KWIN-i-deen

quinidine gluconate
KWIN-i-deen GLUE-con-ate

• Quinaglute

quinidine sulfate
KWIN-i-deen SUL-fate

• Quinidex

Pregnancy Category
Category C

Ther. class.
antiarrhythmics
(class IA)

• Restoration and maintenance of sinus rhythm in patients with atrial fibrillation or flutter.

• Prevention of recurrent ventricular arrhythmias.

• Treatment of malaria.

• Decrease myocardial excitability.

• Slow conduction velocity.

Therapeutic Effect(s):
Suppression of arrhythmias.

Absorption: Bioavailability of oral formulations is 70–80%. Extended-release preparations are absorbed slowly following oral administration.

Distribution: Widely distributed. Cross the placenta; enter breast milk.

Metabolism and Excretion: Metabolized by the liver; 5–20% excreted unchanged by the kidneys.

Half-life: 6–8 hr (↑ in HF or severe liver impairment).

TIME/ACTION PROFILE (antiarrhythmic effects)

ROUTE	ONSET	PEAK	DURATION
PO (sulfate)	30 min	1–1.5 hr	6–8 hr
PO (sulfate-ER)	unknown	4 hr	8–12 hr
PO (gluconate)	unknown	3–4 hr	6–8 hr
IV	1–5 min	rapid	6–8 hr

Contraindicated in:

• Hypersensitivity;

• Conduction defects (in the absence of a pacemaker);

• Myasthenia gravis.

Use Cautiously in:

• HF (dose reduction recommended);

• Severe liver disease (dose ↓ recommended);

• Hypokalemia or hypomagnesemia (↑ risk of torsades de pointes);

• Bradycardia (↑ risk of torsades de pointes);

• Renal impairment;

• OB: Lactation: Pedi: Safety not established; extended-release preparations should not be used in children.

CNS: dizziness, confusion, fatigue, headache, syncope, vertigo.

EENT: blurred vision, diplopia, mydriasis, photophobia, tinnitus.

CV: HYPOTENSION, TORSADES DE POINTES, arrhythmias, palpitations, tachycardia.

GI: anorexia, abdominal cramping, diarrhea, nausea, vomiting, drug-induced hepatitis.

Derm: rash.

Hemat: AGRANULOCYTOSIS, hemolytic anemia, thrombocytopenia.

Neuro: ataxia, tremor.

Misc: fever.

*CAPITALS indicates life-threatening.
*italic indicates most frequent.

Drug-Drug

• May ↑ risk of QT interval prolongation when used with tricyclic antidepressants , erythromycin , clarithromycin , haloperidol , sotalol , or fluoroquinolones .

• ↑ serum digoxin levels and may cause toxicity (dose reduction recommended).

• Phenytoin , phenobarbital , carbamazepine , or rifampin may ↑ metabolism and ↓ effectiveness.

• Cimetidine , diltiazem , verapamil , amiodarone , ketoconazole , itraconazole , and protease inhibitors ↓ metabolism and may ↑ blood levels.

• Excretion is delayed and effects ↑ by drugs that alkalinize the urine, including carbonic anhydrase inhibitors , thiazide diuretics , and sodium bicarbonate .

• Potentiates the effects of neuromuscular blocking agents and warfarin .

• Additive hypotension with antihypertensives , nitrates , and acute ingestion of alcohol .

• May increase procainamide , haloperidol , mexiletine , or tricyclic antidepressant levels and risk of toxicity.

• May antagonize anticholinesterase therapy in patients with myasthenia gravis.

• Additive anticholinergic effects may occur with agents having anticholinergic properties (including antihistamines , tricyclic antidepressants ).

Drug-Food

• Grapefruit juice ↑ serum levels and effect (avoid concurrent use).

• Foods that alkalinize the urine (see Food Sources for Specific Nutrients) may ↑ serum quinidine levels and the risk of toxicity.

Quinidine Gluconate (62% Quinidine)

• PO (Adults): 324–972 mg q 8–12 hr..

• IV (Adults): 200–400 mg given at a rate ≤10 mg/min until arrhythmia is suppressed, QRS complex widens, bradycardia or hypotension occurs..

Quinidine Sulfate (83% Quinidine)

• PO (Adults): Atrial/ventricular arrhythmias—200–400 mg q 4–6 hr; may be ↑ to achieve therapeutic response (not to exceed 3–4 g/day)..

• PO (Children): 6 mg/kg 4–5 times daily..

