Sotalol poisoning and its unique treatment considerations compared with traditional therapies for beta-adrenoceptor blocking drug poisoning

Introduction Sotalol is a beta-adrenoceptor blocking drug with unique physical and pharmacologic properties. Unlike most beta-adrenoceptor blocking drugs, sotalol is amenable to extracorporeal removal and causes QT interval prolongation and ventricular dysrhythmias. These properties have implications for treating sotalol poisoning.Patients Patient 1: A man in his seventh decade of life overdosed on sotalol 9 g and presented with bradycardia, hypotension, QT interval >600 msec and transient ventricular tachycardia. Dopamine, isoprenaline (isoproterenol), and a transvenous pacemaker were used instead of high-dose insulin due to the risk of iatrogenic hypokalemia. Hemodynamics improved, and the pacemaker was removed six days later. Patient 2: A woman in her seventh decade of life on sotalol presented with hypotension in the setting of anuric acute kidney failure. Hypotension worsened after administration of additional sotalol. Hemodialysis was performed for refractory hypotension, followed by improvement in hemodynamics and kidney function.Discussion High-dose insulin, a standard therapy in beta-adrenoceptor blocking drug poisoning, causes hypokalemia, which may exacerbate QT interval prolongation and ventricular dysrhythmias in patients with sotalol poisoning. Sotalol is cleared renally and is amenable to extracorporeal removal; hemodialysis may be a useful therapy in patients with cardiotoxicity and concomitant kidney injury.Conclusions Chronotropes and overdrive pacing may be preferred therapies for patients with severe sotalol poisoning. If concomitant kidney injury occurs, hemodialysis may be a useful adjunctive therapy.