dronedarone

Absorption: Poor bioavailability (4%) due to extensive first-pass hepatic metabolism (4%); food ↑ bioavailability (15%).

Distribution: Unknown.

Protein Binding: >98%.

Metabolism/Excretion: Undergoes extensive first-pass hepatic metabolism; mostly by the CYP3A isoenzyme. 6% excreted in urine as metabolites; 84% excreted in feces as metabolites. Minimal elimination as unchanged drug.

Half-Life: 13–19 hr.

Time/Action Profile ⬆ ⬇

(antiarrhythmic effect)

ROUTE	ONSET	PEAK	DURATION
PO	unknown‡	3–6 hr‡	12 hr

‡Steady state blood levels are attained at 4–8 days.

‡Peak levels after individual doses.

Contraind./Precautions ⬆ ⬇

Contraindicated in:

New York Heart Association Class IV HF or New York Heart Association Class II–III HF with recent decompensation requiring hospitalization (↑ risk of mortality)
;
Permanent AF (↑ risk of mortality, stroke, and hospitalization for HF)
;
2nd- or 3rd-degree heart block or sick sinus syndrome (unless a pacemaker is present);
HR <50 bpm;
Concurrent use of strong CYP3A inhibitors or drugs that prolong QT interval;
Liver or lung toxicity related to previous amiodarone use;
QTc interval ≥500 msec;
PR interval >280 msec;
Concurrent use of Class I or III antiarrhythmics, including amiodarone, flecainide, propafenone, quinidine, disopyramide, dofetilide, and sotalol; must be discontinued prior to treatment;
Severe hepatic impairment;
OB: Pregnancy;
Lactation: Lactation.

Use Cautiously in:

New/worsening HF;
Hypokalemia or hypomagnesemia (may ↑ risk of arrhythmias);
Mild or moderate hepatic impairment;
Rep: Women of reproductive potential;
Pedi: Safety and effectiveness not established in children;
Geri:
Appears on Beers list. Worse outcomes in patients with permanent atrial fibrillation or HF. Avoid use in older adults with permanent AF or HF
.

Adv. Reactions/Side Effects ⬆ ⬇

CV: HF, QT interval prolongation

Derm: photosensitivity

GI: abdominal pain, diarrhea, vomiting, HEPATOTOXICITY, nausea, taste abnormality

GU: ACUTE RENAL FAILURE, renal impairment

Neuro: weakness

Resp: PNEUMONITIS, PULMONARY FIBROSIS

Misc: ANGIOEDEMA

Interactions ⬆ ⬇

Drug-drug:

Strong CYP3A inhibitors, including ketoconazole, itraconazole, voriconazole, cyclosporine, clarithromycin, nefazodone, and ritonavir, or QT interval prolonging drugs, including phenothiazines, tricyclic antidepressants, and other Class I and III antiarrhythmics, may ↑ risk of serious adverse cardiovascular reactions; concurrent use contraindicated.
CYP3A4 inducers, including rifampin, phenobarbital, carbamazepine, or phenytoin, ↓ levels and effectiveness; avoid concurrent use.
May ↑ digoxin levels and risk of toxicity; ↓ digoxin dose by 50% before treatment and monitor carefully.
May ↑ dabigatran levels and risk of bleeding; ↓ dabigatran dose to 75 mg twice daily in patients with moderate renal impairment (CCr 30–50 mL/min); avoid concurrent use in severe renal impairment (CCr 15–30 mL/min).
May ↑ warfarin levels and risk of bleeding; closely monitor INR.
Diltiazem, verapamil, digoxin, or beta blockers may ↑ risk of bradycardia; initiate at lower dose and ↑ only after ECG evaluation.
May ↑ levels and risk of toxicity of tricyclic antidepressants and SSRIs.
May ↑ levels and risk of toxicity of some statins; do not exceed simvastatin dose of 10 mg/day.
May ↑ levels and risk of toxicity of CYP3A substrates, including sirolimus and tacrolimus; monitor and adjust dosage carefully.

Drug-Natural Products:

St. John’s wort may ↓ levels and effectiveness; avoid concurrent use.

Drug-Food:

Grapefruit juice may ↑ levels and risk of toxicity; avoid concurrent use.

Route/Dosage ⬆ ⬇

PO (Adults ): 400 mg twice daily.

Availability ⬆ ⬇

Assessment ⬆ ⬇

Assess for signs and symptoms of AF (palpitations, abnormal ECG) periodically during therapy. If AF occurs, cardiovert or discontinue dronedarone.
Monitor ECG periodically and at least every 3 mo during therapy. If QTc interval ≥500 msec or PR interval >280 msec, discontinue therapy.
Assess for signs and symptoms of hepatic injury (anorexia, nausea, vomiting, fever, malaise, fatigue, right upper quadrant pain, jaundice, dark urine, itching) during therapy. If hepatic injury suspected, discontinue therapy and test serum enzymes (AST, ALT), alkaline phosphatase, and serum bilirubin to determine liver injury. If liver injury occurs, begin treatment. Do not restart therapy without another explanation for liver injury.
Assess for signs of pulmonary toxicity (dyspnea, nonproductive cough) periodically during therapy. If pulmonary toxicity occurs, discontinue therapy.

Lab Test Considerations:

Monitor serum hepatic enzymes periodically, especially during 1st 6 mo of therapy.
- Verify negative pregnancy test before starting therapy.
- Monitor serum potassium and magnesium levels during therapy and maintain within normal range. May cause hypokalemia and hypomagnesemia.
- Monitor serum creatinine levels periodically during therapy. Serum creatinine levels ↑ by about 0.1 mg/dL following initiation of therapy with a rapid onset and plateau after 7 days; reversible with discontinuation. If ↑ and plateau occurs, use increased value as new baseline.

Implementation ⬆ ⬇

Patient should be on concurrent antithrombotic therapy.
PO: Administer twice daily with morning and evening meals.

Patient/Family Teaching ⬆ ⬇

Instruct patient to take dronedarone as directed. Do not stop taking dronedarone, even if feeling better, without consulting health care provider. If a dose is missed, omit and take next dose at regularly scheduled time; do not double dose. Advise patient to read Medication Guide before starting therapy and with each Rx refill in case of changes.
Advise patient to avoid grapefruit juice during therapy; may ↑ drug levels.
Advise patient to notify health care provider if signs and symptoms of HF (weight gain, dependent edema, increasing shortness of breath), hepatic injury, or pulmonary toxicity occur.
Instruct patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care provider before taking other medications, especially St. John's wort.
Rep: May cause fetal harm. Advise women of reproductive potential to use effective contraception during and for 5 days after last dose of therapy and to avoid breastfeeding during and for 5 days after last dose. Advise women of reproductive potential to notify health care provider if pregnancy is planned or suspected.

section name header

Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