Antidysrhythmic (class IA)US FDA Database Verified

quiNIDine gluconate (Rx)

Generic: QuiNIDine gluconate

Brand: not specified

(kwin'i-deen)

Pregnancy Category: C

Pharmacological Action

Prolongs action potential duration and effective refractory period, thus decreasing myocardial excitability; anticholinergic properties

Therapeutic outcome: Treatment of dysrhythmias

Uses

Wolff-Parkinson-White syndrome, PVST, atrial fibrillation, flutter; paroxysmal atrial tachycardia, ventricular tachycardia, malaria (IV quiNIDine gluconate) Unlabeled uses: Singultus (hiccups)

Contraindications

Hypersensitivity or idiosyncratic response, digoxin toxicity, blood dyscrasias, myasthenia gravis, AV block

Precautions: Pregnancy C, breastfeeding, children, geriatric, renal/hepatic disease, potassium imbalance, CHF, respiratory depression, bradycardia, hypotension, syncope

BLACK BOX WARNING: Cardiac arrhythmias, MI

Dosage & Routes

QuiNIDine sulfate Atrial fibrillation/flutter/PVST/WPW

Adult: PO 200 mg q6-8 hr × 5-8 doses; may increase daily until sinus rhythm is restored; max 4 g/day given only after digitalization; maintenance 200-300 mg tid-qid or 300-600 mg q8-12 hr (EXT REL) Hiccups (unlabeled)

Adult: PO 200 mg qid QuiNIDine gluconate

Adult: PO 324-648 mg q8-12 hr (EXT REL); IM 600 mg, then 400 mg q2 hr; IV give 16 mg/min

Available forms:

Gluconate: ext rel tabs 324, 330 mg; inj gluconate 80 mg/ml; sulfate: tabs 200, 300 mg; ext rel tabs 300 mg

Implementation - Give AV node blocker (digoxin) before starting quiNIDine to avoid increased ventricular rate PO route - Do not break, crush, or chew ext rel tab - Give on an empty stomach with a full glass of water; may be given with meals if GI irritation occurs, absorption will be decreased - Ext rel forms not interchangeable - Tab may be crushed and mixed with fluid or foods for patients with swallowing difficulties IM route - Give IM injection in deltoid, aspirate to avoid intravascular administration Intermittent IV infusion route - Give after diluting 800 mg/50 ml or more D5 W (16 mg/ml); give max 0.25 mg/kg/min, quiNIDine is absorbed by PVC tubing, minimize length; use inf pump

Y-site compatibilities: Alfentanil, amikacin, anidulafungin, ascorbic acid, atenolol, atracurium, atropine, benztropine, bleomycin, bumetanide, buprenorphine, butorphanol, calcium gluconate, caspofungin, chlorproMAZINE, cimetidine, CISplatin, cyanocobalamin, cycloSPORINE, DACTINomycin, digoxin, diltiazem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, DOPamine, doxycycline, enalaprilat, ePHEDrine, EPINEPHrine, epoetin alfa, erythromycin, esmolol, etoposide, famotidine, fenoldopam, fentaNYL, fluconazole, fludarabine, gatifloxacin, gemcitabine, gentamicin, glycopyrrolate, granisetron, HYDROmorphone, IDArubicin, imipenem-cilastatin, irinotecan, isoproterenol, labetalol, lidocaine, linezolid, LORazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methoxamine, methyldopate, metoclopramide, metoprolol, metroNIDAZOLE, miconazole, milrinone, mitoXANtrone, morphine, multiple vitamins, mycophenolate, nalbuphine, naloxone, nesiritide, netilmicin, nitroglycerin, norepinephrine, octreotide, ondansetron, oxaliplatin, PACLitaxel, palonosetron, pamidronate, pancuronium, papaverine, pentamidine, pentazocine, phenylephrine, phytonadione, polymyxin B, potassium chloride, procainamide, prochlorperazine, promethazine, propranolol, protamine, pyridoxine, ranitidine, ritodrine, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, tirofiban, tobramycin, tolazoline, trimetaphan, urokinase, vancomycin, vasopressin, verapamil, vinorelbine, voriconazole, zoledronic acid

Adverse Effects

CNS: Headache, dizziness, involuntary movement, confusion, psychosis, restlessness, irritability, syncope, excitement, depression, ataxia

