Table 7

Ongoing Drug Therapy for SVT, Oral Administration

DrugInitial Daily Dose(s)Maximum Total Daily Maintenance DosePotential Adverse EffectsPrecautions (Exclude or Use With Caution) and Interactions
Beta blockers
Atenolol25–50 mg QD100 mg QD
(reduced dosing in patients with severe renal dysfunction)
Hypotension, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF

  • Hypotension

  • Reactive airway disease

  • Severe renal dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

Metoprolol tartrate25 mg BID200 mg BIDHypotension, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF

  • Hypotension

  • Reactive airway disease

  • Drugs with SA and/or AV nodal–blocking properties

Metoprolol succinate (long-acting)50 mg QD400 mg QDHypotension, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF

  • Hypotension

  • Reactive airway disease

  • Drugs with SA and/or AV nodal–blocking properties

Nadolol40 mg QD320 mg QD
(reduced dosage with renal impairment)
Hypotension, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Reactive airway disease

  • Cardiogenic shock

  • Decompensated HF

  • Hypotension

  • Renal dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

Propranolol30–60 mg in divided or single dose with long-acting formulations40–160 mg in divided or single dose with long-acting formulationsHypotension, worsening HF, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Reactive airway disease

  • Decompensated systolic HF

  • Hypotension

  • Drugs with SA and/or AV nodal–blocking properties

Nondihydropyridine calcium channel antagonists
Diltiazem120 mg daily in divided or single dose with long-acting formulations360 mg daily in divided or single dose with long-acting formulationsHypotension, worsening HF in patients with pre-existing ventricular dysfunction, bradycardia, abnormal liver function studies, acute hepatic injury (rare)
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Hypotension

  • Decompensated systolic HF/severe LV dysfunction

  • WPW with AF/atrial flutter

  • Drugs with SA and/or AV nodal–blocking properties

  • Diltiazem is a substrate of CYP3A4 (major) and a moderate CYP3A4 inhibitor

  • Apixaban, itraconazole, bosutinib, ceritinib, cilostazol, cyclosporine, everolimus, ibrutinib, idelalisib, ivabradine, lomitapide, olaparib, ranolazine, rifampin, simeprevir

Verapamil120 mg daily in divided or single dose with long-acting formulations480 mg daily in divided or single dose with long-acting formulationsHypotension, worsening HF in patients with pre-existing ventricular dysfunction, pulmonary edema in patients with hypertrophic cardiomyopathy, bradycardia, abnormal liver function studies
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF/severe LV dysfunction

  • Hypotension

  • WPW with AF/atrial flutter

  • Verapamil is a moderate CYP3A4 inhibitor and also inhibits P-glycoprotein

  • Contraindicated with dofetilide

  • Itraconazole, bosutinib, ceritinib, cilostazol, colchicine, cyclosporine, everolimus, dabigatran, edoxaban, flecainide, ibrutinib, ivabradine, olaparib, ranolazine, rivaroxaban, rifampin, silodosin, simeprevir, rivaroxaban, rifampin, simvastatin, topotecan, trabectedin, vincristine, grapefruit juice

Cardiac glycosides
DigoxinLoading: 0.5 mg, with additional 0.125–0.25-mg doses administered at 6–8-h intervals until evidence of adequate effect (maximum dose 8–12 mcg/kg over 24 h)0.25 mg QD
Maintenance: 0.125–0.25 mg QD, with dosing based on patient’s age, lean body weight, and renal function and drug interactions; occasionally down to 0.0625 mg in cases of renal impairment (trough serum digoxin level 0.5 to 1 ng/mL)
Bradycardia, heart block, anorexia, nausea, vomiting, visual changes and cardiac arrhythmias in cases of digoxin toxicity (associated with levels >2 ng/mL, although symptoms may also occur at lower levels)
  • Renal dysfunction

  • WPW with AF/atrial flutter

  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Drugs with SA and/or AV nodal–blocking properties

  • Reduce dose by 30%–50% when administering with amiodarone and by 50% when administering with dronedarone

