quinidine (Rx)

Brand and Other Names:Quinaglute, Quinidex, more...quinidine gluconate
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

tablet

  • 200mg (as sulfate)
  • 300mg (as sulfate)

tablet, extended-release

  • 300mg (as sulfate)
  • 324mg (as gluconate)

injectable solution

  • 80mg/mL (as gluconate) - discontinued from U.S. market

Arrhythmias

Quinidine Sulfate

  • Test Dose: 200 mg PO quinidine sulfate several hr before full dosage
  • Atrial fibrillation: 300-400 mg PO q6hr
  • PSVT: 400-600 mg PO q2-3hr until paroxysm terminated
  • Atrial/Ventricular Premature Contractions: 200-300 mg PO q6-8hr
  • Maint: 200-400 mg PO q6-8hr or 600 mg of SR PO q8-12hr
  • No more than 3-4 g/day

Quinidine Gluconate

  • 324-660 mg PO q8-12hr
  • Maintenance: 648 mg PO q12hr OR 324-660 mg PO q8hr
  • PSVT: 400 - 600 mg PO q2-3hr until paroxysm is terminated
  • IV: Usual <5 mg/kg (but may need up to 10 mg/kg) at 0.25 mg/kg/min

Malaria

Quinidine gluconate for injection is no longer available in the U.S.

Quinidine Gluconate

  • Regimen I
  • Load: 24 mg/kg diluted in 250 mL NS IV infusion over 4 hours  
  • Maintenance: Follow by 12 mg/kg IV infusion over 4 hours q8hr beginning 8 hr after initiation of loading dose except in patients able to swallow the same doses of quinidine are administered using 300 mg quinidine sulfate tablets
  • Regimen II
  • Load: 10 mg/kg diluted in 5 mL/kg NS IV over 1-2 hr  
  • Maintenance: Follow by 0.02 mg/kg/min continuous IV infusion; in patients able to swallow oral quinine is administered every 8 hr to give as much quinine as patient received in quinidine q8hr
  • PO regimen: 300 mg quinidine or 650 mg quinine PO q8hr for 3 days (Africa and South America) or 7 days (Southeast Asia) or until parasitemia is reduced to 1%

Dosage Modifications

Hepatic impairment: Not studied

Renal impairment

  • CrCl <10 mL/min: Administer 75% of normal dose
  • CrCl ≥10 L/min: Dose adjustment not necessary

Pseudobulbar Affect (Off-Label)

Excessive laughing or crying, or involuntary emotional expression affects 20-50% of patients with ALS

30 mg PO bid (administer with dextromethorphan)

Dosage Forms & Strengths

tablet

  • 200mg (as sulfate)
  • 300mg (as sulfate)

tablet, controlled-release

  • 300mg (as sulfate)
  • 324mg (as gluconate)

injectable solution

  • 80mg/mL

Arrhythmias

Quinidine sulfate: 30 mg/kg/day or 900 mg/m²/day PO given in 5 divided doses OR 15-60 mg/kg/day divided q6hr PO

Test dose: 2 mg/kg PO quinidine sulfate; test dose not to exceed 200 mg

Malaria

Quinidine gluconate for injection is no longer available in the U.S.

Load: 10 mg/kg diluted in 5 mL/kg NS IV over 1-2 hr

Maintenance: Follow by 0.02 mg/kg/min continuous IV infusion; in patients able to swallow oral quinine is administered every 8 hr to give as much quinine as patient received in quinidine q8hr

PO regimen: 650 mg quinine PO q8hr for 3 days (Africa and South America) or 7 days (Southeast Asia) or until parasitemia is reduced to 1%

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Interactions

Interaction Checker

and quinidine

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            Adverse Effects

            >10%

            Diarrhea (35%)

            Stomach cramping (22%)

            Lightheadedness (15%)

            QTc prolongation (modest prolongation common; excessive prolongation rare & indicates toxicity) (>10%)

            Anorexia (>10%)

            Bitter taste (>10%)

            Diarrhea (>10%)

            Upper GI distress (>10%)

