was significant but relatively poor, however. Consequently, mixed salivary disopyramide concentrations are a poor indicator of plasma concentrations, even if correction is made for pH change.

Disopyramide↗

Negative inotropic effect of class-I-antiarrhythmic drugs: comparison of flecainide with disopyramide and quinidine.

An important side-effect of antiarrhythmic drugs is their negative inotropic action. To investigate this after i.v. administration we compared the newer class-I-antiarrhythmic drug flecainide (2 mg, 4 mg and 8 mg kg-1) with disopyramide (1 mg, 4 mg and 8 mg kg-1), quinidine (5 mg and 10 mg kg-1) and saline (controls). Isovolumic measurements of ventricular function by short aortic crossclamping were performed in 82 open-chest rats and peak left ventricular isovolumic pressure (LVSP) and peak isovolumic dp/dt max were determined 5 and 15 minutes after intravenous drug injection. All drugs decreased isovolumic indices of myocardial function dose-dependently. Flecainide reduced peak isovolumic LVSP and dp/dt max only after 8 mg kg-1 (to 85 +/- 3% and 45 +/- 5%, resp., means +/- SE, P less than 0.01), 2 mg kg-1 and 4 mg kg-1 had no significant effect. Disopyramide influenced myocardial function already at 4 mg kg-1 (peak LVSP 88 +/- 4%, P less than 0.05, peak dp/dt max 64 +/- 7%, P less than 0.01, means +/- SE), 8 mg kg-1 had an even more marked depressive effect (peak LVSP 81 +/- 4%, peak dp/dt max 50 +/- 8%, means +/- SE, P less than 0.01). 5 mg kg-1 and 10 mg kg-1 quinidine both decreased peak LVSP and peak dp/dt max (91 +/- 3% and 92 +/- 1%, resp., and 80 +/- 5% and 74 +/- 6% means +/- SE, P less than 0.05). Thus, disopyramide had the most marked negative inotropic potential of the investigated class-I-antiarrhythmic drugs.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Electrophysiological and hemodynamic disturbances in a patients overdosed with disopyramide.

Disopyramide exerts a quinidinelike effect on the heart and is a valuable drug for treating atrial and, especially, ventricular tachyarrhythmias. The therapeutic plasma concentration of disopyramide is thought to be 2.0-4.0 (5.0) microgram/ml. We here report the cardiac effects of a high dose of disopryamide in a patient with extensive coronary artery disease complicated by ventricular extrasystoles. At plasma levels above approximately 7.0 micrograms/ml, heart rate was decreased, while PQ interval, width, and QT interval were increased. At concentrations above approximately 6.0 micrograms/ml, disopyramide exerted negative intropic effects as judged by increases in mean right atrial, pulmonary arteriolar, and pulmonary capillary venous pressures and a decrease in cardiac output.

Adult↗

Disopyramide and quinidine bind with inverse selectivity to muscarinic receptors in cardiac and extracardiac rat tissues.

We investigated the interactions of disopyramide and quinidine with the muscarinic receptor in tissue homogenates from rat atrium, ventricle, cortex, submandibular gland, and urinary bladder by means of competition binding experiments, using the tritium-labeled antagonist N-methyl-4-piperidyl benzilate. The drugs displayed heterogeneous characteristics of binding to the muscarinic receptors in the different tissues. The binding affinity of quinidine to the muscarinic receptor in atrial tissue was five to 10 times greater than in the other tissues studied, whereas the affinity of disopyramide to the muscarinic receptor in the heart was five times lower than in the other tissues. This inverse selectivity shown by the two drugs in their binding to cardiac and to noncardiac tissues may explain the extracardiac antimuscarinic side effects of treatment with disopyramide and their absence with quinidine.

Animals↗

Antiarrhythmic effects of combined application of class I antiarrhythmic drugs; addition of low-dose mexiletine-enhanced antiarrhythmic effects of disopyramide and aprindine in various-rate canine ventricular tachycardias.