CV: Hypotension, bradycardia, PVCs, heart block, cardiovascular collapse, arrest, torsades de pointes, widening QRS complex, ventricular tachycardia

EENT:

Cinchonism: tinnitus, blurred vision, hearing loss, mydriasis, disturbed color vision

GI: Nausea, vomiting, anorexia, diarrhea, hepatotoxicity, abdominal pain

HEMA: Thrombocytopenia, hemolytic anemia, agranulocytosis, hypoprothrombinemia

INTEG: Rash, urticaria, angioedema, swelling, photosensitivity, flushing with severe pruritus

RESP: Dyspnea, respiratory depression

Pharmacokinetics

Absorption: Well absorbed (PO, IM), slowly absorbed (sus rel)

Distribution: Widely distributed, crosses placenta, protein binding 80%-90%

Metabolism: Liver

Excretion: Kidney unchanged, 10%-50% breast milk

Half-life: 6-7 hr (prolonged in geriatrics, cirrhosis, CHF)

Pharmacodynamics

PO (SULFATE): Onset ½ hr, Peak 1-6 hr, Duration 6-8 hr PO EXT

REL: Onset Unknown, Peak 4 hr, Duration 8-12 hr PO (GLUCONATE): Onset Unknown, Peak 4 hr, Duration 6-8 hr

IM: Onset ½ hr, Peak ½-1½ hr, Duration 6-8 hr

IV: Onset 5 min, Peak Unknown, Duration 6-8 hr

Interactions

Individual drugs

Amiodarone, cimetidine,

NIFEdipine: increased quiNIDine level

Digoxin: increased digoxin level NIFEdipine, sodium bicarbonate, verapamil: increased quiNIDine effect Phenytoin, rifampin, sucralfate: decreased effects of quiNIDine

Propranolol: increased effect of propranolol

Reserpine: increased cardiac depression

Warfarin: increased levels of warfarin

Drug classifications

Antacids, carbonic anhydrase inhibitors, hydroxide suspensions: increased effects of quiNIDine Anticholinergic blockers: increased vagolytic effects Anticoagulants (oral): increased levels of anticoagulant Antidepressants (tricyclics): increased effect of antidepressant

Antidysrhythmics: increased cardiac depression Barbiturates, cholinergics: decreased effects of quiNIDine Neuromuscular blockers: increased neuromuscular blocking

Phenothiazines: increased cardiac depression

Drug/herb

Hawthorn: increased quiNIDine effect

Drug/food

Grapefruit juice: decreased absorption, decreased metabolism

Drug/lab test

Increased: CPK

Interference: triamterene therapy interferes with quiNIDine test levels

Nursing Considerations

Assessment - Monitor ECG continuously to determine product effectiveness, measure PR, QRS, QT intervals, check for PVCs, other dysrhythmias; monitor B/P continuously for hypo/hypertension; for rebound hypertension after 1-2 hr; check for dehydration or hypovolemia - Monitor blood levels (therapeutic level 2-7 mcg/ml) -

Cinchonism: assess for tinnitus, headache, nausea, dizziness, fever, vertigo, tremor, may lead to hearing loss - Monitor • I&O ratio, electrolytes (potassium, sodium, chloride); check weight daily; check for signs of CHF or pulmonary toxicity: dyspnea, fatigue, cough, fever, chest pain; if these occur, product should be discontinued - Monitor liver function tests: AST, ALT, bilirubin, alkaline phosphatase - Assess for CNS symptoms: confusion, psychosis, numbness, depression, involuntary movements; if these occur, product should be discontinued - Monitor cardiac rate, respiration: rate, rhythm, character, chest pain; watch for ventricular tachycardia, supraventricular tachycardia, or fibrillation that indicates toxicity Patient/family education - Instruct patient to report adverse effects immediately to prescriber - Caution patient that sunglasses may be needed for photophobia; to use sunscreen, protective clothing, or stay out of sun to prevent burns - Instruct patient to complete follow-up appointments with health care provider including pulmonary function tests, chest x-ray, ophth and otoscopic exams - Advise patients to report signs of cinchonism, diarrhea, anorexia, decreased B/P - Avoid grapefruit

Evaluation

Positive therapeutic outcome: Resolution of dysrhythmias

Reference

Mosby's Drug Guide; Davis Drug Guide

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