  • Monitor digoxin concentrations with verapamil, clarithromycin, erythromycin, itraconazole, cyclosporine, propafenone, flecainide

Class Ic antiarrhythmic agents
Flecainide50 mg every 12 h150 mg every 12 h
(PR and QRS intervals should be monitored. May consider monitoring flecainide plasma levels, keeping trough plasma levels below 0.7–1.0 mcg/mL)
Atrial flutter with 1:1 AV conduction, QT prolongation, torsades de pointes, worsening HF, bradycardia
  • Sinus or AV conduction disease (in absence of pacemaker)

  • Cardiogenic shock

  • Avoid in structural heart disease (including ischemic heart disease)

  • Atrial flutter (unless concomitant AV nodal therapy to avoid 1:1 conduction)

  • Brugada syndrome

  • Renal dysfunction

  • Hepatic dysfunction

  • QT-prolonging drugs

  • Amiodarone, digoxin, ritonavir, saquinavir, tipranavir

Propafenone150 mg every 8 h (immediate release);
225 mg every 12 h (extended release)
300 mg every 8 h (immediate release);
425 mg every 12 h (extended release)
(PR and QRS interval should be monitored. Consider dosage reduction with hepatic impairment)
Atrial flutter with 1:1 AV conduction, QT prolongation, torsades de pointes, bradycardia, bronchospasm
  • Sinus or AV conduction disease (in absence of pacemaker)

  • Cardiogenic shock

  • Hypotension

  • Reactive airway disease Avoid in structural heart disease (including ischemic heart disease)

  • Atrial flutter (unless concomitant AV nodal therapy to avoid 1:1 conduction)

  • Brugada syndrome

  • Hepatic dysfunction

  • QT-prolonging drugs

  • Drugs with SA and/or AV nodal–blocking properties

  • Amiodarone, ritonavir, saquinavir, tipranavir

Class III antiarrhythmic agents
Amiodarone400–600 mg QD in divided doses for 2-4 wk (loading dose); followed by 100–200 mg QD (maintenance dose)Up to 1200 mg QD may be considered in an inpatient monitoring setting (loading dose); up to 200 mg QD maintenance (to minimize long-term adverse effects)Bradycardia, QT prolongation, torsades de pointes (rare), gastrointestinal upset, constipation, hypothyroidism, hyperthyroidism, pulmonary fibrosis, hepatic toxicity, corneal deposits, optic neuritis, peripheral neuropathy, photosensitivity, adult respiratory distress syndrome after cardiac or noncardiac surgery (rare)
  • Sinus or AV conduction disease (in absence of pacemaker)

  • Inflammatory lung disease

  • Hepatic dysfunction

  • Hypothyroidism, hyperthyroidism

  • Peripheral neuropathy

  • Abnormal gait/ataxia

  • Optic neuritis

  • Drugs with SA and/or AV nodal–blocking properties

  • Amiodarone is a substrate of and inhibits P-glycoprotein and CYP2C9 (moderate), CYP2D6 (moderate), and CYP3A4 (weak); amiodarone is a substrate for CYP3A4 (major) and CYP2C8 (major); amiodarone is an inhibitor of OCT2

  • Reduce warfarin dose by 50%, and reduce digoxin dose by 30%–50%

  • Agalsidase alfa, agalsidase beta, azithromycin, bosutinib, ceritinib, colchicine, dabigatran, edoxaban, flecainide, ivabradine, ledipasvir/sofosbuvir, lopinavir, lopinavir/ritonavir, lovastatin, nelfinavir, pazopanib, propafenone, simvastatin, ritonavir, rivaroxaban, saquinavir, sofosbuvir, topotecan, vincristine, grapefruit juice

Dofetilide
  • 500 mcg every 12 h (if CrCl >60 mL/min)

  • 250 mcg every 12 h (if CrCl 40–60 mL/min)

  • 125 mcg every 12 h (if CrCl 20 to <40 mL/min)

  • Not recommended if CrCl <20 mL/min

  • Adjust dose for renal function, body size, and age

  • Initiate for minimum of 3 d in a facility that can provide continuous ECG monitoring and cardiac resuscitation