We examined the possible beneficial effects of combined application of class I drugs using digitalis-induced and two-stage coronary ligation-induced canine ventricular arrhythmia models. Combination treatment with disopyramide (0.3 mg/kg/min for 10 min) and mexiletine (0.3 mg/kg/min for 5 min) enhanced the antiarrhythmic effect of a single treatment of disopyramide (0.3 mg/kg/min for 10 min). Combination treatment with aprindine (0.1 mg/kg/min for 10 min) and mexiletine (0.3 mg/kg/min for 5 min) enhanced antiarrhythmic effects of a single treatment of aprindine (0.1 mg/kg/min for 10 min) on digitalis and 24-h two-stage coronary ligation-induced arrhythmia models, but in the 48-h two-stage coronary ligation-induced arrhythmia model, a slow ventricular tachycardia (VT) model, addition of mexiletine to aprindine caused no enhancement of antiarrhythmic effects. The results support those of a previous electrophysiologic study of combination treatment with class I drugs in which disopyramide and mexiletine acted additively but aprindine and mexiletine did not act additively when the ventricular preparation was driven at slow rates. Total heart rate (HR) and mean blood pressure (MAP) were not influenced by additional application of mexiletine.

Animals↗

Disopyramide hepatotoxicity and disseminated intravascular coagulation.

A 55-year-old white woman had severe hepatocellular damage after taking disopyramide. Simultaneously, disseminated intravascular coagulation developed with thrombocytopenia, prolonged prothrombin time, and elevated fibrin split products. Both problems gradually subsided 14 days after cessation of disopyramide therapy. This case report shows that disopyramide can have the serious side effect of hepatocellular toxicity and provides evidence of the association of hepatocellular damage and disseminated intravascular coagulation.

Chemical and Drug Induced Liver Injury↗

Use of silica gel with aqueous eluent for simultaneous high performance liquid chromatographic assay of disopyramide and mono-N-dealkyldisopyramide.

Disopyramide and its pharmacologically active metabolite, mono-N-dealkyldisopyramide, were determined simultaneously in serum by high performance liquid chromatography using a bare (unbonded) silica gel with aqueous eluents. p-Chlorodisopyramide was used as the internal standard. Separations of all compounds, which contain amine moiety in their chemical structures, were easily accomplished with a good peak symmetry on silica. The method is sufficiently precise, sensitive, and specific. Analytical recoveries of all compounds were greater than 96%; CVs for reproducibility were less than 6.5% for disopyramide and mono-N-dealkyldisopyramide; the lower detection limits of both analytes were 0.05 mg/L. Comparison of the present method with a fluorescence polarization immunoassay for disopyramide gives a good correlation (r = 0.992).

Chromatography, High Pressure Liquid↗

Rapid sample preparation and high performance liquid chromatographic determination of total and unbound serum disopyramide.

A rapid sample preparation procedure, which requires no solvent extraction or concentration, for the high performance liquid chromatographic (HPLC) determination of disopyramide is described. The chromatography is performed on a C-18 radial compression mu-Bondapak column and detection by absorbance at 254 nm with a run time of 12 min. The mobile phase is 10 mM sodium acetate (pH 4.5)/acetonitrile (3:1 vol/vol). For the total drug assay, 50 microliter 30% (wt/vol) trichloroacetic acid is added to 500 microliter serum, which causes the precipitation of protein. Following centrifugation, 100 microliter of supernatant is mixed with 25 microliters of internal standard (25 micrograms/ml, ethyl p-aminobenzoate), and 50 microliters of this mixture is injected into the HPLC. Unbound disopyramide is separated from protein-bound drug by filtration with an Amicon Centrifree filter, which removes 99.6% of protein and does not retain disopyramide. To 100 microliters of this filtrate is added 25 microliters of internal standard, and 50 microliters is injected into the HPLC. The assay is linear to at least 20 micrograms/ml. The total drug assay shows an average recovery of 93.0% with an average coefficient of variation (CV) of 3.4%. The unbound drug assay shows an average CV of 4.1%. The percentage of free drug in a sample containing 4.85 g/dl protein varies from 68.0 to 83.5% at concentrations of 2.5-10 micrograms/ml, which illustrates the concentration-dependent nature of the protein binding, and the need to measure the unbound fraction of drug. Of 31 drugs tested for interference, none was found to interfere.

