rrently did not experience an increased incidence of side effects. nevertheless, the possibility of additive negative inotropic effects of beta blockers and flecainide should be recognized. flecainide is not extensively bound to plasma proteins. in vitro studies with several drugs which may be administered concomitantly showed that the extent of flecainide binding to human plasma proteins is either unchanged or only slightly less. consequently, interactions with other drugs which are highly protein bound (e.g., anticoagulants ) would not be expected. flecainide acetate has been used in a large number of patients receiving diuretics without apparent interaction. limited data in patients receiving known enzyme inducers ( phenytoin, phenobarbital, carbamazepine ) indicate only a 30% increase in the rate of flecainide elimination. in healthy subjects receiving cimetidine (1 g daily) for one week, plasma flecainide levels increased by about 30% and half-life increased by about 10%. when amiodarone is added to flecainide therapy, plasma flecainide levels may increase two-fold or more in some patients, if flecainide dosage is not reduced. (see dosage and administration .) drugs that inhibit cytochrome p450iid6, such as quinidine , might increase the plasma concentrations of flecainide in patients that are on chronic flecainide therapy; especially if these patients are extensive metabolizers. there has been little experience with the coadministration of flecainide acetate and either disopyramide or verapamil . because both of these drugs have negative inotropic properties and the effects of coadministration with flecainide acetate are unknown, neither disopyramide nor verapamil should be administered concurrently with flecainide acetate unless, in the judgment of the physician, the benefits of this combination outweigh the risks. there has been too little experience with the coadministration of flecainide acetate with nifedipine or diltiazem to recommend concomitant use.

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.

y increasing the flecainide acetate tablets dose from 50 to 100 mg bid. the maximum recommended dose for patients with paroxysmal supraventricular arrhythmias is 300 mg/day. for sustained vt the recommended starting dose is 100 mg every 12 hours. this dose may be increased in increments of 50 mg bid every four days until efficacy is achieved. most patients with sustained vt do not require more than 150 mg every 12 hours (300 mg/day) and the maximum dose recommended is 400 mg/day. in patients with sustained vt, use of higher initial doses and more rapid dosage adjustments have resulted in an increased incidence of proarrhythmic events and chf, particularly during the first few days of dosing (see warnings ). therefore, a loading dose is not recommended. intravenous lidocaine has been used occasionally with flecainide acetate tablets while awaiting the therapeutic effect of flecainide acetate tablets. no adverse drug interactions were apparent. however, no formal studies have been performed to demonstrate the usefulness of this regimen. an occasional patient not adequately controlled by (or intolerant to) a dose given at 12-hour intervals may be dosed at eight-hour intervals. once adequate control of the arrhythmia has been achieved, it may be possible in some patients to reduce the dose as necessary to minimize side effects or effects on conduction. in such patients, efficacy at the lower dose should be evaluated. flecainide acetate tablets should be used cautiously in patients with a history of chf or myocardial dysfunction (see warnings ). any use of flecainide acetate tablets in children should be directly supervised by a cardiologist skilled in the treatment of arrhythmias in children. because of the evolving nature of information in this area, specialized literature should be consulted. under six months of age, the initial starting dose of flecainide acetate tablets in children is approximately 50 mg/m 2 body surface area daily, divided into two or three equally spaced doses. over six months of age, the initial starting dose may be increased to 100 mg/m 2 per day. the maximum recommended dose is 200 mg/m 2 per day. this dose should not be exceeded. in some children on higher doses, despite previously low plasma levels, the level has increased rapidly to far above therapeutic values while taking the same dose. small changes in dose may also lead to disproportionate increases in plasma levels. plasma trough (less than one hour pre-dose) flecainide levels and electrocardiograms should be obtained at presumed steady state (after at least five doses) either after initiation or change in flecainide acetate tablets dose, whether the dose was increased for lack of effectiveness, or increased growth of the patient. for the first year on therapy, whenever the patient is seen for reasons of clinical follow-up, it is suggested that a 12-lead electrocardiogram and plasma trough flecainide level are obtained. the usual therapeutic level of flecainide in children is 200 to 500 ng/ml. in some cases, levels as high as 800 ng/ml may be required for control. in patients with severe renal impairment (creatinine clearance of 35 ml/min/1.73 square meters or less), the initial dosage should be 100 mg once daily (or 50 mg bid); when used in such patients, frequent plasma level monitoring is required to guide dosage adjustments (see plasma level monitoring ). in patients with less severe renal disease, the initial dosage should be 100 mg every 12 hours; plasma level monitoring may also be useful in these patients during dosage adjustment. in both groups of patients, dosage increases should be made very cautiously when plasma levels have plateaued (after more than four days), observing the patient closely for signs of adverse cardiac effects or other toxicity. it should be borne in mind that in these patients it may take longer than four days before a new steady-state plasma level is reached following a dosage change. based on theoretical considerations, rather than experimental data, the following suggestion is made: when transferring patients from another antiarrhythmic drug to flecainide acetate tablets allow at least two to four plasma half-lives to elapse for the drug being discontinued before starting flecainide acetate tablets at the usual dosage. in patients where withdrawal of a previous antiarrhythmic agent is likely to produce life-threatening arrhythmias, the physician should consider hospitalizing the patient. when flecainide is given in the presence of amiodarone, reduce the usual flecainide dose by 50% and monitor the patient closely for adverse effects. plasma level monitoring is strongly recommended to guide dosage with such combination therapy (see below). plasma level monitoring the large majority of patients successfully treated with flecainide acetate tablets were found to have trough plasma levels between 0.2 and 1 mcg/ml. the probability of adverse experiences, especially cardiac, may increase with higher trough plasma levels, especially when these exceed 1 mcg/ml. periodic monitoring of trough plasma levels may be useful in patient management. plasma level monitoring is required in patients with severe renal failure or severe hepatic disease, since elimination of flecainide from plasma may be markedly slower. monitoring of plasma levels is strongly recommended in patients on concurrent amiodarone therapy and may also be helpful in patients with chf and in patients with moderate renal disease.

