Flecainide poisoning and prolongation of elimination due to alkalinization

• Published in: The American journal of emergency medicine 2022-06, Vol.56, p.394.e1-394.e4
• Main Authors: McCabe, Daniel J., Walsh, Rachel D., Georgakakos, Peter K., Radke, Joshua B., Wilson, Bryan Z.
• Format: Article
• Language: English
• Subjects: Alkalinization; Anti-Arrhythmia Agents - therapeutic use; Arrhythmia; Arrhythmias, Cardiac; Cardiac arrhythmia; Cardiovascular disease; Case reports; Dosage; Drug Overdose - drug therapy; Electrocardiography; Emergency medical care; Fatalities; Flecainide - therapeutic use; Humans; Hypotension; Ingestion; Intubation; Overdose; Patients; Pharmacokinetics; Resuscitation; Sodium; Sodium bicarbonate; Sodium Bicarbonate - therapeutic use; Tachycardia; Toxicity; Toxicology; Urine; Ventricle
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2022.03.006

Flecainide is a 1C antidysrhythmic that is primarily used for ventricular tachycardia or premature ventricular contractions when other treatment is ineffective. It has a very narrow therapeutic window which may cause death in a double dose and requires inpatient initiation for cardiac monitoring. Despite established pharmacokinetic data from flecainide in therapeutic dosing, there is negligible data on flecainide toxicokinetics after an intentional overdose. Due to the inherent differences in pharmacokinetic and toxicokinetic principles, rarely can the peak effect or elimination half-life accurately be applied to the poisoned patient after an overdose. In overdose, flecainide can cause a variety of fatal dysrhythmias which may require sodium bicarbonate for stabilization but also may reduce the renal elimination of flecainide, meaning the life-saving treatment may prolong the time of toxicity. We present a case of an acute ingestion of flecainide with a known time of ingestion and known amount of ingestion who experienced subsequent life-threatening effects which required endotracheal intubation, sodium bicarbonate, aggressive electrolyte repletion, and multiple days in an intensive care unit. Serial serum and urine samples revealed a prolonged toxic serum concentration of flecainide. These results demonstrate the change in elimination kinetics of flecainide in the setting of urinary alkalization which is evident through prolonged morphologic changes present on serial electrocardiograms.