Flecainide Acetate

INDICATIONS AND USAGE In patients without structural heart disease, flecainide acetate tablets, USP are indicated for the prevention of — paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disabling symptoms — paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms Flecainide acetate tablets, USP are also indicated for the prevention of — documented ventricular arrhythmias, such as sustained ventricular tachycardia ( sustained VT), that in the judgment of the physician are life-threatening. Use of flecainide acetate tablets, USP for the treatment of sustained VT, like other antiarrhythmics, should be initiated in the hospital. The use of flecainide acetate tablets, USP are not recommended in patients with less severe ventricular arrhythmias even if the patients are symptomatic. Because of the proarrhythmic effects of flecainide acetate tablets, USP, its use should be reserved for patients in whom, in the opinion of the physician, the benefits of treatment outweigh the risks. Flecainide acetate tablets, USP should not be used in patients with recent myocardial infarction. (See BOXED WARNINGS .) Use of flecainide acetate tablets, USP in chronic atrial fibrillation has not been adequately studied and is not recommended. (See BOXED WARNINGS .) As is the case for other antiarrhythmic agents, there is no evidence from controlled trials that the use of flecainide acetate tablets, USP favorably affects survival or the incidence of sudden death.

ADVERSE REACTIONS In post-myocardial infarction patients with asymptomatic PVCs and non-sustained ventricular tachycardia, flecainide acetate therapy was found to be associated with a 5.1% rate of death and non-fatal cardiac arrest, compared with a 2.3% rate in a matched placebo group. (See WARNINGS .) Adverse effects reported for flecainide acetate, described in detail in the WARNINGS section, were new or worsened arrhythmias which occurred in 1% of 108 patients with PSVT and in 7% of 117 patients with PAF; and new or exacerbated ventricular arrhythmias which occurred in 7% of 1330 patients with PVCs, non-sustained or sustained VT. In patients treated with flecainide for sustained VT, 80% (51/64) of proarrhythmic events occurred within 14 days of the onset of therapy. 198 patients with sustained VT experienced a 13% incidence of new or exacerbated ventricular arrhythmias when dosage was initiated at 200 mg/day with slow upward titration, and did not exceed 300 mg/day in most patients. In some patients, flecainide acetate treatment has been associated with episodes of unresuscitatable VT or ventricular fibrillation (cardiac arrest). (See WARNINGS .) New or worsened CHF occurred in 6.3% of 1046 patients with PVCs, non-sustained or sustained VT. Of 297 patients with sustained VT, 9.1% experienced new or worsened CHF. New or worsened CHF was reported in 0.4% of 225 patients with supraventricular arrhythmias. There have also been instances of second- (0.5%) or third-degree (0.4%) AV block. Patients have developed sinus bradycardia, sinus pause, or sinus arrest, about 1.2% altogether (see WARNINGS ). The frequency of most of these serious adverse events probably increases with higher trough plasma levels, especially when these trough levels exceed 1 mcg/mL. There have been rare reports of isolated elevations of serum alkaline phosphatase and isolated elevations of serum transaminase levels. These elevations have been asymptomatic and no cause and effect relationship with flecainide acetate has been established. In foreign postmarketing surveillance studies, there have been rare reports of hepatic dysfunction including reports of cholestasis and hepatic failure, and extremely rare reports of blood dyscrasias. Although no cause and effect relationship has been established, it is advisable to discontinue flecainide acetate in patients who develop unexplained jaundice or signs of hepatic dysfunction or blood dyscrasias in order to eliminate flecainide acetate as the possible causative agent. Incidence figures for other adverse effects in patients with ventricular arrhythmias are based on a multicenter efficacy study, utilizing starting doses of 200 mg/day with gradual upward titration to 400 mg/day. Patients were treated for an average of 4.7 months, with some receiving up to 22 months of therapy. In this trial, 5.4% of patients discontinued due to non-cardiac adverse effects. Table 1 Most Common Non-Cardiac Adverse Effects in Ventricular Arrhythmia Patients Treated with Flecainide Acetate in the Multicenter Study Adverse Effect Incidence Incidence by Dose During Upward Titration All 429 Patients at Any Dose 200 mg/Day (N=426) 300 mg/Day (N=293) 400 mg/Day (N=100) * Dizziness includes reports of dizziness, lightheadedness, faintness, unsteadiness, near syncope, etc. † Visual disturbance includes reports of blurred vision, difficulty in focusing, spots before eyes, etc. Dizziness* 18.9% 11% 10.6% 13% Visual Disturbances † 15.9% 5.4% 12.3% 18% Dyspnea 10.3% 5.2% 7.5% 4% Headache 9.6% 4.5% 6.1% 9% Nausea 8.9% 4.9% 4.8% 6% Fatigue 7.7% 4.5% 4.4% 3% Palpitation 6.1% 3.5% 2.4% 7% Chest Pain 5.4% 3.1% 3.8% 1% Asthenia 4.9% 2.6% 2% 4% Tremor 4.7% 2.4% 3.4% 2% Constipation 4.4% 2.8% 2.1% 1% Edema 3.5% 1.9% 1.4% 2% Abdominal Pain 3.3% 1.9% 2.4% 1% The following additional adverse experiences, possibly related to flecainide acetate therapy and occurring in 1% to less than 3% of patients, have been reported in acute and chronic studies: Body as a Whole – malaise, fever Cardiovascular – tachycardia, sinus pause or arrest Gastrointestinal – vomiting, diarrhea, dyspepsia, anorexia Skin – rash Visual – diplopia Nervous System – hypoesthesia, paresthesia, paresis, ataxia, flushing, increased sweating, vertigo, syncope, somnolence, tinnitus Psychiatric – anxiety, insomnia, depression. The following additional adverse experiences, possibly related to flecainide acetate, have been reported in less than 1% of patients: Body as a Whole – swollen lips, tongue and mouth; arthralgia, bronchospasm, myalgia Cardiovascular – angina pectoris, second-degree and third-degree AV block, bradycardia, hypertension, hypotension Gastrointestinal – flatulence Urinary System – polyuria, urinary retention Hematologic – leukopenia, granulocytopenia, thrombocytopenia Skin – urticaria, exfoliative dermatitis, pruritis, alopecia Visual – eye pain or irritation, photophobia, nystagmus Nervous System – twitching, weakness, change in taste, dry mouth, convulsions, impotence, speech disorder, stupor, neuropathy Respiratory – pneumonitis/pulmonary infiltration possibly due to chronic flecainide treatment Psychiatric – amnesia, confusion, decreased libido, depersonalization, euphoria, morbid dreams, apathy. For patients with supraventricular arrhythmias, the most commonly reported noncardiac adverse experiences remain consistent with those known for patients treated with flecainide acetate for ventricular arrhythmias. Dizziness is possibly more frequent in PAF patients.