Quinidine

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Quinidine
Quinidine structure.svg
Clinical data
Trade names Quinaglute, Quinidex
Synonyms (2-Ethenyl-4-azabicyclo[2.2.2]oct-5-yl)-(6-methoxyquinolin-4-yl)-methanol
AHFS/Drugs.com Monograph
Pregnancy
category
  • AU: C
  • US: C (Risk not ruled out)
Routes of
administration
By mouth, intramuscular injection, intravenous
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability 70–85%
Metabolism 50–90% (by liver)
Biological half-life 6–8 hours
Excretion By the liver (20% as unchanged quinidine via urine)
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
ECHA InfoCard 100.000.254
Chemical and physical data
Formula C20H24N2O2
Molar mass 324.417 g/mol
3D model (JSmol)
 NYesY (what is this?)  (verify)

Quinidine is a pharmaceutical agent that acts as a class I antiarrhythmic agent (Ia) in the heart.[1] It is a stereoisomer of quinine, originally derived from the bark of the cinchona tree. The drug causes increased action potential duration, as well as a prolonged QT interval.

Medical uses[edit]

Quinidine is used as a class I antiarrhythmic agent, that is, to prevent ventricular arrhythmias.[1] It is also used to maintain sinus rhythm after cardioversion of atrial fibrillation and to treat short QT syndrome.[1][2]

Other uses[edit]

A combination of dextromethorphan and quinidine has been shown to alleviate symptoms of easy laughing and crying (pseudobulbar affect) in patients with amyotrophic lateral sclerosis and multiple sclerosis.[3] This drug is marketed as Nuedexta in the United States.

Intravenous quinidine is also indicated for treatment of Plasmodium falciparum malaria.[4] However, quinidine is not considered the first-line therapy for P. falciparum. The recommended treatments for P. falciparum malaria, according to the Toronto Notes 2008, are a combination of either quinine and doxycycline or atovaquone and proguanil (Malarone).

Side effects[edit]

Quinidine is also an inhibitor of the cytochrome P450 enzyme 2D6, and can lead to increased blood levels of lidocaine, beta blockers, opioids, and some antidepressants. Quinidine also inhibits the transport protein P-glycoprotein and so can cause some peripherally acting drugs such as loperamide to have central nervous system side effects, such as respiratory depression, if the two drugs are coadministered.[5]

Quinidine can cause thrombocytopenia, granulomatous hepatitis, myasthenia gravis, and torsades de pointes, so is not used much today. Torsades can occur after the first dose. Quinidine-induced thrombocytopenia (low platelet count) is mediated by the immune system, and may lead to thrombocytic purpura.

Quinidine intoxication can lead to a collection of symptoms collectively known as cinchonism, with tinnitus (ringing in the ears) being among the most characteristic and common symptoms of this toxicity syndrome. Quinidine toxicity can also invoke episodes of Torsades de Pointes - a rapid and dangerous ventricular rhythm.[6]

Pharmacology[edit]

Pharmacodynamics[edit]

Quinidine acts as a blocker of voltage-gated sodium channels.[7][8] Inhibition of the Nav1.5 channel is specifically involved in its antiarrhythmic effects as a class I antiarrhythmic agent.[9] Quinidine also blocks certain voltage-gated potassium channels (e.g., Kv1.4, Kv4.2, hERG, among others),[10][11] acts as an antimuscarinic and alpha-1 blocker,[12] and is an antimalarial.[9]

Mechanism of action[edit]

Like all other class I antiarrhythmic agents, quinidine primarily works by blocking the fast inward sodium current (INa). Quinidine's effect on INa is known as a 'use dependent block'. This means at higher heart rates, the block increases, while at lower heart rates, the block decreases. The effect of blocking the fast inward sodium current causes the phase 0 depolarization of the cardiac action potential to decrease (decreased Vmax).

Quinidine also blocks the slowly inactivating, tetrodotoxin-sensitive Na current, the slow inward calcium current (ICa), the rapid (IKr) and slow (IKs) components of the delayed potassium rectifier current, the inward potassium rectifier current (IKI), the ATP-sensitive potassium channel (IKATP) and Ito.

At micromolar concentrations, quinidine inhibits Na+/K+-ATPase by binding to the same receptor sites as the digitalis glycosides such as ouabain.

The effect of quinidine on the ion channels is to prolong the cardiac action potential, thereby prolonging the QT interval on the surface ECG.

Other ECG effects include a wide notched P wave, wide QRS complex, depressed ST segment, and U waves. These are the results of both slowed depolarization and repolarization.

Pharmacokinetics[edit]

Elimination[edit]

The elimination half-life of oral quinidine is 6 to 8 hours, and it is eliminated by the cytochrome P450 system in the liver. About 20% is excreted unchanged via the kidneys.

History[edit]

The effects of cinchona bark (the botanical source from which quinidine is extracted) had been commented on long before the understanding of cardiac physiology arose. Jean-Baptiste de Sénac, in his 1749 work on the anatomy, function, and diseases of the heart, had this to say,

"Long and rebellious palpitations have ceded to this febrifuge".[13]

"Of all the stomachic remedies, the one whose effects have appeared to me the most constant and the most prompt in many cases is quinquina [Peruvian bark] mixed with a little rhubarb."[14]

Sénac subsequently became physician to Louis XV of France, a counselor of the state, and superintendent of the mineral waters and medicinals in France. As a result of his influence, throughout the 19th century, quinine was used to augment digitalis therapy. It was described as das Opium des Herzens (the opium of the heart).