Chromatography, High Pressure Liquid↗

Binding of disopyramide, methadone, dipyridamole, chlorpromazine, lignocaine and progesterone to the two main genetic variants of human alpha 1-acid glycoprotein: evidence for drug-binding differences between the variants and for the presence of two separate drug-binding sites on alpha 1-acid glycoprotein.

Human alpha 1-acid glycoprotein (AAG), a plasma drug transport protein, has three main genetic variants, the A variant and the F1 and S variants, which are encoded by two different genes. The binding of disopyramide, methadone, dipyridamole, chlorpromazine, lignocaine and progesterone to the two main gene products of AAG-the A variant and a mixture of the F1 and S variants (60% F1 and 40% S)-separated by chromatography from native commercial AAG, a mixture of almost equal proportions of the F1, S and A variants, was studied by equilibrium dialysis. A selective binding of disopyramide and methadone to the A variant and a preferential binding of dipyridamole to the F1S variant mixture were found. Lignocaine and chlorpromazine had a slight preference for binding to the A variant and to the F1S mixture, respectively, but progesterone showed no selectivity with regard to any of the variants of AAG. The differences in drug-binding demonstrated between the A variant and the F1S mixture confirmed those of a previous study, in which a selective binding of imipramine to the A variant and of warfarin and mifepristone to the F1S mixture have been found. These results indicate specific drug transport roles for each AAG variant, according to its separate genetic origin. The results of control binding experiments performed with (unfractionated) commercial AAG and the series of tested ligands concurred with that for the separate AAG variants, with respect to the proportion of the A variant (27%) and that of the F1 and S variants (73%) in the commercial protein. In addition, disopyramide, methadone, dipyridamole, chlorpromazine, lignocaine and progesterone were used in equilibrium dialysis displacement experiments to study interactions on binding sites labelled with imipramine for the A variant and with warfarin for the F1S variant mixture. The four latter ligands were found to competitively inhibit the binding of warfarin to the F1S variant mixture and all of them that of imipramine to the A variant. The ligands association constants to each AAG variant obtained from such inhibitory experiments were comparable to those determined in the direct binding studies. As the stochlometry of the interactions of the A variant and the F1S variants, respectively, with their specific ligands was approximately one (1), it was concluded that these ligands bind to each of these variants via a single common binding site. These results indicate that the AAG molecule would have for its ligands at least two separate binding sites, showing different specificity and localization, and not one site, as it is generally assumed. The possible pharmacological and clinical consequences of the binding results with the separate AAG variants are discussed.

Binding, Competitive↗

Kinetics of hemodynamic and electrocardiographic changes following intravenous disopyramide.

Changes in hemodynamic and ECG variables following disopyramide (1.7 mg = 3.9 mmol/kg b.wt.) were studied in 9 patients with ventricular arrhythmias. All patients displayed a marked reduction in the number of ventricular ectopic beats, all except one exhibiting complete abolition of the arrhythmia for at least 30 min. QT and QRS intervals showed statistically significant prolongations, and thereafter decreased exponentially with time. Above a certain concentration threshold that varied between the patients, systolic time intervals and aortic (dp/dt)max showed linear changes with increasing drug serum levels. Changes in diastolic pulmonary artery pressure showed no simple relationship with disopyramide concentration or time after injection. In 3 out of 4 patients studied, there was a good correlation between the lowest level of disopyramide that elicited both an antiarrhythmic effect and a demonstrable decrease in cardiac contractility.

Adult↗

Disopyramide serum and pharmacologic effect kinetics applied to the assessment of bioavailability.