Quinidine Gluconate

• Extended-release tablets: 324 mg

• Solution for Injection: 80 mg/mL

Quinidine Sulfate

• Tablets: 200 mg, 300 mg

• Extended-release tablets: 300 mg

• In combination with: dextromethorphan hydrobromide (Nuedextra); see combination drugs.

• Monitor ECG, pulse, and BP periodically during therapy.

Lab Test Considerations

• Monitor hepatic and renal function, CBC, and serum potassium and magnesium levels periodically during prolonged therapy.

Toxicity and Overdose

• Serum quinidine levels may be monitored periodically during dose adjustment. Therapeutic serum concentrations are 2–6 mcg/mL. Toxic effects usually occur at concentrations >8 mcg/mL.

» Signs and symptoms of toxicity or cinchonism include tinnitus, hearing loss, visual disturbances, headache, nausea, and dizziness. These may occur after a single dose.

» Cardiac signs of toxicity include QRS widening, cardiac asystole, ventricular ectopic beats, idioventricular rhythms (ventricular tachycardia, ventricular fibrillation), paradoxical tachycardia, and torsades de pointes.

• Decreased cardiac output (Indications)

• Do not confuse quinidine with quinine.

• PO: Administer with a full glass of water on an empty stomach either 1 hr before or 2 hr after meals for faster absorption. If GI irritation becomes a problem, may be administered with or immediately after meals. Extended-release preparations should be swallowed whole; do not break, crush, or chew.

IV Adminstration:

• pH:
5.5–7.0.

• IV:
Use only clear, colorless solution.

• Intermittent Infusion:

Diluent: Dilute 800 mg of quinidine gluconate (10 mL) in 50 mL of D5W. Infusion is stable for 24 hr at room temperature or 48 hr if refrigerated.
Concentration: 16 mg/mL.

• Rate:
Administer quinidine gluconate at a rate not to exceed 0.25 mg/kg/min. Administer via infusion pump to ensure accurate dose. Rapid administration may cause peripheral vascular collapse and severe hypotension.

• Y-Site Compatibility:

» amikacin

» atropine

» bumetanide

» calcium gluconate

» caspofungin

» cimetidine

» cyclosporine

» digoxin

» diltiazem

» diphenhydramine

» dobutamine

» dopamine

» doxycycline

» enalaprilat

» epinephrine

» erythromycin

» esmolol

» famotidine

» fenoldopam

» fentanyl

» fluconazole

» gentamicin

» granisetron

» hydromorphone

» imipenem

» isoproterenol

» labetalol

» lidocaine

» linezolid

» lorazepam

» meperidine

» metoclopramide

» metoprolol

» milrinone

» morphine

» nesiritide

» nitroglycerin

» norepinephrine

» ondansetron

» palonosetron

» phenylephrine

» phytonadione

» potassium chloride

» procainamide

» prochlorperazine

» promethazine

» propranolol

» protamine

» ranitidine

» succinylcholine

» tacrolimus

» tirofiban

» tobramycin

» vancomycin

» vasopressin

» verapamil

» voriconazole

• Y-Site Incompatibility:

» acyclovir

» aminophylline

» ampicillin

» ampicillin/sulbactam

» aztreonam

» cefazolin

» cefotaxime

» cefoxitin

» ceftazidime

» ceftriaxone

» cefuroxime

» chloramphenicol

» clindamycin

» daptomycin

» dexamethasone

» ertapenem

» furosemide

» ganciclovir

» hydrocortisone sodium succinate

» insulin

» ketorolac

» methylprednisolone sodium succinate

» metronidazole

» nafcillin

» nitroprusside

» pantoprazole

» penicillin G potassium

» phenytoin

» piperacillin/tazobacatam

» sodium bicarbonate

» sulfamethoxazole/trimethoprim

» ticarcillin/clavulanate

• Instruct patient to take medication around the clock, exactly as directed, even if feeling well. Take missed doses as soon as remembered if within 2 hr; if remembered later, omit. Do not double doses.

• Instruct patient or family member on how to take pulse. Advise patient to report changes in pulse rate or rhythm to health care professional.

• May cause dizziness or blurred vision. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.

• Inform patient that quinidine may cause increased sensitivity to light. Dark glasses may minimize this effect.

• Advise patient to inform health care professional of medication regimen prior to treatment or surgery.

• Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.

• Advise patient to consult health care professional if symptoms of cinchonism, rash, or dyspnea occur or if diarrhea is severe or persistent.

• Advise patient to carry identification at all times describing disease process and medication regimen.

• Emphasize the importance of routine follow-up exams to monitor progress.

• Decrease or cessation of cardiac arrhythmia.

• Resolution of malarial infection.