Pharmacokinetics and pharmacodynamic effects of amiodarone in plasma of ponies after single intravenous administration

Fundamentals of arrhythmogenic mechanisms and treatment strategies for equine atrial fibrillation

Atrial fibrillation (AF) is the most common pathological arrhythmia in horses. Although it is not usually a life-threatening condition on its own, it can cause poor performance and make the horse unsafe to ride. It is a complex multifactorial disease influenced by both genetic and environmental factors including exercise training, comorbidities or ageing. The interactions between all these factors in horses are still not completely understood and the pathophysiology of AF remains poorly defined. Exciting progress has been recently made in equine cardiac electrophysiology in terms of diagnosis and documentation methods such as cardiac mapping, implantable electrocardiogram (ECG) recording devices or computer-based ECG analysis that will hopefully improve our understanding of this disease. The available pharmaceutical and electrophysiological treatments have good efficacy and lead to a good prognosis for AF, but recurrence is a frequent issue that veterinarians have to face. This review aims to summarise our current understanding of equine cardiac electrophysiology and pathophysiology of equine AF while providing an overview of the mechanism of action for currently available treatments for equine AF.

Atrial fibrillation in horses Part 2: Diagnosis, treatment and prognosis

Atrial fibrillation (AF) is suspected by an irregularly irregular rhythm during auscultation at rest and should be confirmed by electrocardiography. Heart rate monitoring is potentially interesting for AF detection by horse owners, based on the disproportionally high heart rate during exercise or increased heart rate variability. Echocardiography and laboratory analysis are useful to identify underlying cardiac disease. Horses with severe cardiac disease should not undergo cardioversion due to the risk of recurrence. Cardioversion is recommended especially in horses performing high intensity exercise or showing average maximal heart rates higher than 220 beats per min or abnormal ventricular complexes during exercise or stress. Pharmacological cardioversion can be performed using quinidine sulphate administered orally, with an overall mean reported success rate around 80%. Other therapeutic drugs have been described such as flecainide, amiodarone or novel atrial specific compounds. Transvenous electrical cardioversion (TVEC) is performed by delivering a shock between two cardioversion catheters positioned in the left pulmonary artery and right atrium, with a success rate of >95%. After cardioversion, most horses return to their previous level of performance. However, the recurrence rate after pharmacological or electrical cardioversion is up to 39%. Recurrence has been related to previous unsuccessful treatment attempts, valvular regurgitation and the presence of atrial premature depolarisations or low atrial contractile function after cardioversion. Large atrial size and long AF duration have also been suggested as risk factors. Different approaches for preventing recurrence have been described such as the administration of sotalol, however, large clinical studies have not been published.

Cardiac Therapeutics in Horses

Many cardiac therapeutics lack significant evidence of benefit in the horse, and in many cases their use is based on extrapolation of evidence from other species. In recent years there has been a push to develop a better understanding of both the pharmacodynamics and pharmacokinetics of these drugs. Recent data have described the use of antiarrhythmic agents including sotalol, flecainide, and amiodarone. Data about the use of ACE inhibitors in the management of congestive heart failure are encouraging and support their use in certain cases, wheras evidence for other medicines, such as pimobendan, remain speculative.

A physiologically based model for tramadol pharmacokinetics in horses

This work proposes an application of a minimal complexity physiologically based pharmacokinetic model to predict tramadol concentration vs time profiles in horses. Tramadol is an opioid analgesic also used for veterinary treatments. Researchers and medical doctors can profit from the application of mathematical models as supporting tools to optimize the pharmacological treatment of animal species. The proposed model is based on physiology but adopts the minimal compartmental architecture necessary to describe the experimental data. The model features a system of ordinary differential equations, where most of the model parameters are either assigned or individualized for a given horse, using literature data and correlations. Conversely, residual parameters, whose value is unknown, are regressed exploiting experimental data. The model proved capable of simulating pharmacokinetic profiles with accuracy. In addition, it provides further insights on un-observable tramadol data, as for instance tramadol concentration in the liver or hepatic metabolism and renal excretion extent.

Risk factors for recurrence of atrial fibrillation in horses after cardioversion to sinus rhythm

Background

Although atrial fibrillation (AF) can be successfully treated in horses, recurrence occurs frequently. In humans, atrial function after cardioversion can predict recurrence.

Objectives

To examine the prognostic value of atrial mechanical function at 24 hours after cardioversion and other potential predictor variables for AF recurrence in horses.

Animals

117 horses treated for AF at 4 referral centers.

Methods

Retrospective study. Inclusion criteria were successful cardioversion, echocardiography at 24 hours after cardioversion and ≥4 months follow‐up. To determine factors associated with AF recurrence, a multivariable survival model was built.