1 Serum, urine and pharmacologic effect (prolongation of the QT interval) kinetics of the antiarrhythmic disopyramide have been investigated in eight volunteers after intravenous administration (2 mg/kg) and oral administration (300 mg) of the two commercially available preparations, Rythmodan (Roussel Laboratories) and Norpace (Searle Laboratories). 2 An open one compartment body model adequately described the kinetics of disopyramide in serum and urine. 3 After intravenous administration, the following average pharmacokinetic parameters were found: biological half-life, 7.8 h; total clearance, 95 ml/min; renal clearance, 54 ml/min; apparent volume of distribution, 60 litres. 4 After oral Rythmodan and Norpace, serum concentration profiles and urinary excretion data revealed significant differences in rates of absorption, times required to achieve peak serum concentrations and biological half-lives. These differences were largely due to the relatively slow absorption characteristics of Norpace. 5 The absence of hysteresis in plots of QT prolongation against disopyramide serum concentration after oral administration indicated that serum and pharmacologic effect kinetics were indistinguishable within a kinetically equivalent compartment. 6 Analysis of both serum and urine data showed that while Norpace had a significantly higher degree of bioavailability (P less than 0.005), the 5--15% difference between the two formulations should not normally be of any clinical significance.

Administration, Oral↗

Maintenance therapy after i.v. administration of disopyramide with an oral sustained release preparation, a pharmacokinetic study.

The blood levels in 20 patients were studied during the change from parenteral administration of disopyramide to an oral sustained release preparation containing the same active substance. From this study it is concluded that 100 mg i.v. bolus injection of disopyramide can safely be followed by the immediate administration of one sustained release tablet containing 250 mg disopyramide. In case of an i.v. infusion (0.4 mg kg-1h-1) it seems wise not to start earlier with the administration of the sustained release preparation than at the moment of stopping the infusion.

Administration, Oral↗

Comparative haemodynamic effects of intravenous lignocaine, disopyramide and flecainide in uncomplicated acute myocardial infarction.

A prospective study evaluated the comparative haemodynamic effects of three Class I antiarrhythmics (lignocaine Class 1B, disopyramide Class 1A and flecainide Class 1C) in 30 patients with uncomplicated acute myocardial infarction. Three groups, each of 10 patients, were allocated to lignocaine (Group I) 1.5 mg kg-1 i.v. loading dose over 10 min followed by infusion at 3 mg kg-1 h-1, disopyramide (Group II) or flecainide (Group III), both administered as a 1.0 mg kg-1 i.v. loading bolus over 10 min followed by a 1.6 mg kg-1 h-1 infusion for 120 min. The plasma levels of each drug were in the described therapeutic range. Lignocaine decreased cardiac index (-0.3 l min-1 m-2 (9%); P less than 0.05) and stroke volume index (-5 ml m-2 (11%); P less than 0.01). Systemic blood pressure, heart rate and systemic vascular resistance index were unchanged. There was a small increase (+3 mm Hg (30%); P less than 0.01) in pulmonary artery occluded pressure (PAOP). Both disopyramide and flecainide increased systemic blood pressure; the maximum increases for mean blood pressure were +10 mm Hg (11%) and +4 mm Hg (4%) respectively. Both drugs reduced cardiac index (-0.5 l min-1 m-2 (16%): -0.4 l min-1 m-2 (11%)) and stroke volume index (-11 ml m-2 (25%): -5 ml m-2 (11%)). There were increases in heart rate (+13: +5 beats min-1) pulmonary artery occluded pressure (+2: +3 mm Hg) and systemic vascular resistance index (+696: +275 dyn s cm-5 m2).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Plasma protein binding of disopyramide in pregnant and postpartum women, and in neonates and their mothers.

