In this study we reviewed the literature on the use of drugs in BrS-patients and made recommendations about their safety that were based on the literature and expert opinion. We also initiated a website (www.brugadadrugs.org
) where these drugs and the recommendations can be accessed by all physicians who treat patients with BrS and by others with possible interest (e.g., patients). On this website, we provide more detailed information on drugs in BrS than reviewed in this manuscript. In addition, the website is updated frequently (drugs added or removed, recommendations changed) according to the latest evidence.
Patients with BrS should be advised not to take the drugs from the ‘avoid’ and ‘preferably avoid’ lists or to use these drugs only after extensive consideration and/or in controlled conditions. We advise patients to give a list of these drugs to all of their health care providers (including their general practitioner, dentist and pharmacist). In many BrS-patients, avoidance of these drugs (and treatment of fever)6,7
is probably an appropriate and safe treatment. Furthermore, some BrS-patients seem to perform well on quinidine.8-10
Recently, a prospective registry has started investigating the use of empiric quinidine therapy for asymptomatic BrS-patients (ClinicalTrials.gov
Further, the QUIDAM study (HydroQui
nidine to D
rrhythmic events in Brugada syndrom
e patients, ClinicalTrials.gov
identifier NCT00927732), a French national double blinded randomized study, is currently performed on the role of quinidine therapy to improve the outcome in high risk BrS-patients. Reports have postulated an antiarrhythmic effect of other drugs (amrinone,13
dimethyl lithospermate B,16
). We consider the evidence on use of these drugs as antiarrhythmic treatment in Brugada syndrome patients currently to be too low.
An important issue regarding ventricular tachyarrhythmias in Brugada syndrome patients is that they can present as an epileptic seizure and that the cerebral hypoperfusion may create a clinical picture easily confused with a postictal phase. Therefore, in patients with seizures both epilepsy and arrhythmia syndromes such as Brugada syndrome7
(or, e.g., Long-QT syndrome)22
are part of the differential diagnosis. Many antiepileptic drugs, such as carbamazepine or phenytoin, act through cerebral ion channel blockade but will also result in cardiac ion channel blockade.23-25
The latter may have a deleterious (and possibly fatal) effect in patients with an arrhythmia syndrome such as Brugada syndrome. Therefore, it is important to exclude arrhythmia syndromes such as Brugada syndrome in patients suspected of epilepsy before a possible harmful treatment is started.
We hope that the website will be of help to physicians who are in need of this information and we welcome your suggestions and/or documentation on the safe or unsafe use of drugs in BrS-patients. Further, we hope that the information on our website will prevent BrS-patients from suffering a cardiac arrest or sudden cardiac death initiated by drugs that should be avoided.
The principal limitation of the association between certain drugs, BrS and arrhythmias, is the limited number of case reports and experimental studies suggesting an effect in BrS. Further, there may be conflicting results and large variability may exist between BrS-patients in their response to certain drugs. This response may also vary in different conditions (e.g., with or without fever, drug in therapeutic range, overdosed or in combination with other drugs etc.). Therefore, clinical decision making should be based on more than the presence or absence of a (single) association in another patient. Additionally, it remains important for health care providers to recognize the active substances in medicines containing a combination of drugs, and to be aware of the drug category (e.g., many tricyclic antidepressants will be potentially proarrhythmic in BrS-patients).