Results

133 AF episodes in 117 horses were included. AF recurred in 36/100 horses with a first AF episode and in 57/133 AF episodes overall. Factors associated with recurrence in horses with a first episode were previous unsuccessful treatment attempt (hazard ratio HR 2.36, 95% confidence interval CI 1.11–4.99, P = .025) and mild or moderate mitral regurgitation (HR 2.70, 95% CI 1.23–5.91, P = .013). When the last AF episode of all horses was included, previous AF (HR 2.53, 1.33–4.82, P = .005) and active left atrial fractional area change ≤9.6% (HR 3.43, 1.22–9.67, P = .020) were significant predictors.

Conclusions and Clinical Importance

The only echocardiographic variable of left atrial function with significant prognostic value for recurrence was low active left atrial fractional area change. Further research is necessary to evaluate whether echocardiography at a later timepoint could provide more prognostic information.

Torsade de Pointes and Persistent QTc Prolongation after Intravenous Amiodarone

We report a case of torsade de pointes after intravenous amiodarone and concurrent hypokalemia. Despite treatment cessation and correction of electrolyte abnormalities, excessive QTc prolongation was noted, which persisted for 14 days. This prolonged course for QTc normalization may be attributed to the high rate of amiodarone loading and concurrent electrolyte disturbances coupled with possible underlying individual variability in pharmacokinetics.

Whole-body physiologically based pharmacokinetic models

This review summarizes the most recent developments in and applications of physiologically based pharmacokinetic (PBPK) modeling methodology originating from both the pharmaceutical and environmental toxicology areas. It focuses on works published in the last 5 years, although older seminal papers have also been referenced. After a brief introduction to the field and several essential definitions, the main body of the text is structured to follow the major steps of a typical PBPK modeling exercise. Various applications of the methodology are briefly described. The major future trends and perspectives are outlined. The main conclusion from the review of the available literature is that PBPK modeling, despite its obvious potential and recent incremental developments, has not taken the place it deserves, especially in pharmaceutical and drug development sciences.

Intravenous amiodarone treatment in horses with chronic atrial fibrillation

Six horses without underlying cardiac disease were presented because of atrial fibrillation of between 5 and 12 months duration. These horses received an intravenous amiodarone treatment of 5mg/kg/h for 1 h followed by 0.83mg/kg/h for 23h and subsequently 1.9mg/kg/h for 30h. During treatment, clinical signs were monitored and a surface ECG and an intra-atrial electrogram were recorded. Infusion was discontinued when sinus rhythm or side effects occurred. Four horses successfully cardioverted, of which one showed symptoms of hind limb weakness and weight shifting. Two horses did not cardiovert and showed similar side effects. In all horses, side effects disappeared within 6h after termination of treatment. Cardiac side effects, such as pro-arrhythmia, were not seen in any of the horses. Total bilirubin slightly increased in three horses and normalised within four days. It was concluded that amiodarone has the potential to treat naturally occurring chronic atrial fibrillation in horses, although further research is needed to refine the infusion protocol.

Evaluation of the pharmacokinetics and bioavailability of intravenously and orally administered amiodarone in horses

OBJECTIVE

To determine the clinical effects and pharmacokinetics of amiodarone after single doses of 5 mg/kg administered orally or intravenously.

ANIMALS

6 healthy adult horses.

PROCEDURE

In a cross over study, clinical signs and electrocardiographic variables were monitored and plasma and urine samples were collected. A liquid chromatography-mass spectrometry method was used to determine the percentage of protein binding and to measure plasma and urine concentrations of amiodarone and the active metabolite desethylamiodarone.

RESULTS

No adverse clinical signs were observed. After IV administration, median terminal elimination half-lives of amiodarone and desethylamiodarone were 51.1 and 75.3 hours, respectively. Clearance was 0.35 L/kg x h, and the apparent volume of distribution for amiodarone was 31.1 L/kg. The peak plasma desethylamiodarone concentration of 0.08 microg/mL was attained 2.7 hours after IV administration. Neither parent drug nor metabolite was detected in urine, and protein binding of amiodarone was 96%. After oral administration of amiodarone, absorption of amiodarone was slow and variable; bioavailability ranged from 6.0% to 33.7%. The peak plasma amiodarone concentration of 0.14 microg/mL was attained 7.0 hours after oral administration and the peak plasma desethylamiodarone concentration of 0.03 microg/mL was attained 8.0 hours after administration. Median elimination half-lives of amiodarone and desethylamiodarone were 24.1 and 58.6 hours, respectively.

CONCLUSION AND CLINICAL RELEVANCE

Results indicate that the pharmacokinetic distribution of amiodarone is multicompartmental. This information is useful for determining treatment regimens for horses with arrythmias. Amiodarone has low bioavailability after oral administration, does not undergo renal excretion, and is highly protein-bound in horses.