1. The protein binding of disopyramide was measured in plasma obtained from nonpregnant women, pregnant women in the first, second, and third trimesters, matched pairs of mothers and neonates (cord plasma), and 1 month postpartum women (n = 6 or 8 of each). 2. Plasma samples spiked with 0.2-12.0 micrograms ml-1 of the drug were ultrafiltered and the free fractions were measured with a fluorescent polarization immunoassay. 3. The mean (+/- s.d.) percentages of free drug at a total concentration of 3.0 micrograms ml-1 observed in the third trimester (46 +/- 9%) and neonate (79 +/- 5%) groups were greater (P less than 0.05 or 0.01) than that in the non-pregnant group (34 +/- 7%). In contrast, the corresponding value observed in the postpartum group (23 +/- 8%) was less (P less than 0.05) than that in the non-pregnant group. In addition, there was a significant (P less than 0.01) difference in the mean percentage of free drug at 3.0 micrograms ml-1 in plasma from mothers (43 +/- 9%) and neonates (79 +/- 5%). 4. A multiple regression analysis indicated that alpha 1-acid glycoprotein (r = -0.88, P less than 0.01), rather than albumin (r = -0.008), dominated the binding of disopyramide within the therapeutic range of drug concentration. An analysis of the binding parameters of disopyramide suggested that alterations in binding were attributable to changes in the capacity rather than the affinity of binding.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Effects of quinidine and disopyramide on serum digoxin concentrations.

Although quinidine and digoxin are frequently given together, it has only recently become apparent that serum digoxin concentration may rise during quinidine treatment. A prospective study was performed to compare the effects of quinidine and disopyramide in patients receiving maintenance digoxin therapy. During quinidine administration serum digoxin concentration rose by more than 50% in seven of nine patients (the mean concentration rising from 1.43 +/- 0.20 to 2.61 +/- 0.43 nmol/l, P < 0.005). During the disopyramide treatment a small rise in serum digoxin was noted (mean 1.3 +/- 0.16 to 1.5 +/- 0.19 nmol/l, P < 0.05). We suggest that digoxin doses should be reduced immediately prior to commencing quinidine therapy in patients already receiving adequate maintenance digoxin, and patients should be followed carefully for evidence of digoxin toxicity. Disopyramide appears a suitable alternative anti-arrhythmic drug to quinidine in patients on maintenance digoxin.

Adult↗

The antiarrhythmic effect of intravenous disopyramide in an open study.

The antiarrhythmic effect of intravenous disopyramide phosphate was assessed in a multicentre open study of 141 patients admitted to coronary care units. Disopyramide was administered in a bolus dose of 2 mg/kg over 10 min with an optional second bolus of 1 mg/kg and infusion of 0.4 mg/kg hour. Atrial fibrillation was terminated in 57% of 56 patients, supraventricular tachycardia in 82% of 11 patients, ventricular tachycardia in 88% of 17 patients and premature ventricular contractions were controlled in 85% of 55 patients. Atrial flutter was terminated in only 2 of 17 patients (12%). Side effects occurred in 38% of the patients, the most frequent being those relating to anticholinergic properties of the drug (15%) or systemic hypotension (13%). Occasionally worsening of the arrhythmia (4%), QRS widening (3) or apparent hypertension (2%) were noted. It was concluded that intravenous disopyramide is an effective antiarrhythmic agent in the coronary care unit setting, but that side effects require close monitoring of dosage.

Adolescent↗

A COMPARISON OF THE ANTIFIBRILLATORY ACTIONS AND EFFECTS ON INTRACELLULAR CARDIAC POTENTIALS OF PRONETHALOL, DISOPYRAMIDE AND QUINIDINE.

A quantitative comparison of the effects of quinidine, pronethalol and gamma-di-isopropylamino-alpha-phenyl-alpha-pyrid-2-ylbutyramide (disopyramide) has been made on rabbit isolated atria. All three drugs raised the electrical threshold and reduced the contractions, the conduction velocity and the maximal frequency at which the atria would follow a stimulus. The descending order of potency was pronethalol, quinidine and disopyramide, but the range was small, pronethalol having about twice the activity of disopyramide. Both the new compounds affected intracellular potentials in the same way as quinidine, causing little change in the resting potential or duration of the action potential, but reducing the overshoot potential and slowing the rate of rise of the action potential. These results support the view that interference with depolarization is an essential feature of antifibrillatory activity.

Action Potentials↗