            Nausea (>10%)

            Vomiting (>10%)

            1-10%

            Syncope (1-8%)

            Palpitation (7%), new or worsened arrhythmias (proarrhythmic effect),

            Headache (7%)

            Fatigue (7%)

            Angina (6%)

            Rash (5%)

            Weakness (5%)

            Sleep disturbance (3%)

            Nervousness (2%)

            Tremor (2%)

            Incoordination (1%)

            Blurred vision

            Tinnitus

            Wheezing

            Frequency Not defined

            Hypotension

            Hepatotoxicity

            Arthralgia

            Diplopia

            Night blindness

            Hypersensitivity reactions (eg, fever, hemolytic/aplastic anemia, respiratory arrest, agranulocytosis)

            Systemic lupus erythematosus may occur if taking quinidine for prolonged period of time

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            Warnings

            Black Box Warnings

            Antiarrhythmic drugs have not been shown to enhance survival in non-life-threatening ventricular arrhythmias and they may increase mortality. The mortality risk increases with structural heart disease.

            Quinidine may increase mortality in treatment of atrial fibrillation or atrial flutter

            Contraindications

            Hypersensitivity to quinidine or cinchona alkaloids

            Absence of atrial activity, aberrant impulses or abnormal rhythm due to escape mechanisms, complete AV block or AV dissociation, digoxin toxicity, wide QRS, history of torsades, long QT syndrome, thrombocytopenia, myasthenia gravis, contraindicated w/pregnancy (neonatal thrombocytopenia) and lactation

            Drugs or conditions that prolong QT interval

            Cautions

            In non-life-threatening ventricular arrhythmias, mortality associated with quinidine was consistently greater than that associated with any of a variety of alternative antiarrhythmics

            Acute rheumatic fever, acute thyrotoxicosis, bradycardia, CHF, hypokalemia or hypomagnesemia, hypotension, incomplete AV block, sick sinus syndrome, subacute bacterial endocarditis, syncope, concomitant use of digoxin, liver disease, renal impairment, pregnancy/lactation

            Electrolyte imbalances due to severe N/V, diarrhea, eating disorders

            IV administration requires continuous cardiac & blood pressure monitoring

            Low salt diet may increase blood concentrations

            Dose should be adjusted within range to achieve desired therapeutic effects within therapeutic plasma concentration and in absence of toxic SE

            Avoid grapefruit juice

            Very high dosages may induce abortion in pregnant women due to oxytocic effect

            Extended release not recommended in children

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            Pregnancy & Lactation

            Pregnancy

            There are no adequate and well-controlled studies in pregnant women

            Animal reproductive studies have not been conducted

            Lactation

            Lactation: crosses into breast milk, use extreme caution (AAP Committee states compatible with nursing)

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Class IA (membrane stabilizing) antiarrhythmic agent; inhibits recovery after repolarization resulting in decreasing myocardial excitability & conduction velocity

            Direct membrane depressant that decreases conduction velocity, prolongs refractoriness, decreases automaticity and reduces repolarization abnormalities

            Absorption

            Bioavailability: Sulfate 70%; gluconate 70-80%

            Peak Plasma Time: 2 hr (sulfate); 3-6 hr (gluconate)

            Onset: PO: 1-3 hr

            Duration: 6-8 hr

            Distribution

            Vd: 2-3 L/kg (adults); 0.5 L/kg (heart failure)

            Protein Bound: 80-88% (adults); 50-70% (newborns)

            Metabolism

            Metabolism: Liver via hepatic P450 enzyme CYP3A4

            Metabolites: 3-hydroxyquinidine and 2-quinidinone (some have antiarrhythmic effects)

            Enzymes inhibited: CYP2D6

            Elimination

            Half-Life: 6-8 hr (adults); 3-4hr (children)

            Clearance: 3-5 mL/min/kg (adults); 1-2.5 mL/min/kg (children)

            Excretion: Urine (15-25%); feces (5%)

            Dialyzable: HD: Yes; PD: No

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            Administration

            Oral Administration

            May take with or without food

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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
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            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
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            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.