European Medicines Agency Recommends Restricting Use of Multaq

Benefit-risk balance of anti-arrhythmic medicine remains positive in a limited population of patients with paroxysmal or persistent atrial fibrillation

The European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) has recommended restricting the use of Multaq. The anti-arrhythmic medicine should only be prescribed for maintaining heart rhythm in patients with paroxysmal or persistent atrial fibrillation for the maintenance of sinus rhythm after successful cardioversion. Due to an increased risk of liver, lung and cardiovascular adverse events, Multaq should only be prescribed after alternative treatment options have been considered. The Committee also recommended a number of other risk minimisation measures to reduce the risk of injuries to liver, lung and cardiovascular system.

Patients who are currently taking Multaq are recommended to have their treatment evaluated by their doctor at their next scheduled appointment.

Multaq (dronedarone) is an anti-arrhythmic medicine. It was authorised in 2009 for use in adults who have had atrial fibrillation in the past or who currently have non-permanent fibrillation.

The review of the overall balance of benefits and risks of Multaq was initiated in January 2011 because of reports of severe liver injury in patients treated with the medicine. During the review the CHMP was informed of the early termination of a clinical trial, the PALLAS study, due to the occurrence of severe cardiovascular side effects such as cardiovascular death, stroke and cardiovascular hospitalisation in patients taking the medicine. The PALLAS study investigated the use of Multaq compared to placebo in patients over 65 years of age with permanent atrial fibrillation and several risk factors. Although Multaq has not been approved for this patient population, the CHMP was concerned about the outcome of the PALLAS study and extended its review to also look at the data relating to cardiovascular safety of the medicine as well as other data that became available on the risk of damage to the lungs.

On the basis of the evaluation of the currently available data, the Committee concluded that there was an increased risk of Multaq causing injury to the liver as well as the lungs when used in accordance with the currently approved prescribing information. The Committee also considered that the cardiovascular events shown in the population in the PALLAS study could mean an increased risk of cardiovascular side effects for some patients with non-permanent atrial fibrillation.

However, the Committee considered that the availability of a range of treatments for a difficult condition such as atrial fibrillation was important and that for some patients with non-permanent atrial fibrillation Multaq remains a useful treatment option. The CHMP therefore was of the opinion that the benefits of Multaq outweigh its risks in these patients, provided that further changes to the information for prescribers and patients will be introduced to minimise the risk of injury to the liver, lung and heart. These include:

* Treatment with Multaq should be restricted to patients with paroxysmal or persistent atrial fibrillation when sinus rhythm has been obtained. It is no longer indicated for use in patients when atrial fibrillation is still present.
* Treatment with Multaq should only be started and monitored by a specialist after other anti-arrhythmic medicines have been considered.
* Multaq must not be used in patients with permanent atrial fibrillation, heart failure or left ventricular systolic dysfunction (impairment of the left side of the heart).
* Doctors should consider discontinuation of treatment if atrial fibrillation reoccurs.
* Multaq must not be used in patients who have had previous liver or lung injury following treatment with amiodarone, another anti-arrhythmic medicine.
* Patients on Multaq should have their lung and liver function as well as their heart rhythm regularly monitored. Especially the liver function should be closely monitored during the first few weeks of treatment.

The Committee’s opinion has now been forwarded to the European Commission for the adoption of a decision.

Notes

* Multaq has been authorised in the European Union since 26 November 2009 and is marketed in Austria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Ireland, Italy, Lithuania, Malta, Poland, Slovakia, Slovenia, Spain, Sweden and the United Kingdom, as well as in Iceland and Norway.
* During the assessment the CHMP also received advice from the Scientific Advisory Group on Cardiovascular Issues. This group includes experts in the treatment of cardiovascular diseases and patient representatives More information is available here.
* All other opinions and documents adopted by the CHMP at their September 2011 plenary meeting will be published on Friday, 23 September 2011 at 12.00 noon UK time on a dedicated web page.

Posted: September 2011


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