However, the use of quinidine to treat arrhythmia really only came into its own because a physician listened to the astute observation of one of his patients. In 1912, Karel Frederik Wenckebach saw a man with atrial fibrillation. He was a Dutch merchant, used to good order in his affairs. He would like to have good order in his heart business, also, and asked, "why there were heart specialists if they could not abolish this very disagreeable phenomenon ... he knew himself how to get rid of his attacks. As I did not believe him, he promised to come back next morning with a regular pulse, and he did."

The man had found by chance that when he took one gram of quinine during an attack, it reliably halted it in 25 minutes; otherwise it would last for two to 14 days. Wenckebach often tried quinine again, but he succeeded in only one other patient.[13]

He made passing mention of it in his book on cardiac arrhythmias published in 1914. Four years later, Walter von Frey of Berlin reported in a leading Viennese medical journal that quinidine was the most effective of the four principal cinchona alkaloids in controlling atrial arrhythmias.[15]

Chemistry[edit]

Quinidine-based ligands are used in AD-mix-β for sharpless asymmetric dihydroxylation.

Veterinary use[edit]

Quinidine sulfate is used in the treatment of atrial fibrillation in horses.[16][17]

References[edit]

  1. ^ a b c Grace AA, Camm AJ (1998). "Quinidine". N. Engl. J. Med. 338 (1): 35–45. doi:10.1056/NEJM199801013380107. PMID 9414330. 
  2. ^ Kaufman ES (2007). "Quinidine in short QT syndrome: an old drug for a new disease". J. Cardiovasc. Electrophysiol. 18 (6): 665–6. doi:10.1111/j.1540-8167.2007.00815.x. PMID 17521305. 
  3. ^ Brooks, BR; Thisted, RA; Appel, SH; Bradley, WG; Olney, RK; Berg, JE; Pope, LE; Smith, RA; AVP-923 ALS Study Group (2004). "Treatment of pseudobulbar affect in ALS with dextromethorphan/quinidine: a randomized trial". Neurology. 63 (8): 1364–70. doi:10.1212/01.wnl.0000142042.50528.2f. PMID 15505150. 
  4. ^ "From the Centers for Disease Control and Prevention. Availability and use of parenteral quinidine gluconate for severe or complicated malaria". JAMA. 285 (6): 730. February 2001. doi:10.1001/jama.285.6.730. PMID 11236771. 
  5. ^ Sadeque AJ, Wandel C, He H, Shah S, Wood AJ (2000). "Increased drug delivery to the brain by P-glycoprotein inhibition". Clin. Pharmacol. Ther. 68 (3): 231–7. doi:10.1067/mcp.2000.109156. PMID 11014404. 
  6. ^ Rapid Interpretation of EKG's 6th Ed., Dubin
  7. ^ de Lera Ruiz M, Kraus RL (2015). "Voltage-Gated Sodium Channels: Structure, Function, Pharmacology, and Clinical Indications". J. Med. Chem. 58 (18): 7093–118. doi:10.1021/jm501981g. PMID 25927480. 
  8. ^ Hugues Abriel (1 September 2015). Cardiac Sodium Channel Disorders, An Issue of Cardiac Electrophysiology Clinics, E-Book. Elsevier Health Sciences. pp. 695–. ISBN 978-0-323-32641-4. 
  9. ^ a b Hugh C. Hemmings; Talmage D. Egan (2013). Pharmacology and Physiology for Anesthesia: Foundations and Clinical Application: Expert Consult - Online and Print. Elsevier Health Sciences. pp. 451–. ISBN 1-4377-1679-2. 
  10. ^ Laszlo Urban; Vinod Patel; Roy J. Vaz (23 February 2015). Antitargets and Drug Safety. Wiley. pp. 303–. ISBN 978-3-527-67367-4. 
  11. ^ Stephen L. Archer; Nancy J. Rusch (6 December 2012). Potassium Channels in Cardiovascular Biology. Springer Science & Business Media. pp. 343–. ISBN 978-1-4615-1303-2. 
  12. ^ Shibata K, Hirasawa A, Foglar R, Ogawa S, Tsujimoto G (1998). "Effects of quinidine and verapamil on human cardiovascular alpha1-adrenoceptors". Circulation. 97 (13): 1227–30. PMID 9570190. 
  13. ^ a b Hollman, A (1991). "Plants in Cardiology: Quinine and Quinidine". British heart journal. 66 (4): 301. doi:10.1136/hrt.66.4.301. PMC 1024726Freely accessible. PMID 1747282. 
  14. ^ Bowman, IA (1987). "Jean-Baptiste Senac and His Treatise on the Heart". Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital. 14 (1): 5–11. PMC 324686Freely accessible. PMID 15227324. 
  15. ^ Sneader, Walter (Jun 20, 2005). Drug Discovery: A History. John Wiley and Sons. p. 95. ISBN 978-0-471-89980-8. 
  16. ^ KURAKANE, Eiji; AMADA, Akio (1982). "Pharmacokinetic Studies on Quinidine Sulfate Orally Administered in Horses". Bulletin of Equine Research Institute. 1982 (19): 59–68. doi:10.11535/jes1977.1982.59. Retrieved March 3, 2017. 
  17. ^ HIRAGA, Atsushi; SUGANO, Shigeru (2015). "History of research in Japan on electrocardiography in the racehorse". Journal of Equine Science. 26 (1): 1–13. doi:10.1294/jes.26.1. 

External links[edit]