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.

rrently did not experience an increased incidence of side effects. nevertheless, the possibility of additive negative inotropic effects of beta blockers and flecainide should be recognized. flecainide is not extensively bound to plasma proteins. in vitro studies with several drugs which may be administered concomitantly showed that the extent of flecainide binding to human plasma proteins is either unchanged or only slightly less. consequently, interactions with other drugs which are highly protein bound (e.g., anticoagulants ) would not be expected. flecainide acetate has been used in a large number of patients receiving diuretics without apparent interaction. limited data in patients receiving known enzyme inducers ( phenytoin, phenobarbital, carbamazepine ) indicate only a 30% increase in the rate of flecainide elimination. in healthy subjects receiving cimetidine (1 g daily) for one week, plasma flecainide levels increased by about 30% and half-life increased by about 10%. when amiodarone is added to flecainide therapy, plasma flecainide levels may increase two-fold or more in some patients, if flecainide dosage is not reduced. (see dosage and administration .) drugs that inhibit cytochrome p450iid6, such as quinidine , might increase the plasma concentrations of flecainide in patients that are on chronic flecainide therapy; especially if these patients are extensive metabolizers. there has been little experience with the coadministration of flecainide acetate and either disopyramide or verapamil . because both of these drugs have negative inotropic properties and the effects of coadministration with flecainide acetate are unknown, neither disopyramide nor verapamil should be administered concurrently with flecainide acetate unless, in the judgment of the physician, the benefits of this combination outweigh the risks. there has been too little experience with the coadministration of flecainide acetate with nifedipine or diltiazem to recommend concomitant use.