  • Contraindicated if the baseline QTc interval or QTc >440 ms or 500 ms in patients with ventricular conduction abnormalities

Repeat ECG 2–3 h after administering the first dose to determine QTc; if the QTc increased by >15% compared with baseline or if QTc is >500 ms (550 ms in patients with ventricular conduction abnormalities), subsequent dosing should be down titrated by 50%; at 2–3 h after each subsequent dose, determine QTc (for in-hospital doses 2–5); if at any time after the second dose the QTc is >500 ms (550 ms in patients with ventricular conduction abnormalities), dofetilide should be discontinuedQT prolongation, torsades de pointes
  • Severe renal dysfunction (contraindicated if CrCl <20 mL/min)

  • Prolonged QT

  • History of torsades de pointes

  • Concomitant use of hydrochlorothiazide, cimetidine, dolutegravir, itraconazole, ketoconazole, megestrol, trimethoprim, prochlorperazine trimethoprim/sulfamethoxazole or verapamil, contraindicated

  • Avoid other QT-prolonging drugs

Sotalol40–80 mg every 12 h
(Patients initiated or reinitiated on sotalol should be placed in a facility that can provide cardiac resuscitation and continuous electrocardiographic monitoring for a minimum of 3 d).
Contraindicated if the QTc interval is >450 ms.
CrCl should be calculated before dosing. If CrCl >60 mL/min, then dosing frequency is twice daily. If CrCl 40-60 mL/min, dosing interval is every 24 h. If CrCl <40 mL/min, should not be used.)
160 mg every 12 h
(During initiation and titration, the QT interval should be monitored 2–4 h after each dose. If the QT interval prolongs to ≥500 ms, the dose must be reduced or the drug discontinued.)
QT prolongation, torsades de pointes, bradycardia, bronchospasm
  • Prolonged QT

  • Renal dysfunction

  • Hypokalemia

  • Diuretic therapy

  • Avoid other QT-prolonging drugs

  • Sinus or AV nodal dysfunction (in absence of pacemaker)

  • Decompensated systolic HF

  • Cardiogenic shock

  • Reactive airway disease

  • Drugs with SA and/or AV–nodal blocking properties

Miscellaneous
Ivabradine5 mg BID7.5 mg BIDPhosphenes, AF
  • Concomitant drugs that can exacerbate bradycardia

  • Contraindicated in decompensated HF

  • Contraindicated if BP <90/50 mm Hg

  • Contraindicated in severe hepatic impairment

  • Hypertension

  • Ivabradine is a substrate of CYP3A4 (major)

  • Avoid use with concomitant strong CYP3A4 inhibitors (boceprevir, clarithromycin, indinavir, itraconazole, lopinavir/ritonavir, nelfinavir, ritonavir, saquinavir, telaprevir, posaconazole, voriconazole)

  • Avoid use with strong CYP3A4 inducers (carbamazepine, phenytoin, rifampin, St. John’s wort)

  • Avoid use with diltiazem, verapamil, grapefruit juice

Note: For this reference table, drugs are presented in alphabetical order within the drug classes, not by COR and LOE.

AF indicates atrial fibrillation; AV, atrioventricular; BID, twice daily; BP, blood pressure; CrCl, creatinine clearance; ECG, electrocardiogram/electrocardiographic; HF, heart failure; INR, international normalized ratio; LV, left ventricular; QD, once daily; QID, 4 times a day; QTc, corrected QT interval; SA, sinoatrial; SVT, supraventricular tachycardia; TID, 3 times a day; and WPW, Wolff-Parkinson-White.

  • When 1 drug is used in combination with other drugs, appropriate dosing adjustments should be made with consideration of at least additive effects during dosage titration. All potential drug–drug interactions and adverse reactions are not included in this list. For a more detailed list of drug interactions and adverse responses, clinicians should consult additional resources; for example, www.crediblemeds.org may be consulted for potential prolongation of the QT interval.

  • QTc calculation used the Bazett’s Formula in most clinical studies.

  • Recommended given in conjunction with a beta blocker or nondihydropyridine calcium channel antagonist.