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Antiarrhythmic Pregnancy: Use with caution — neonatal bradycardia and hypoglycaemia; use only if benefit clearly outweighs risk

Sotalol

Brand names: Beta-Cardone, Sotacor

Adult dose

Dose: 80 mg twice daily initially; titrate to 160-320 mg/day in divided doses
Route: Oral
Frequency: Twice daily
Max: 640 mg/day (high TdP risk at higher doses)
Class II + Class III antiarrhythmic. Non-selective beta-blocker + potassium channel blockade. Used for AF rhythm control and ventricular arrhythmias. Renally excreted — critical dose adjustment in CKD. QTc monitoring mandatory.

Paediatric dose

Dose: 2 mg/day/kg
Route: Oral
Frequency: Divided twice daily
Max: 8 mg/kg/day
Specialist paediatric electrophysiology only. QTc monitoring mandatory. BNFc for age-specific dosing.

Dose adjustments

Renal

eGFR 10-30: 80 mg once daily maximum. eGFR <10: avoid — significant accumulation and QTc prolongation. Half-life extends from 12h (normal) to >40h in severe CKD.

Hepatic

No dose adjustment required — not hepatically metabolised

Paediatric weight-based calculator

Specialist paediatric electrophysiology only. QTc monitoring mandatory. BNFc for age-specific dosing.

Clinical pearls

  • Sotalol causes TdP in a reverse-use-dependent manner: at slow heart rates (bradycardia), the QTc-prolonging effect is GREATER. This means nocturnal TdP risk is highest — often presents as collapse during sleep.
  • ECG monitoring protocol: baseline QTc; repeat 4 hours after first dose and after dose increases. If QTc >500 ms — halve dose. If >550 ms — stop immediately.
  • Hypokalaemia danger: K+ <3.5 mmol/L dramatically increases TdP risk. Always correct electrolytes before starting. Avoid loop diuretics without potassium replacement.
  • Renal dosing critical: sotalol is renally excreted unchanged. Half-life extends >40h in severe CKD — accumulation causes progressive QTc prolongation. Do not use if eGFR <10.
  • Less effective than amiodarone for AF rhythm control but fewer long-term toxicities. Preferred in structural heart disease where Class IC drugs (flecainide) are contraindicated.

Contraindications

  • QTc >450 ms at baseline
  • Hypokalaemia or hypomagnesaemia (correct before starting)
  • 2nd/3rd degree AV block (without pacemaker)
  • Uncompensated heart failure
  • Severe renal impairment (eGFR <10)
  • Congenital long QT syndrome

Side effects

  • Torsades de pointes (TdP) — dose-related; most important risk
  • QTc prolongation
  • Bradycardia
  • Hypotension
  • Fatigue
  • Bronchospasm (non-selective beta-blockade)

Interactions

  • QTc-prolonging drugs (antipsychotics, macrolides, quinolones, hydroxychloroquine) — additive TdP risk; avoid
  • Diuretics — hypokalaemia lowers TdP threshold
  • Digoxin — additive bradycardia
  • Non-dihydropyridine CCBs — additive bradycardia/AV block

Monitoring

  • ECG and QTc (baseline, 4h after first dose, after each dose increase)
  • Electrolytes (potassium, magnesium)
  • eGFR
  • Heart rate and blood pressure

Reference: BNFc; BNF 90; NICE NG196 (AF); ESC 2020 AF Guidelines; BNFc; SPC Sotacor. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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