e pvcs and can suppress recurrence of ventricular tachycardia. in limited studies of patients with a history of ventricular tachycardia, flecainide acetate has been successful 30 to 40% of the time in fully suppressing the inducibility of arrhythmias by programmed electrical stimulation. based on pvc suppression, it appears that plasma levels of 0.2 to 1 mcg/ml may be needed to obtain the maximal therapeutic effect. it is more difficult to assess the dose needed to suppress serious arrhythmias, but trough plasma levels in patients successfully treated for recurrent ventricular tachycardia were between 0.2 and 1 mcg/ml. plasma levels above 0.7 to 1 mcg/ml are associated with a higher rate of cardiac adverse experiences such as conduction defects or bradycardia. the relation of plasma levels to proarrhythmic events is not established, but dose reduction in clinical trials of patients with ventricular tachycardia appears to have led to a reduced frequency and severity of such events. hemodynamics flecainide acetate does not usually alter heart rate, although bradycardia and tachycardia have been reported occasionally. in animals and isolated myocardium, a negative inotropic effect of flecainide has been demonstrated. decreases in ejection fraction, consistent with a negative inotropic effect, have been observed after single administration of 200 to 250 mg of the drug in man; both increases and decreases in ejection fraction have been encountered during multidose therapy in patients at usual therapeutic doses. (see warnings .) metabolism in humans following oral administration, the absorption of flecainide acetate is nearly complete. peak plasma levels are attained at about three hours in most individuals (range, 1 to 6 hours). flecainide does not undergo any consequential presystemic biotransformation (first-pass effect). food or antacid do not affect absorption. milk, however, may inhibit absorption in infants. a reduction in flecainide acetate dosage should be considered when milk is removed from the diet of infants. the apparent plasma half-life averages about 20 hours and is quite variable (range, 12 to 27 hours) after multiple oral doses in patients with premature ventricular contractions (pvcs). with multiple dosing, plasma levels increase because of its long half-life with steady-state levels approached in 3 to 5 days; once at steady-state, no additional (or unexpected) accumulation of drug in plasma occurs during chronic therapy. over the usual therapeutic range, data suggest that plasma levels in an individual are approximately proportional to dose, deviating upwards from linearity only slightly (about 10 to 15% per 100 mg on average). in healthy subjects, about 30% of a single oral dose (range, 10 to 50%) is excreted in urine as unchanged drug. the two major urinary metabolites are meta-o-dealkylated flecainide (active, but about one-fifth as potent) and the meta-o-dealkylated lactam of flecainide (non-active metabolite). these two metabolites (primarily conjugated) account for most of the remaining portion of the dose. several minor metabolites (3% of the dose or less) are also found in urine; only 5% of an oral dose is excreted in feces. in patients, free (unconjugated) plasma levels of the two major metabolites are very low (less than 0.05 mcg/ml). in vitro metabolic studies have confirmed that cytochrome p450iid6 is involved in the metabolism of flecainide. when urinary ph is very alkaline (8 or higher), as may occur in rare conditions (e.g., renal tubular acidosis, strict vegetarian diet), flecainide elimination from plasma is much slower. the elimination of flecainide from the body depends on renal function (i.e., 10 to 50% appears in urine as unchanged drug). with increasing renal impairment, the extent of unchanged drug excretion in urine is reduced and the plasma half-life of flecainide is prolonged. since flecainide is also extensively metabolized, there is no simple relationship between creatinine clearance and the rate of flecainide elimination from plasma. (see dosage and administration .) in patients with nyha class iii congestive heart failure (chf), the rate of flecainide elimination from plasma (mean half-life, 19 hours) is moderately slower than for healthy subjects (mean half-life, 14 hours), but similar to the rate for patients with pvcs without chf. the extent of excretion of unchanged drug in urine is also similar. (see dosage and administration .) under one year of age, currently available data are limited but suggest that the half-life at birth may be as long as 29 hours, decreasing to 11 to 12 hours by three months of age and 6 hours by one year of age. the pharmacokinetics in hydropic infants have not been studied, but case reports suggest prolonged elimination. in children aged 1 year to 12 years the half-life is approximately 8 hours. in adolescents (age 12 to 15) the plasma elimination half-life is approximately 11 to 12 hours. since milk may inhibit absorption in infants, a reduction in flecainide acetate dosage should be considered when milk is removed from the diet (e.g., gastroenteritis, weaning). plasma trough flecainide levels should be monitored during major changes in dietary milk intake. from age 20 to 80, plasma levels are only slightly higher with advancing age; flecainide elimination from plasma is somewhat slower in elderly subjects than in younger subjects. patients up to age 80+ have been safely treated with usual dosages. the extent of flecainide binding to human plasma proteins is about 40% and is independent of plasma drug level over the range of 0.015 to about 3.4 mcg/ml. thus, clinically significant drug interactions based on protein binding effects would not be expected. hemodialysis removes only about 1% of an oral dose as unchanged flecainide. small increases in plasma digoxin levels are seen during coadministration of flecainide acetate with digoxin. small increases in both flecainide and propranolol plasma levels are seen during coadministration of these two drugs. (see precautions, drug interactions .) clinical trials in two randomized, crossover, placebo-controlled clinical trials of 16 weeks double-blind duration, 79% of patients with paroxysmal supraventricular tachycardia (psvt) receiving flecainide were attack free, whereas 15% of patients receiving placebo remained attack free. the median time-before-recurrence of psvt in patients receiving placebo was 11 to 12 days, whereas over 85% of patients receiving flecainide had no recurrence at 60 days. in two randomized, crossover, placebo-controlled clinical trials of 16 weeks double-blind duration, 31% of patients with paroxysmal atrial fibrillation/flutter (paf) receiving flecainide were attack free, whereas 8% receiving placebo remained attack free. the median time-before-recurrence of paf in patients receiving placebo was about 2 to 3 days, whereas for those receiving flecainide the median time-before-recurrence was 15 days.

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